Vaccinium macrocarpon) and European (Vaccinium oxycoccus) cranberry species are rich in polyphenols such as phenolic acids, anthocyanins and flavonoids, and is one of the few fruits that is high in proanthocyanidins, which is linked to many health benefits. The review systematizes information on the chemical composition of cranberry, its antioxidant effect, and the beneficial impact on human health and disease prevention after cranberry consumption, and in particular, its effect against urinary tract inflammation with both adults and children, cardiovascular, oncology diseases, type 2 diabetes, metabolic syndrome, obesity, tooth decay and periodontitis, Helicobacter pylori bacteria in the stomach and other diseases. Additional research needs to study cranberry proteomics profiling, polyphenols interaction and synergism with other biologically active compounds from natural ingredients and what is important in formulation of new functional foods and supplements.Cranberries are a rich source of bioactive compounds that comprise a healthy diet. Cranberry is abundant in nutritional components and many bioactive compounds that have antioxidant properties. Both American ( Vaccinium macrocarpon, and is cultivated in the northern parts of the country. It is mainly produced in New Jersey, Massachusetts, Oregon, Washington, Wisconsin and, in the Canadian provinces of British Columbia and Quebec . Sm. Sm11]. 4.3 g/kg . Vaccinium macrocarpon ‘Pilgrim’ (38.4%), ‘Stevens’ (34.9%) and ‘Ben Lear’ (40.9%) . La. La11]. .44 g, fr (40.9%) . Fructos (40.9%) . Vaccinium macrocarpon) grown in a horticultural farm with similar conditions in a region of Poland, ‘Pilgrim’ had the highest content of Vitamin C (20.74 mg/100 g fresh matter (fm)) and ‘Red Star’ had the lowest content (10.07 mg/100 g fm) [Cranberries contain a wide range of water-soluble and fat-soluble vitamins . Antioxi00 g fm) . Viskeli00 g fm)  determin00 g fm) .Vaccinium oxycoccos) and American cranberries (Vaccinium macrocarpon) showed similar average mineral content for the macronutrients, potassium , calcium , and sulfur  [p < 0.05) were found for nitrogen , phosphorus , and magnesium  for the cranberries. Potassium and nitrogen were the major minerals identified in these two varieties of cranberry fruits [Minerals encompassed 0.19 to 0.28% fresh weight (fw) of the small cranberry . Europeactively) . Statisty fruits ,16. AmerCranberries contain chemically diverse, secondary metabolites, polyphenols that have antimicrobial and antioxidant properties ,3. ChemiVaccinium macrocarpon Ait., Vacciniumoxycoccos L., and Vaccinium vitisidaea (lingonberry grown in North America and Europe), 4624 compounds were identified with about 8000–10,000 phytochemicals found in each type [Both types of cranberries, the large and small, contain many phenolic compounds, such as phenolic acids, flavonoids (anthocyanins and flavonols), and tannins. The large cranberry has been recognized as an important food and healing agent because of these compounds. Flavonoids were the major compounds identified among over 150 compounds in the large cranberry . Flavonoach type . p-hydroxybenzoic, and o-hydroxybenzoic acids. The hydroxycinnamic acids in cranberry are p-coumaric, sinapic, caffeic, and ferulic acids [Cranberries constitute phenolic acids that include hydroxybenzoic and hydroxycinnamic acids ,18,19,20p-coumaric acid as the most abundant compound followed by caffeic acid, ferulic acid and chlorogenic acid in a cranberry wild clone and the cultivar ‘Pilgrim’ , p-hydroxybenzoic acid (55 mg/kg), kaempherol-3-O-glucoside (11.0 mg/kg), caffeic acid (5.0 mg/kg) and ellagic acid (3.0 mg/kg) as the main phenolic compounds in extracts of Vaccinium macrocarpon. Abeywickrama et al.  observedPilgrim’ . Kylli en et al.  detectedTotal phenolic acids ranged from the lowest concentration of 327 mg/100 g dry matter (dm) in ‘Pilgrim’ to the highest content of 649 mg/100 g dm in ‘Howes’ when six cultivars of cranberry fruit grown in Poland were tested . CranberAnthocyanins are natural water-soluble pigments that give cranberries their reddish color. Anthocyanins in the small berry were found to be 6 to 10 times higher in the external layer of the berry skin than in the pulp ,14. Vaccinium macrocarpon L. grown in Poland [Vacciniun macrocarpon Aiton, and two cultivars, ‘Franklin’ and ‘Bergman’, Debnath and An [p < 0.05). Variation ranged from the least amount of total anthocyanins in the wild clone cranberry NL77 of 0.13 mg/g fw to the highest amount detected in the genotype ‘Franklin’ of 2.27 mg/g fw [Vaccinium macrocarpon and Vaccinium oxycoccos. These are cyanidin-3-galactoside, cyanidin-3-glucoside, cyanidin-3-arabinoise, peonidin-3-galactoside, peonidin-3-glucoside and peonidin-3-arabinoside. The content of total anthocyanins ranged from 695 to 1716 mg/100 g dm for the six cultivars of n Poland . Of one h and An  observed mg/g fw . In anot mg/g fw , six antVaccinium macrocarpon L.), ‘Ben Lear’ consisted of the highest average level of anthocyanins (690.4 mg/100 g dm) when analyzed at the four different maturity stages of ripening and was 50.6% and 6.0% higher than ‘Pilgrim’ and ‘Stevens’, respectively. There was a sharp increase in anthocyanins content in ‘Pilgrim’, ‘Stevens’, and ‘Ben Lear’  during ripening from the immature stage to the commercially mature stage [Of the three cranberry fruits  in the total flavonoid content among the 136 wild clones and two cultivars ranging from 2.78 to 7.51 for the wild clones, NL51 and NL92, respectively. The cultivar ‘Franklin’ (5.81 mg/g fw) had more total flavonoids than ‘Bergman’ (4.06 mg/g fw) [Flavonols are abundant in cranberries ,13,18,19a et al.  were myra et al.  showed smg/g fw) . About 1mg/g fw) . Flavonol concentrations show a slight increase in cranberries during ripening ,13. ‘PilVaccinium macrocarpon L. cultivars at the different ripening stages [Flavonoids are important in plant defense and are strong antioxidants. They also exhibit antibacterial, antiviral, anticarcinogenic, and anti-inflammatory activities . Flavonog stages . The cong stages . Vacciniummacrocarpon Ait., the small European cranberry, Vaccinium oxycoccus, and the lingonberry, Vaccinium vitis-idaea L. Only two A-type trimers were detected in Vaccinium oxycoccus. Vaccinium vitis-idaea showed the greatest variation with a pattern similar to that of Vaccinium macrocarpon [Vaccinium macrocarpon and Vaccinium oxycoccus exhibited higher amounts of A-type than B-type trimers and dimers [Vaccinium macrocarpon varieties ranged from 4.10 to 5.49 mg/100 g of fresh berries. For Vaccinium vitis-idaea, the concentration of procyanidin A2 was 2.11 mg/100 g fw for the European berries and 7.98 mg/100 g fw for the Chinese berries. The lowest concentration of procyanidin A2 was observed in the Vaccinium oxycoccus berries at a range of 0.13–0.21 mg/100 g fw. Vaccinium vitis-idaea had the highest amount of A-type dimer, followed by Vaccinium macrocarpon and the least by Vaccinium oxycoccus [Jungfer et al.  noticed rocarpon . B-type d dimers . The amoxycoccus . Abeywicxycoccus  determinxycoccus   than catechin (0.33–0.61 mg/100 g fw), while the ratio of epicatechin to catechin in Vaccinium oxycoccus (1:1) was lower. This suggests that different ratios of the flavan-3-ols may depend on the origin of the berries [All varieties of the  berries . Additio berries .Vaccinium macrocarpon  ranged from 192.1 mg/100 g fm (‘Pilgrim’) to 374.2 mg/100 g fm (‘Ben Lear’) as compared to the European wild-grown cranberry Vaccinium oxycoccus at 288.5 mg/100 g [Vaccinium macrocarpon Ait. cultivar ‘Early Black’ contained the highest amount of anthocyanins and phenolic  than ‘Stevens’, ‘Bergman’, ‘Pilgrim’, ‘Septembra’ and the wild cranberry Vaccinium oxycoccus L. The results showed there are statistically significant differences (p < 0.05) between the biochemical constituents of the cranberry cultivars and the species [The amount of total phenolic compounds for the five American cranberry cultivars mg/100 g . The higmg/100 g . This wamg/100 g . Tikuma mg/100 g  observed species .Vaccinium oxycoccus and protects against oxidative damage and lipid oxidation [Cranberry fruits also contain triterpenoids. Two of the major triterpenoids, ursolic acid and its isomer, oleanic or oleanolic acid are found in the wax of the skin of the cranberry fruit and are mostly responsible for anti- inflammatory, antitumor and anticancer activities ,28. Ursoxidation  and has xidation ,18.β-sitosterol, and stigmasterol in Vaccinium macrocarpon cranberry extracts. β-sitosterol and stigmasterol showed a total of 107.83 mg/g. The cranberry extract also contained ursolic acid and oleanic acid at concentrations of 372.97 mg/g and 79.16 mg/g, respectively. Oszmiański et al. [Wu et al.  identifii et al.  detectedi et al. . Higher i et al. . The average content of triterpenoids for ‘Pilgrim’, ‘Stevens’, and ‘Ben Lear’ was 2528 mg/kg dm, 2736 mg/kg dm, and 3201 mg/kg dm, respectively, during the maturing stage of the three cranberry cultivars . The conCranberry fruit is an important source of antioxidants, such as polyphenols , ascorbic acid, and triterpene compounds ,10. TheyVaccinium oxycoccus) and five American cranberry cultivars and observed a statistically significant difference (p < 0.05) between the wild cranberry fruit and the cultivars. The wild cranberry fruit possessed greater antioxidant activity (AOC) [Borowska et al.  comparedty (AOC) . This stty (AOC) .Vaccinium oxycoccus cranberry to be 18.6 µmol of Fe2+/g, whereas Diaconeasa et al. [2+/g. The greatest amount of antioxidant activity detected by ABTS, DPPH, and FRAP assays in the different cultivars of Vaccinium macrocarpon was in ‘Franklin’ at 264, 320, and 139 µmol TE/g dm, respectively [2 = 0.508, 0.584, 0.591), anthocyanins , and flavonols  in cranberry fruit. The antioxidant activity also correlated with the triterpenoids . Ursolic acid showed the strongest correlation with the ABTS, DPPH and FRAP assays  [The total content of antioxidants in cranberry was found to be 270 mg/100 g when measured by an amperometric method . Borges a et al.  noted 19ectively . The lowctively) . Abeywicp < 0.05) for the antioxidant activity with the DPPH assay among 136 wild cranberry genotypes and two cultivars tested by Debnath and An [A significant difference was observed  bacteria from attaching to cells in the urinary tract and causing infection [European colonists who arrived in North America immediately recognized cranberries’ healing powers, such as poultice for wounds and cure for blood poisoning . Cranbernfection . Today, nfection ,31. Crannfection ,31.E. coli to uroepithelial cells in the urinary tract [In a study of the cranberry effects on human health, since 1984, several articles and reviews have been published. The most common issues on the cranberry effect on human health are investigated in reviews ,31,32,33ry tract ,45,56.In clinical studies, products containing cranberry were found to prevent recurrent UTIs in young women and middle-aged women ,57,58. CMen receiving radiation for prostate cancer usually have a side effect of acute radiation cystitis, inflammation of the bladder. There is no effective treatment for preventing or treating radiation cystitis. In a pilot study, Hamilton et al.  determinE. coli adhesion to the urothelium [Lactobacillus plantarum and Lactobacillus paracasei LPCO9 significantly improved the uncomfortable symptoms associated with acute cystitis in women [Antibiotics are also used to treat women with chronic cystitis. However, there has been adverse effects and increased risk of resistance with antibiotics. Studies show that cranberry can be used as an alternative ,60. Proaothelium . The occothelium ,60,61,62Cranberry has a strong anti-oxidant property due to the presence of its rich polyphenol content such as flavonoids, proanthocyanidin dimers and oligomers, which prevents oxidative stress, the precursor to many chronic diseases . ConsumiCranberry helps treat cardiovascular diseases, improving the lipid profile, minimizing the likelihood of atherosclerosis by decreasing low density lipoproteins, reducing blood pressure and increasing high density lipoproteins (good) and preventing metabolic syndrome ,71,72,73Helicobacter pylori bacterium in the human stomach [Vaccinium oxycoccos fruits can suppress the spread of breast cancer cells, which may bring about apoptosis and GI phase arrest [Cranberry is effective against all inflammatory processes, and now it is known that even cardiovascular and oncology diseases lead up to inflammatory responses. Cranberry can be used to prevent stomach ulcers by suppressing the activity of the  stomach ,78,79,80 stomach ,82,83. SCranberry consumption helps against rheumatoid arthritis with women . CranberCranberries have been shown to have a high antiviral effect with a positive effect shown between anti-influenza viral activity and total polyphenol content, which indicates high amounts of polyphenols are an important factor in the antiviral effect of berries ,93.E. coli, Salmonella typhimurium, Enteroccocus faecalis, Listeria monocytogenes, Staphylococcus and Bacillus subtilis [Cranberry also exhibited microbial activity. It slowed the growth of human pathogenic bacteria such as subtilis ,95,96,97This review summarized available data on cranberry phytochemicals characterization and their impact on human health. Cranberries represent a rich source of phenolic acids and flavonoids that have been linked to various health benefits. Cranberry fruit phytonutrients include anthocyanins, phenolic acids, flavonols, flavan-3-ols, proanthocyanidins, triterpenoids and their antioxidant activities. It has been shown that consumption of cranberry offers a reliable protection from and prevention of many chronic diseases. In general, cranberry fruit has cardioprotective, anti-carcinogenic, anti-diabetic, anti-inflammatory, antipyretic, antiseptic, antibacterial, antiviral, and other effects. All this information will potentially add to an already high level of interest toward cranberry cultivars and should certainly be incorporated as an integral part of healthy, nutritious eating, and at formulation of new functional food ingredients and dietary supplements.An increase in demand for functional foods has led to development of food products with added protein. Additional representation of cranberry with full screening of proteomics characterization is needed. This information should be helpful in describing the mechanism of biological activity of cranberry constituents in the human body. It is also important to investigate the interaction between cranberry polyphenols with different proteomics and polysaccharides during and after processing. This information can be used for optimization of the processing method and formulation of high-protein cranberry juice products so that the protein digestibility and antioxidant activity is increased after digestion .Polyphenols naturally bind to proteins to form insoluble, stable colloidal protein-polyphenol particles, which when used as food ingredients provide more health benefits to consumers from additional bioactives . StrauchCharacterization of extractable polyphenols from cranberries have been extensively assessed. However, investigations on residuals of total polyphenols, non-extractable polyphenols have been limited . More chIt is also important to investigate the synergism of cranberry phenolics with other natural ingredients for different biological activities. Vattem et al.  studied


One of the well-accepted principles of epidemiology is the need to draw upon ancillary evidence from biological research in the selection of topics to pursue, design of studies, and especially, the interpretation of the results. In environmental epidemiology, understanding the biological pathways by which the exposure of concern may affect health often has a great value in framing research questions and guiding the studies that are done but calls for deeper reflection of how that ancillary biological information should (and should not) be used.validity of the study calls for a closer look.Biological evidence of potential health harm may motivate epidemiologic studies and help to guide exposure assessment to maximize the likelihood of identifying an etiologic relationship if one is present. Decisions regarding exposure aggregation (lumping or splitting), duration of exposure, the timing of exposure in relation to disease occurrence, exploration of dose-response patterns (thresholds and ceilings), and other chemical and physical features of exposure to be examined in epidemiologic studies benefit from drawing on knowledge from pertinent biological research. Similarly, the choice of specific disease entities should be informed by knowledge of biological mechanisms in the analogous decisions regarding grouping, timing of onset, distinctive features of the disease , and clinical manifestations. Markers of susceptibility that could result in effect-modification may be gleaned from biological research as well as candidate confounders. The product of this knowledge drawn from work done in other fields, if considered in advance, is an enhanced ability to design and conduct epidemiologic studies in which the measure of association is most likely to identify any causal effects that are present, that is, more valid studies. If positive or negative associations are found, they would be seen as concordant with expectations based on biology and if null associations are found, this would provide meaningful evidence that the plausible etiologic relationship is not likely to be present. But the dividing line between using biological evidence to optimize the design of studies and the use of biological evidence to render a verdict on the 1 raises some concerns when considering why measured associations may or may not reflect a causal effect. To the extent that the epidemiologic research is informed by sound biological insights, we will benefit from having focused on the most pertinent exposure and disease measures, minimizing exposure and disease misclassification, and isolating the most highly susceptible subgroups. Once we have gleaned all that we can from ancillary biological research on the topic, however, the epidemiologic study must stand on its merits in order to approximate the causal effect of interest, driven solely by freedom from biases. As elucidated below, the presence (or absence) of biological information does not independently influence the validity of the epidemiologic study that was conducted, which is determined solely by the usual methodological considerations. There is no validity bonus at the end for the epidemiologic studies because other lines of evidence point in the same direction nor are validity points deducted because of the lack of such support.The consideration of biological plausibility in the interpretation of the study results, as advocated by Sir Austin Bradford HillIf valuable information from biological research is not taken into account in the epidemiologic study due to lack of knowledge at the time the study was undertaken or because the biological research came later, validity will suffer. In that sense, the biological evidence does help to inform us as to whether misclassification is likely to have been present, for example, or whether underlying effect modification has not been taken into account. But this reconciliation of what is known from the varying lines of evidence can only take place when the research from multiple disciplines is compiled and then integrated for a global assessment of causality. With the comprehensive body of relevant research, we may find converging evidence from the varying lines of evidence supporting causality or that the epidemiologic research provides a flawed assessment of the etiologic process once evidence from other disciplines is taken into account. The aggregation of knowledge from the multiple contributing disciplines is needed for a fully informed assessment of causality, rather than looking to epidemiology alone or epidemiology interpreted through biology.2 with a clear role for toxicologic and mechanistic evidence as contributors to causal assessment. Note that the mechanistic evidence is drawn upon not through its effect on interpreting the epidemiologic evidence but as an independent contributor to the ultimate assignment that integrates all sources of relevant evidence. The need for rigorous evaluation of epidemiologic methods remains the basis for assessing epidemiology’s contribution to that assignment. The key distinction is as indicated in the diagram below:Epidemiology alone is generally not the sole basis for causal inference and subsequent policy decisions, nor should it be. Such evaluations call for a comprehensive assessment of all relevant evidence, including epidemiology, biological research, and other relevant lines of investigation. The system used by the International Agency for Research on Cancer makes that strategy quite explicit,interpreting the epidemiologic evidence or as an independent contributor to causal inference, there are a number of potentially important consequences of that choice. It is worth noting that Professor Hill’s original article did not provide considerations in the interpretation of epidemiologic evidence (as they have come to be used) but rather for making an overall judgment regarding whether environmental exposures cause disease.1 Reasons for favoring the use of the biological evidence directly rather than as an adjunct to the interpretation of epidemiology are noted below.The diagram on the left suggests that the value of the epidemiology to causal inference is modified by ancillary evidence whereas the diagram on the right indicates each is independently contributing to causal inference. While it may seem like a minor semantic distinction whether the biological evidence is brought to bear as a means of 3 While ancillary evidence from other disciplines may help to inform how effective the epidemiologic study was in addressing the most important or relevant potential effects, the study’s results can only be judged based on whether or not the resulting measure of association does or does not reflect the causal impact of the exposure and disease that were addressed, that is, its internal validity.The goal of etiologic epidemiology research is to generate measures of association that approximate the causal effect of interest. The extent to which these deviate from one another is solely a function of the susceptibility of the study to biases, that is, confounding, measurement error, selection bias, or random error. Logically, a spurious positive result is not in error because it does not make biological sense but because some bias is operating to indicate an association when no underlying causal effect is in fact present. Likewise, an erroneous null finding in an epidemiologic study must be attributed to methodologic limitations if a causal effect is in fact present. As noted in a commentary on the relationship between the GRADE approach and Bradford Hill criteria, biological plausibility does not contribute to the assessment of the validity of the research.6 A frequent criticism of biophysicists and engineers was that the epidemiologic findings must be wrong because they run counter to well-established findings from these other disciplines, but this is logically impossible. If the epidemiologic studies identified spurious positive associations when no causal effect was, in fact, present, then the problem had to lie within the epidemiologic studies, for example, selection bias or measurement error. The source of error cannot be attributed to contradictory evidence from other lines of research.Some years ago, epidemiologic studies suggested a possible effect of electromagnetic fields from power lines on the risk of cancer.While epidemiologists may be conversant with the biological research on the etiologic relationship that they are studying, without deep subject matter knowledge it is very difficult to fully appreciate the validity and relevance of research from these other disciplines. The methods and implications of various types of biological research are no less subtle than their counterparts in epidemiologic studies, subject to critical evaluation by experts in those fields. Just as is the case for epidemiology, experimental studies in the laboratory have varying degrees of both internal validity and applicability to the study of humans in the real world. This goes beyond the familiar observation that exposure levels or modes of administration differ, and includes nuances of species differences in metabolism, laboratory artifacts, and validity of outcome measurement.A common challenge is to distinguish between biological responses indicative of normal variation or adaptation to environmental stressors versus indicators of disease processes, which can be quite subtle. Just as those lacking expertise in epidemiology often interpret our work simplistically and fail to appreciate the nuances of methods and implications for validity, the same problems are inevitable when epidemiologists attempt to interpret research in biologically complex disciplines in which they have minimal training and experience. In collective assessments of evidence such as those that are routinely undertaken by the International Agency for Research on Cancer or the US National Academy of Sciences, Engineering, and Medicine, the full range of needed disciplinary experts is engaged and the informed evaluation of each relevant line of evidence is essential to integrate them.2 The “bottom line” judgment of causality is based on the entire array of relevant research in proportion to their informativeness in both absolute terms and relative to one another. Since epidemiologic studies address the relevant species (humans) in the environments of interest , there is a temptation to treat those results as providing the ultimate answers regarding human health, but the power of various forms of biological research is pertinent and has complementary methodologic strengths and weaknesses relative to epidemiology. Ultimately, inferences regarding causality and subsequent policy decisions require a level of generalization and abstraction that goes beyond any particular study or line of research.There is an implicit downgrading of biological evidence when it is used only to assist in the interpretation of epidemiologic evidence. Toxicology can and often does contribute significantly to judgments of causality and regulatory decisions to protect human health. Increasingly, as understanding of biological interactions between environmental exposures and humans expands, mechanistic studies have come to be recognized as important contributors to an overall assessment of human health risks.1 Some are pertinent to assessing the potential for bias as the basis for observed associations rather than a causal effect—magnitude of effect, dose-response, and experimentation concern potential confounding and specificity indirectly addresses measurement error . But the consideration of biological plausibility, unquestionably relevant to causal inference, is external to epidemiologic studies. To treat biological plausibility as a tool to aid in the interpretation of epidemiology overstates its value in assessing the validity of epidemiologic evidence and understates its real value in assessing causality.The considerations offered by Sir Austin Bradford Hill over 50 years ago provide a diverse menu of ideas that were offered to judge environmental causes of disease but contribute to the interpretation of epidemiologic evidence in several ways.The author declares that he has no conflicts of interest with regard to the content of this repor


Purpose: The spleen is a fist-sized largest lymphoid organ located in the left hypochondrium. It has a unique location, embryological and histological structure that differs significantly from other lymphoid organs. The present work was undertaken to study the microscopic and ultramicroscopic histogenesis patterns of the spleen in relation to gestational age.Methods: The splenic tissue of nine aborted fetuses of various gestational ages was studied. For cytology study, special stains like Masson’s trichrome, Periodic Acid-Schiff, and Reticulin were used; immunohistochemical staining was performed with triple antibodies ; and for ultrastructure study, aluminum mounted specimens coated with gold and argon gas were observed under scanning electron microscopy (SEM).Results: Microscopy and immunohistochemistry showed the developmental changes in the spleen from the emergence of the primordium to the end of the embryonic period in all stages of fetogenesis. The spleen primordium of a fetus at the developmental stage of the primary vascular reticulum was seen in the first trimester fetuses. The primordium is comprised mainly of mesenchymal tissue; numerous lymphocytes invading the area surrounding the central artery forming the periarterial lymphoid sheaths (PALS) were seen surrounded by venous sinuses in the early second trimester fetuses.Conclusion: The organizational changes in the reticuloendothelial system and microstructure of the spleen during fetogenesis are very crucial to achieving adult morphology in the future. Histogenesis of the fetal spleen follows a multistep process depending upon the gestational age. Any deviation from normalcy may lead to structural and functional abnormality later in life. The skeletal framework of the spleen resembles a large lymph node, primarily acts as a blood filter. It plays important role in regard to red blood cells (erythrocytes) and the immune system. The mononuclear phagocyte system is responsible for taking apart the old red blood cells and recycling them. It also breaks down the heme portion of the hemoglobin into its constitutive amino acids . The splThe splenic tissue of aborted human fetuses of first, second, and third trimesters of gestation, which did not show any evidence of external morphological abnormality, was collected from the Department of Gynaecology and Obstetrics, All India Institute of Medical Sciences, Bhubaneswar after therapeutic abortion, which was used in this study after approval of the Institutional Ethical Committee of Human Research (IEC) and Institute Research Board (IRB) of AIIMS Bhubaneswar (T/IM-NF/Anatomy/18/84). They were collected after obtaining written informed consent of the legal guardian accorded with institutional guidelines, which is maintained in the Fetal Death Register in the Department of Anatomy, AIIMS Bhubaneswar.For cytological studyThe fetuses were dissected by dissecting microscope and the splenic tissue of 2 mm size were immediately fixed in 10% formalin for 24 hours. After fixation by formalin, the tissues were processed for routine histological procedures using special stains such as Masson’s trichrome and reticulin stain, and then photomicrographs were taken by the camera using a microscope adapter.For immunohistochemical studyThree-millimeter sections of splenic tissues were fixed in 10% neutral buffered formalin (NBF) for seven hours followed by routine processing and paraffin embedding. Unstained sections were immersed in DAKO Target Retrieval Solution and heated for antigen retrieval from tissues. Deparaffinized sections were incubated with 3% hydrogen peroxide for five minutes, which block and inhibit the endogenous enzymes to avoid producing non-specific binding of antigen on the cell surface, followed by sequential 10 minutes incubation in xylene and alcohol. The sections were put in a pressure cooker for 20 minutes  to unmask the antigen epitopes in order to allow the antibodies to bind which was followed by a biotinylated link antibody and peroxidize-labeled streptavidin, which augmented the antigen expression on the tissue surface. A modified labeled avidin-biotin immunohistochemical staining was performed with triple antibodies C-myc, Ki-67, and Ber-H2 with the help of an immunoperoxidase kit on DAKO auto Stainer. Staining was completed after a 10 minutes incubation with DAKO 3,3’-diaminobenzidine (DAB) chromogen, which was used as a signal enhancer.For the ultramicroscopic or ultrastructural study2 sizes and was put in primary fixative (Karnovsky's fixative)-2.5% glutaraldehyde + 2% paraformaldehyde in 0.1 M PB (pH 7.4) for 12 hr at 4 °C followed by secondary fixation - 1% OsO4 for 1 hour at 4 °C.The splenic tissue was cut in 2 × 2 mmThe tissue was then dehydrated in ascending grades of alcohol at 4 °C and kept in acetone at room temperature followed by processing with xylene. Epoxy resin infiltration was done with descending toluene: ascending resin ratio for better infiltration of tissue.The resin block was then cut by knife boat into 50-70 nm sections by ultramicrotome. Double staining was done by aqueous uranyl acetate and alkaline lead citrate. The slides were then viewed under transmission electron microscopy (TEM) and photomicrographs were taken.Microscopic findingsFirst TrimesterThe appearance of splenic capsule, reticular framework developed, and lymphoblasts were seen in scattered groups. Lymphocytes surrounded by newly forming blood vessels can be seen in Masson’s trichome stain . Red pulp was visualized as sinusoids and RBCs in between white pulp.Third TrimesterThe structure is similar to the adult spleen, thickened well-defined capsule with trabeculae dividing parenchyma into lobules. Characteristics of red and white pulp became more prominent.Immunohistochemical studySplenic chordal macrophages showed many immune positive dendritic cytoplasm. Sinus endothelial cells were demonstrated by their expression of the antigen. Erythrophagocytosis by rounded macrophages was seen apparently within sinuses in a fetal spleen. Scattered mid and late normoblasts with characteristic condensed nuclear chromatin were also seen in the fetal spleen. Scattered reticular fibers and white pulp with a brownish tinge suggestive of immune positivity were seen in reticular-stained specimens Figure .In later weeks of gestation, the immune positive splenic capsule was also visualized along with splenic lobulations. The fetal spleen was characterized by the presence of splenic lobule in the early stage of development (first trimester). A lightly stained "island" with a central artery was seen in the mesenchymal reticulum. These lightly stained "islands" around the central artery become more prominent with C-myc antibody stain Figure .These “islands” were surrounded by the developing red pulp with numerous venous sinuses. At some places, the basal lamina of these venous sinuses was discontinuous at some places, indicating open communication to the reticulum. The central artery in developing white pulp exhibiting relatively high endothelial cells with a continuous basal lamina was seen in the Ki-67 antibody stain. The artery was surrounded by myoblasts with large, lightly stained, ovoid, or kidney-shaped nuclei Figure .Smooth muscle similar to the bundles of myofilaments in oval or fusiform dense patches was also seen. These dense patches were more aggregated near the basal lamina between the myoblasts. Precursors of fibroblastic reticulum cells, normoblast, and thrombocytes were seen in the developing red pulp.Numerous lymphocytes were seen infiltrating and surrounding the central artery forming the PALS and surrounded by venous sinuses in CD30 antibody stain Figure .This process of infiltration obscures the splenic lobules. The trabecular arteries and veins are embedded in dense connective tissue. The periarterial lymphoid sheath has widened remarkably. An eccentric accumulation of lymphoid cells indicates the initial formation of a follicle, while the B-cell region in the white pulp can be seen.Ultramicroscopic studyThe splenic primordium was seen in the development stage of its primary vascular reticulum. It was mainly composed of mesenchymal tissue. The specific organization of the spleen was not yet identifiable. The area under the capsule was infiltrated by itinerant cells, chiefly erythrocytes, and their precursors. Whereas, the central areas were densely packed by argyrophilic reticular fibers. Mesenchymal cells were with an irregularly shaped euchromatic nucleus and had a narrow rim of marginal heterochromatin. The cytoplasm of these cells contained a few cisternae of the rough endoplasmic reticulum. The cells were interconnected by desmosomes with reticular fibers and macrophages in close vicinity.Lymphoid cells in the PALS have morphological criteria of T-cell precursors with a blunt lobular nucleus and broad cytoplasmic rim containing mitochondria, polyribosomes, and few lysosomal structures near the nuclear notch. Precursor of an interdigitating cell (IDC) was seen in the PALS. The cytoplasm was electron translucent and possessed short processes. It contained a single lamella of the endoplasmic reticulum. The nucleus showed an irregular shape and a narrow margin of heterochromatin. Follicular dendritic reticulum cell (FDRC) precursor was also seen in electron microscopy. The nuclei were elongated and irregular. The cytoplasmic processes form an interwoven root-like network Figure .Developmental changes in the microscopic features of the spleen were studied by few researchers earlier but most of them used commonly available hematoxylin and eosin (H&E) for staining purposes, moreover, a simple microscopy technique was used to visualize the structures of the fetal spleen. These are the major flaws in the detailed microscopic study of the spleen.According to Hamilton et al. , at arouFetal spleen as an active site for the production of hematopoietic progenitors and normoblasts is a matter of debate, while most of the textbooks of pathology describe the spleen of mid-gestation as a site for erythropoiesis and granulocytopoiesis. Calhoun et al.  showed tWhile in the present study, we have observed the hemopoietic cells throughout all the stages. Precursor of a fibroblastic reticulum cell, a normoblast, and a thrombocyte in the forming red pulp was seen. Precursor of a monocyte (rarely seen in the developing spleen) was also noticed. The nucleus of these cells was a kidney-shaped euchromatic nucleus with a prominent rim of marginal heterochromatin. Whereas, the cytoplasm contained polyribosomes and numerous small granules.Van Furth et al.  observedFormation of the skeletal framework of the spleen takes place during fetogenesis and it is a multistage process. Various textbooks and researchers have described the histogenesis of the spleen. According to Potter , the splAccording to Hamilton et al. , splenicIn the present study, the formation of splenic lobules was seen in the early developmental stage. A lightly stained "island" with a central artery was seen in the mesenchymal reticulum. Large cells with lightly stained nuclei were arranged around the blood vessel. Frequently, veins were associated with trabeculae within the forming red pulp. The lightly stained "islands" around the central artery became more prominent and surrounded by the forming red pulp with numerous venous sinuses at a later stage. Mesenchymal condensation forming the connective tissue and the developing blood vessels were noted in the 13th and 14th weeks of gestation, which was consistent with Vellguth et al.  and HolkSatoh et al.  describeIn the present study, splenic lobules were seen to form the primary vascular reticulum in the initial stage, followed by the blood vessels developing in the trabeculae without distinct lobules. The emergence of periarteriolar lymphoid colonization indicated the formation of white pulp. Later on, white pulp gradually grew while red pulp seemed to stop growing further. In the 24th week, white pulp occupied about 50% of the organ volume, whereas, in the postnatal spleen proportion changed, the red pulp made up more than 80% of organ volume . These fThe neovascularization of the human fetal spleen which can be grafted in splenic transplantation is crucial, as angiogenesis is mediated by fibroblast growth factors (FGF) mediated signaling pathway by stimulation of hedgehog proteins like angiotensin II. The vasculogenesis will promote the acceptance of the transplanted spleen, in patients with splenectomy. Our study also showed lymphoid colonization around the arterioles thus forming white pulp which appeared more in the first week of gestation, while in the post-natal spleen, the red pulp is made up of more than 80% volume. This lymphoid tissue found more in human fetuses will decrease the chances of graft versus host disease as the VEGF-B proteins  is responsible for the lymphocyte infiltration in splenic primordium .To date, the only in clinical trials approach of transplantation available is the transplantation of the mesenchymal stem cells but such allograft causes more graft rejection as they are cultured in vivo medium in exogenous models, so the findings of the current study will enhance the literature finding of earlier researchers regarding the future implications of human fetal splenic transplantation, in view of the appearance of angiogenesis and lymphoid aggregation in splenic primordium .LimitationsFurther studies on a large sample are required to give a significant reference dataset about the cytoarchitecture of the spleen during development. The mass spectrophotometry to compare the cytoarchitecture of the normal fetal spleen with pathological one and micrometry by image processing program such as Image J Software has to be done to show the number of immunopositivity cells in the field. Also, the grading of the immunostaining has to be performed on a sliding scale of 1+ to 4+ according to the percentage of reactive cells.The organizational changes in the splenic primordium, and microstructure of the spleen during fetogenesis are very crucial to achieve the adult morphology in feature. Histogenesis of the fetal spleen follows a multistep process depending upon the gestational age. Any deviation from normalcy may lead to structural and functional abnormality later in life. The findings on the ultrastructural organization of the splenic primordium of the fetal spleen of various weeks of gestation will be beneficial in segmental resection of the spleen as function-preserving therapy in pediatric rupture of the spleen and transplantation surgery among the pediatric age group.


The purpose was to provide insight into and knowledge on evolving knowledge fronts and to highlight the turning points in the existing literature between 1980 and 2019. Scientific literacy in society can potentially help to answer unsolved riddles of socio-scientific issues (SSI) to enable people to become smart and responsible global citizens. Specifically, two decades before and after the year 2000 was taken into account as it comprised the most noticeable revolutionary developments in terms of economics, technology, culture, and society. Interestingly, the attention paid to scientific literacy significantly increased after the financial crisis of 2008. International Journal of Science Education and the Journal of Research in Science Teaching were observed to be the top-cited and top publishing journals, respectively. Similarly, Jonathan Osborne, Rosalind Driver, and Norman G. Lederman were recorded as the most cited and most published authors, respectively, during the study period. Alarmingly, most of the literature evolved in and was dominated by the Western region, indicating the need to understand the regional-cultural complexities of the East and the rest of the world. The recent evolving clusters, with titles of literacy (as a concept), learning progression, and informal reasoning, were observed to be currently active knowledge areas in the evolution of the intellectual structure of scientific literacy-related literature. However, no recent trend or emerging research direction was noticed in the last decade, even though new and digital media (including immersive media) have revolutionized the communication channels and public understanding of science and socio-scientific issues.A holistic view of  Moreover, scientific reflects knowledge  to perform a comprehensive review of the intellectual structure of scientific literacy with the aid of available data visualization techniques; and (2) to generate a bibliometric view of scientific literacy to achieve a better understanding of the knowledge area by highlighting the dominant research contribution, authors, and countries in the literature evolution. In other words, the purpose of the study is to highlight the evolution of scientific literacy in terms of research focus (area of the curriculum) as well as the future directions (research fronts) and academic foundations  of scientific literacy.The evolution of the scientific and science literacy literature over the last six decades has left it sufficiently mature as an academic discipline and strategically valuable as a research area to strengthen the workforce, nations, and economies. Thus, the structural evolution of scientific literacy include the notable contribution of International Journal of Science Education in the growth of academic literature of scientific literacy. scientific literacy, scientific literacy and the related need of redefining curriculum. However, no initiative has been taken to examine the intellectual structures through visual citation analysis in the concerned knowledge area. Specifically, intellectual structure development comprises a four-step procedure. First, nodes (document or author) which received a citation above the predefined threshold are taken under consideration. Second, an algorithm  is applied which computes the correlation and factor analysis of co-cited nodes. Third, sub-groups  of the knowledge domain through inter-connectivity are computed. Fourth, the citation of the highly cited node within each subgroup is listed to define the nodes’ impact and magnetite in terms of influence within sub-groups  in the existing literature  the co-citation of nodes (articles and authors) using the data visualization tool (CiteSpace); and (2) the co-occurrence of nodes (countries) observed in the crawled data through the data patterns and trend identifiers (CiteSpace). In summary, the bibliometric analysis initiative reveals the intellectual bases, knowledge fronts, and dominant contributing nodes . The current study followed the methodology previously used in studies of a similar nature .scientific literacy. After reviewing the pre-analysis settings, a customized search query was used to explore and extract data from the Scopus database. The searching filter was as follows: ALL (“Scientific Literacy”), where ‘ALL’ was defined as all fields to be searched . To render the search results relevant and reliable, further filters were added to exclude all reviews (588), notes (86), editorials (85), letters (30), short surveys (18), conference reviews (7), and errata (3) as suggested by the previous studies , the University of Oslo .The current section comprises quantitative findings on 1948 authors, representing 135 countries, with 159 funding agencies and 158 academic journals observed to have participated in the evolution of the academic literature related to scientific literacy-related literature, International Journal of Science Education (498), Journal of Research in Science Teaching (321), Science Education (281), Research in Science Education (249), and Science and Education (172) were noted as the most active contributors to the literature related to scientific literacy. Interestingly, 1,521 research documents by these top 5 contributed journals comprised the subject area of Social Science (84.5%) and Art and Humanities (15.5%).While examining the contribution of journals in the growth of It is noticed that 50% of the funding institutions belong to North America. The other funding institutions include the Australian Research Council , Vetenskapsrådet (Sweden), European Commission, Deutsche Forschungsgemeinschaft (Germany), Ministry of Science and Technology (Taiwan), Economic and Social Research Council (United Kingdom), and Fundação para a Ciência e a Tecnologia  as shown in the To perform intellectual structural analysis, a co-citation analysis of academic publications and authors was performed. Moreover, the co-occurrence of country was analyzed. The intellectual turning points, most valued articles, and perdition and understanding of the existing and upcoming research fronts were usually driven by the co-citation analysis of the articles. Moreover, the micro- and macro-level structural evolution was examined through the authors’ analyses, respectively.In terms of evolution, the divergence in socio-economic environments always triggers and initiates new interdisciplinary dimensions to better understand social and economic events . The purscientific literacy, 1,648 nodes and 1907 links were identified in the examination of cited references, with the top 50 per slice being initially fixed as the selection criterion. CiteSpace usually considered the rounded shape node as a single cited entity , professional development of science teachers (in four levels), assessment of science education (in five levels), and standardization of science content. The third highest cited document is written by Science Education in Europe: Critical Reflections (co-citation=136), and they questioned science education in Europe .In ‘Next Generation Science Standards (NGSS): For States, By States’ with a co-citation count of 125. The document examined the NGSS’s consistency with the previously defined vision of K-12 science education (framework) and required changes. In the fifth position with a co-citation count of 123, another document by the Scientific Literacy/Science Literacy as a book chapter by scientific literacy by whom, for whom, and their justification of argumentation.Moreover, they proposed seven recommendations to improve science education . The fourth highly co-cited reference noted was A new dawn for Citizen Science had a co-citation count of 109. The author discussed citizen science as a strategic tool to increase public engagement, accountability, and the sense of free labor. In the eighth slot of the highest co-cited articles, a document by Interpreting pragmatic meaning when reading popular reports of Science had a co-citation count of 103. This concluded based on 91 12th grade students’ experiments that students are failing to interpret the pragmatic meaning of news reports and failing to accurately understand the scientific status in news in media. In ninth position, Argument to foster Scientific Literacy: A review of argument interventions in K-12 Science contexts, with a co-citation count of 87, emphasized the significance of scientific literacy as it provokes argument-based intervention in science education, and explained the wide spectrum of orientations while discussing the nature of argumentation. The tenth most co-cited reference is by Doulas Evaluating knowledge of the nature of (whole) science and a co-citation count of 84. He analyzed the methods to assess the nature of knowledge, with the intentions to transform individuals from declarative to functional, and interpretative into more critical with the ability to profile key information without it being stated.The seventh highest co-cited document written by scientific literacy in society; and (4) scientific literacy among students.The following portion of the co-citation investigation through CiteSpace was performed to identify the evolutionary turning points in the literature over the specified period . The nodscientific literacy. Apart from the contribution made by the highly cited contributors as discussed above, the documents by CiteSpace provides a ‘burst detection’ algorithm, which simplifies the process of identifying hotspots in the intellectual structure of the literature . In otheCiteSpace analyses helped to closely group associated cited references and identify weak bonds with less relevant members . The artscientific literacy are discussed to obtain a high-level view of the cluster analysis in an explorative manner  ‘economic productivity’ was observed, as shown in the lower-left corner of Cognition and Cognitive apprenticeship with a silhouette value of 0.822 from the year 1993 were recorded. Specifically, the prominent contributors were noted such as Rosalind Scientific Reasoning with a silhouette value of 0.810 from the year 1995. This cluster has the greatest number of cited documents by scientific literacy to enhance public understanding of science and related implications for science education.From the era of pre-2000, the clusters with the LLR label of (#4) Regarding the evolutionary timeline before the year 2000, the third biggest cluster with the mean year of 1996 and LLR (#6) Social Knowledge holding a silhouette value of 0.914 was recorded. During the cluster examination, besides the contribution by the National Research Council (United States) and Margaret Eisenhart, the research document contributed by Fouad scientific literacy. Specifically, noticeable clusters in the post-2000 era include (#1) Literacy Component, (#2) Informal Reasoning, and (#7) Learning Progression (argumentation). Scientific literacy (as a component)-related literature has had prominent contributions by scientific literacy, where he observed that K-12 students and teachers hold a weak conception of NOS, and conclude explicit and reflective instruction as the preferred way to learn conception of NOS. Moreover, the cluster also comprised the dominating work of Glen Informal Reasoning cluster is dominated by the contributions of (1) scientific literacy. (2) Learning progression (argumentation) comprises the prominent contribution of the scientific literacy to understand scientific information. Britt also mentioned the intrinsic complexity of scientific phenomena, interlinkage of different pieces of information, and rhetorical layout of the text as hurdles to learning from science-related text.Since the beginning of the 21st century, the academic literature has evolved, addressing the hurdles and barriers to strategically maximize scientific literacy since the year 1980, the most prominent researchers were Wolff-Michael Roth from the University of Victoria, Canada (68), Ingo Eilks from the University of Bremen, Germany (41), and Brian Hand from the University of Iowa, United States (39). However, during the micro-level analysis of the intellectual structure of scientific literacy, the most notable authors with the highest numbers of co-citations were Jonathan Osborne from Stanford University, United States (1058), Rosalind Driver from King’s College London, United Kingdom (958), and Norman G. Lederman from the Illinois Institute of Technology, United States (725).In terms of publishing academic literature on Through the analysis of 931 nodes and 1,611 links during the co-citation analysis using CiteSpace, Rick Bonney had a burst count of 147.42; Janis Dickinson had a burst count of 68.44; Jonathan Silvertown had a burst value of 64.16; David Layton had a burst score of 53.55, and Dominique Brossard had a burst score of 50.66. Interestingly, all the highest bursts scored by individuals emphasized citizen science, technology, and communication as shown in the table below.scientific literacy-related literature, countries and institutional participation can help to construct macro-level structures of the research field. By the country-level co-occurrence analysis of 135 nodes and 516 links, the United States was ranked first with a frequency of 4,305 and a burst value of 91.76. In other words, the United States accounted for 37.19% of the world’s co-citations during the years 1980 to 2019, followed by the United Kingdom , Australia , and Canada . Interestingly, all the dominating countries in terms of co-citation frequency started contributing to the intellectual structure of scientific literacy at the beginning of the 1980s as shown in the In the bibliometric approach to analyzing The findings conclude that in the recent decade, some of the countries which have never dominated in the literature are finally succeeding in marking their presence (in terms of burst) as shown in the table. Moreover, there are many countries from South America, Europe, and Eastern sphere of the globe which are actively contributing to the literature in recent years as shown in scientific literacy in terms of research focus (area of the curriculum) during the last 40years. The main contribution of the current document is to reveal the existing research areas (research fronts) in the discipline through the objective methodology. It further underlines new directions in academic research (by spotting the bursts) in a structured manner. After a quick overview of the intellectual structure, it can be concluded that apart from highly cited articles, documents emphasizing the importance of science and technology in society, challenging the effectiveness of education reforms, and discussing the lack of argumentation can be seen as turning points . Moreover, informal learning environments, NOS, socio-scientific issues, and citizen science (as bursts) are the most trending attributes in the literature. In terms of the cluster developmental pattern, the findings conclude that scientific literacy triggered economic productivity as a prime concern, which further provoked the research related to cognition and cognitive apprenticeship. It initiated a parallel stream of research related to informal learning, social knowledge, instrument development, and learning styles (as dominating clusters). In the present moment, literacy and its components (as concept and NOS), and argumentation are noticed as the most valuable sections of scientific literacy’s intellectual growth.The research work was conducted with the intentions to frame and highlight contributors  through a data visualization technique in the intellectual structure (cognitive structure) of scientific literacy, the current study highlights that the knowledge background of each of the dominating contributors (authors) hold different educational backgrounds. For example, Joe D. Miller and Rick Bonney are only two researchers in the list of top-cited authors whose research emphasis is public engagement, science communication as policy, and government studies. All other contributors are holding a first degree in physics, biology, chemistry, or other related disciplines. Moreover, authors who have the biggest bursts are emphasizing citizen science, science communication and the role of technology in science education, and scientific literacy. In the context of subject areas of literature evolution, the technological aspect is least observed. In other words, literary related to the technology-based environment and its role in scientific literacy is less populated. However, it has been researched that motivation to learning about science exerts a mediating effect on technology use, sponsorship of messages (scientist), and trust in the medium  holds 2,209 records . The purpose of comparing the EU and Indonesia is to predict a sudden growth in the literature, which can bring more challenges in terms of evolving new research fronts in informal reasoning, cognitive abilities, social knowledge, argumentation, instruments, learning styles, and inquiry-based learning. However, none of the new research clusters evolved in the most recent decade, and technology contributed in each of the clusters. Still, new technology in terms of media and communication is struggling to mark a distinctive cluster. For instance, only 138 documents were observed while discussing the role of Augmented Reality (AR) in the academic literature of scientific literacy. However, only 24% of them originated from North America. The purpose of arguing is to highlight that new trends and new subject areas are evolving globally. However, the origin of publication is still dominated by North America and it is significantly influencing the appreciation and future evolution of scientific literacy-related academic literature. Furthermore, it is important to highlight that 96% of scientific literacy-related literature is being produced in English (language). Authors underline that instrumental development, science communication, and scientific literacy in an international perspective holds serious challenges for effective and fruitful reforms and development as literature evolution is dominated by a limited pool of origin, language, and funding bodies.As shown in scientific literacy’s literature, regardless of research focus, which can be complementary or contradictory to the existing literature, is highly influenced by sponsors’ and authors’ contextual factors .In sum, the evolution of Although researchers have raised crucial questions for future research, the present study highlights the following trends which can be predicted in the future.scientific literacy’s instrument development in the context of formal and informal education has rarely been distinctively examined by academicians, educators, and policymakers  is needed.The role of scientific literacy be revisited in emerging economies, as it can be clearly stated that Social Influence was one of the initial research fronts of scientific literacy in the western region of the globe (the same trend can be predicted in the eastern sphere of the globe).Among the most populous regions of the globe, responsible citizens’ behavior and resilient community development are critically important. In other words, diversity of culture demands that the attributes of The technological revolution has transformed the medium of communication , its critical role in learning styles, and individuals’ cognitive abilities, while delivering and communicating NOS and concept of science (as a part of literacy components) hold potential to be game-changers in the future. At the same time, technological advancements also have a dark side, i.e., Google-effect, which is affecting humans’ cognitive abilities and argumentation abilities.scientific literacy do enhance the public understanding of science. However, there is a dearth of wanting to transform scientific literacy into scientific self-efficacy, which can bridge together the construct-level differences of Visions I and II. This transformation both in academic and policy frontiers could be smooth through the strategic use of immersive media. Furthermore, the concerned policy makers can also propose, design, and re-visit the issues related to science curriculum, public understanding, and science communication in light of an explored intellectual structure. This study concludes that in the recent slice of time, Vision II is getting more attention by academicians and dominating the literature evolution (as compared to the rest of the aspects) within the intellectual structure of scientific literacy, as observed nodes related to Vision I in intellectual structure are getting diffused with more inclusion when compared to Vision II, which directs the need and emphasis of academicians towards a scientifically literate populace. The study observed convergence of citizen science and technology-based research fronts within the literature of scientific literacy focusing on SSI . This converging trend of citizen science and technology should include other phenomena related to sustainable behaviors , which can help citizens to become smarter and responsible stakeholders of sustainable society.Moreover, the current initiative holds implications for academicians and policymakers. Noticeably, academicians can use the current research to highlight and understand the evolution of academic literature. The curriculum under the contemporary settings of scientific literacy, authors argue that domination of North American nodes  are depicting skewness in the intellectual structure of scientific literacy, which is also underlining the domination of specific cultures and regions. In other words, existing literature related to instruments of development, argumentation, components of literacy, social knowledge, and influence from the rest of the world is less observable . Moreover, in a global view, the contribution by the eastern sphere  is getting distinction in terms of scientific research studies and nation’s IQ, regardless their less significant contribution in scientific literacy’s intellectual structure. The above argument emphasizes the need to conduct cross-cultural research which can help to (re) align the construct level conceptualization of scientific literacy, and also encourage contributors from the rest of the world to participate in the literature.In terms of Victor scientific literacy is rarely observed in literature. In the authors’ view, a comprehensive framework for the active mode of communication and synchronization among educators, policy makers, and concerned public offices is needed to efficiently design, test, and deliver research-proven and standards-based science curricula. Indeed, for the prosperity and sustainable growth of our planet, scientific literacy is a threshold regarding competencies for every human. However, the ‘soft challenges’ , tangible resources , and institutional forces  have encountered a new spectrum of ‘literacy’ , opening up a large range of interdisciplinary challenges and research directions for all stakeholders in scientific literacy .Strategic stakeholder management in the case of developing The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.YL: conceptualization, funding, acquisition, supervision, and writing. MG: formal analysis, investigation, methodology, software, validation, and visualization. YL and MG: writing - review and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objective: This study aimed to systematically review the status and trends of Chinese clinical practice guidelines (CPGs) during the time period 2010–2020 and explore their methodological characteristics. Then, based on the strengths and weaknesses in development, offer several recommendations for the quality improvement which will serve as a reference for the users and developers of CPG.Introduction: With the development of evidence-based medicine (EBM), the CPGs play an increasingly important role in healthcare decision-making both in China and worldwide.Inclusion criteria: The CPGs that have been used to help the health professionals in the healthcare decision-making were included.Methodology: The China National Knowledge Infrastructure (CNKI) and WanFang databases were searched from 2010 to 2020 for the studies describing the general and methodological characteristics of Chinese CPGs. Comparisons of the methodological characteristics between the groups were conducted using the chi-square test or Fisher's exact test. The M-K test was adopted to identify the monotonically increasing or decreasing trends of methodological characteristics over the timespan.Results: A total of 2,654 CPGs fulfilled the inclusion criteria. The quantity and quality of the guidelines developed in China have improved over the time span. From 2010 to 2020,the guidelines had differing characteristics and covered a wide range of subjects. In total, 2,318(87.34%) guidelines focused on Western Medicine. Eight (0.30%) had been developed for patient versions of guidelines, 10(0.38%) were tentative guidelines, and 16(0.60%) were rapid advice guidelines. Medical specialty societies (including their branches) (71.1%) were the main guideline makers. The most addressed diseases were neoplasms (14.43%). The target population is mainly adults (84.97%). The methodological quality of consensus-based (CB)-CPGs was obviously lower than evidence-based (EB)-CPGs. Except for the item, “recommendations were based on evidence of systematic reviews,” there were statistical differences in all other methodological items between the EB-CPGS and CB-CPGS (P < 0.01). Higher methodological quality has been observed in EB-CPGs. All the data relating to the methodological characteristics indicated that higher methodological quality was present in the guidelines using GRADE (P < 0.01).Conclusion: The quantity and quality of the guidelines developed in China have improved between 2010 and 2020. CB-CPGs have also paid attention to the methodology quality, but obviously, this is lower than that in the EB-CPGs. The clinical practice guidelines (CPGs) have become increasingly prominent in clinical medicine and represent one of the most important tools for potentially improving clinical decision-making and patient outcomes , 2. TheyHowever, the previous studies assessing some CPGs in China have indicated that improvements in the quality, transparency, and usability of the guidelines are required which included identifying, appraising, and synthesizing the evidence underpinning the guideline recommendations, and paying more attention in dealing with and reporting conflicts of interest –5, 7–12.We conducted a systematic review of studies that described the general and methodological characteristics of Chinese guidelines. Reporting of the methods and findings were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria.(1) What are the general characteristics ? (2) What are the methodological characteristics which included sources of evidence, criteria for grading the quality of evidence and strength of recommendations, developing recommendations, sources of guideline funding, and conflicts of interest? (3) What are the differences in the methodological characteristics between the evidence based (EB)-CPGs and consensus-based (CB)-CPGs? (4) What are the differences in the methodological characteristics between GRADE and Non-GRADE CPGs?The China National Knowledge Infrastructure (CNKI) and WANFANG were searched for all the guidelines in China. The keywords for the searches included Chinese words for terms, such as “guidelines,” “practice guideline,” “clinical guideline,” “clinical practice guideline,” “consensus,” “expert consensus,” “expert consensus statements,” “professional consensus,” and “recommendation.” We searched for these terms in the title fields. Considering the time lag for CPGs being included in a database, the time scope of the search was from January 2010 to June 2021.We identified the EB-CPGs and CB-CPGs published in China available in the Chinese electronic databases including China National Knowledge Infrastructure (CNKI) and WANFANG during the time period of January 2010–December 2020. The inclusion criteria were: the articles were considered as guidelines if they met the definition of a guideline as proposed by the Institute of Medicine (IOM) . We clasIf several versions of one guideline existed, only the version that included the greatest detail on the guideline development methodology was assessed. If a guideline had updates, the previous version and updated version both were assessed. If one guideline was published in several parts, we merged them into one complete guideline for the assessment. The systematic reviews, editorials, translations, compilations, adaptions, interpretations, and short summaries for the guideline were excluded.First, title and abstract screening was independently performed by the two reviewers (Yan S-y and Ren X-y). Only clearly irrelevant literature was excluded at this stage. Second, for all the potentially relevant guidelines, the publications were obtained and checked for final inclusion by the two reviewers (Wang Y-y and Ren X-y) independently. Disagreement was resolved through the discussion with a third author (Jin Y-h). Any discrepancies were discussed and resolved through the consensus.Appendices by the two reviewers (Zhang R and Wang Y-y) who are familiar with evidence-based medicine (EBM) and guideline development methodology. Any disagreement was also resolved through the discussion with a third author (Jin Y-h). The variables which comprised the data extraction table included the general and methodological characteristics of the Chinese CPGs and were generated from those characteristics named in the AGREE instrument which were of interest to us. The following data were extracted to present the general characteristics: guideline title, journal name, year of publication, number of publications, update, development body , guideline classification, classification of diseases, theme , CPGs users, target population, pages of CPGs document, and number of references. The guideline classification was based on the WHO guideline classification method. The diseases were classified according to the International Classification of Disease revision 11 (ICD-11).The data were extracted using a double-extraction method from each eligible CPG and its corresponding The following data were extracted to demonstrate the methodological characteristics: multidisciplinary development teams, systematic literature searching, quality evaluation of included literature, recommendations based on the evidence of systematic reviews, clear criteria of grading the quality of evidence and strength of recommendations used, the factors  being considered in the formulation of each recommendation, clear, precise, and actionable recommendations, the level of evidence designated, the strength of recommendations presented, and the conflicts of interest declared.The definitions used related to the methodological characteristics are stated below. A multidisciplinary development team was described as a diverse group that included more than two kinds of the following representatives: relevant technical experts or health professionals, end-users, representatives of groups most affected by the recommendations, methodologists . The systematic literature searching meant accessing and searching at least four databases in English and Chinese . We defined recommendations based on evidence of the systematic reviews of the scientific literature as “at least one piece of the evidence supporting a recommendation came from a systematic review or meta-analysis.” A systematic review was described as “a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to extract and analyze data from the studies that are included in the review.”z value indicated a monotonic upward trend, and a negative one indicated a downward trend. The data were analyzed using SPSS version 22.0 , and a two-sided p-value of < 0.05 was considered as statistically significant.The characteristics of the included guidelines were recorded by two independent reviewers into an EXCEL file. Inter-rater reliability was assessed by the Kappa statistics. The characteristics were summarized and stratified by the year of guideline development. Frequency and percentage were presented for the categorical characteristics. The included guidelines were classified into CB-CPGs and EB-CPGs based on the category or were dichotomized based on whether GRADE was used. Between-group comparisons of the methodological characteristics were conducted using the chi-square test or Fisher's exact test. Mann–Kendall Trend Test (M-K test), a non-Parametric method, was adopted to identify the monotonically increasing or decreasing trends of methodological characteristics over years, a positive  were selected according to the selection criteria Between 2010 and 2020, the production of guidelines was increasing annually  guidelines focused on Western Medicine, 195 (7.35%) on Traditional Chinese Medicine (TCM), and 141 (5.31%) on the combination of Western Medicine and TCM. Eight (0.30%) patient versions of guidelines were developed. According to the WHO guideline classification method, 2,628 (99.02%) were standard guidelines, 10 (0.38%) were tentative guidelines, and 16 (0.60%) were rapid advice guidelines .In the past 11 years,1,066 (40.17%) guidelines have focused on the diagnosis and treatment, 926 (34.89%) on treatment, 211 (7.95%) on diagnosis, 124 (4.67%) on the prevention and control of infectious diseases, 68 (2.56%) on the technical operations, 62 (2.34%) on health policy, 55 (2.07%) on prevention and treatment, 50 (1.88%) on prevention, 46 (1.73%) on nursing, and 46 (1.73%) on rehabilitation  [69 (2.6%)], the medical specialty societies (including their branches) [1887 (71.1%)], the medical institutions or charities [88 (3.32%)], and other [610 (22.98%)]. The guidelines covered a broad range of diseases. The most addressed diseases were neoplasms (14.43%), followed by the circulatory system diseases (11.56%), digestive system diseases (9.23%), certain infectious or parasitic diseases (7.53%), endocrine, nutritional, or metabolic diseases (6.21%), genitourinary system diseases (5.27%), respiratory system diseases (5.16%), diseases of the musculoskeletal system or connective tissue (5.05%), and nervous system diseases (4.18%)  guidelines addressed the obstetric and gynecological patients, and 324 (12.21%) focused on newborns, infants, and children.Although the methodological quality of CB-CPGs was clearly lower than the EB-CPGs and affected the total overall quality level of the CPGs, the methodological quality of all CPGs has continued to improve steadily over time (as shown in P < 0.01) (as shown in P > 0.05). Of all the included guidelines, only three CPGs reported target population (patient) involvement in the guideline development group.The majority of the guideline developers included relevant health professionals  or technical experts, and 167 (6.29%) of guideline groups included at least one methodologist . The EB-CPGs were significantly higher for this item because the development of 10.38%  EB-CPGs and 3.27%  CB-CPGs were supported by the multidisciplinary development teams  (as shown in P < 0.05)  were based on a full literature search which included 12.24% EB-CPGs  and 4.26% CB-CPGs . It was clear that there was a significant difference between the EB-CPGs and CB-CPGs . In addition, P < 0.01).A total of 2,654 guidelines were published, with few guidelines evaluating the quality of the included literature during development which included 110 (9.76%) EB-CPGs and 16 (1.05%) CB-CPGs. P > 0.05) (as shown in P < 0.05)  of the guidelines whose recommendations were based on the evidence of systematic reviews, which consisted of 33.19%  EB-CPGs and 32.55%  CB-CPGs. No significant statistical difference was observed   EB-CPGs and 12.31% (188/1527) CB-CPGs designated clear criteria for grading the quality of evidence and strength of the recommendations. The EB-CPGs were better developed than the CB-CPGs, and there was a significant statistical difference between the two . For the past 11 years, there were 7.23%  guidelines that used GRADE methodology of which 10.65%  were EB-CPGs and 4.72%  were CB-CPGs. We analyzed information about the methodological characteristics and compared those using GRADE with those not using it to assess the certainty of the evidence and/or formulate the recommendation. Among the guidelines which used GRADE vs. those that did not, we observed higher methodological quality in the guidelines using GRADE (P < 0.01), which is shown in P < 0.05)  guidelines described clear, precise, and actionable recommendations, but only 62 (2.34%) considered the factors, such as feasibility, economy, equity, acceptability, values, and preferences of the patient in the formulation of each recommendation of which 48 guidelines considered values and preferences of the patient, 38 guidelines considered economic issues, and two considered equity issues. No GRADE evidence to decision (ETD) tool or other tools were used in the process of developing recommendations. There was a statistically significant difference between 4.88% (55/1127) EB-CPGs and CB-CPGs 0.46% (7/1527)  (as shown in P < 0.01) as shown in A total of 387 (34.34%) EB-CPGs described clear, precise, and actionable recommendations, among which 330 (29.28%) designated the level of evidence, 349 of 387 (30.97%) presented the strength of recommendations, and 300 of 387 (26.62%) presented both the level of evidence and the strength of recommendations. In addition, 366 (23.97%) CB-CPGs present clear, precise, and actionable recommendations, among which 194 (12.70%) have designated the level of evidence, 203 of 366 (13.29%) presented the strength of recommendations, and 161 of 366 (10.54%) presented both the level of evidence and the strength of recommendations. Compared with the CB-CPGs, the EB-CPGs have improved significantly in this item over the time span  of the guidelines were funded during the development; the EB-CPGs were 22.8%  and the CB-CPGs were17.75% . Most of the funding  came from the national government departments, such as 12.18% (96/528) The National Natural Science Foundation of China and 10.04% from the Ministry of Science and Technology of the People's Republic of China. In addition, 26.85% (69/257) were supported by the National Administration of Traditional Chinese Medicine. Furthermore, 0.72% (19/2654) guidelines reported that they received funding from the companies and four guidelines stated that the companies did not participate in or influence the academic content of the guidelines or the evaluation of the evidence.P < 0.01)  of the guidelines declared the result of identifying and managing conflicts of interest, which included 23.07%  EB-CPGs and 15.32%  CB-CPGs. Although all the CPGs have improved in this area of the methodological quality over the time span, a significant statistical difference still remains between the EB-CPGs and CB-CPGs EB-CPGs and 8.38%  CB-CPGs have been updated. These updated guidelines ranged from 1 to 4 times, with 203 (7.65%) updated one time, 35 (1.32%) updated two times, 14 (0.53%) updated 3 times, and 3 (0.11%) updated 4 times. The longest update interval was 10 years, the shortest was 1 year, and 150 (58.82%) guidelines were updated within 2–4 years.In this study, a large number of descriptive and analytic data were used to analyze the general characteristic information and the methodological characteristic of guidelines over the past 11 years in China. The results showed that the quantity and quality of the guidelines developed in China have improved over the time span. Compared with a previous study evaluating the guidelines from 1993 to 2010 , which was consistent with a recently published study . TherefoTo ensure the complete exploration of the status and trends of Chinese CPGs, we included EB-CPGs and CB-CPGs including all levels of developers or organizations no matter which themes the guideline focused on. This systematic review of the status of Chinese CPGs has covered a wide range of subjects, such as the general characteristics and the methodological characteristics over the past decade in China. To our knowledge, this is the first study to examine a large number of CB-CPGs by exploring their methodological quality, and it gives scientific conclusions by comparing the detailed data with EB-CPGs. Here are some suggestions for improving the quality of guidelines: (a) multidisciplinary participation, especially of methodologists, should be encouraged in guideline development and systematic literature searching should be conducted at all times in the guideline development process; (b) clear criteria, such as GRADE, for assessing the quality of evidence and grading recommendations should be applied; (c) the guideline developers especially the medical specialty societies (including their branches) should adhere to the accepted methodological and reporting standards in the guideline development; (d) conflicts of interest must be properly managed during the development of the guidelines; (e) the Editors should strictly review the quality of guidelines before they are published; and (f) the guidelines should at all times be evidence based, and consensus should just be used as a process for forming the recommendations.The systematic review has certain limitations. First, we did not use the AGREE II instrument to assess the quality of the included guidelines. Although we extracted and compared many methodological characteristics in which we were interested between the EB-CPGs and CB-CPGs, they may not comprehensively reflect the quality of the included guidelines. Second, we did not search websites of the National Health Commission or the medical specialty societies maybe leading to publication bias. Third, we defined recommendations based on a systematic review of the scientific literature as “at least one of evidence supported recommendations came from systematic review or meta-analysis.” During data extraction, we noticed that the evidence references for developing recommendations comprised a significantly different proportion of different guidelines, recommendations; with some guidelines citing inappropriate or insufficient evidence although they had cited a systematic review.This study shows that the quantity and quality of the guidelines developed in China have been improved over the time span of our study. But this is patchy across different methodological quality criteria. Although there are some obstacles to good practice that are needed to overcome in the development of guidelines, the CPGs will continue to play a critical role in helping the decision-making in the medical environment.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Y-hJ and Y-yW designed the study and formulated inclusion criteria. S-yY, X-yR, and Y-yW searched and identified eligible guidelines. RZ and Y-yW extracted important information. RZ, QH, RT, Z-rZ, and Y-hJ analyzed the data. RZ, L-xS, Y-bW, Y-qD, and Y-hJ contributed to the discussion of the findings. RZ, X-yR, and Y-hJ developed the final manuscript. All the authors have read and approved the manuscript.This work was supported (in part) by the National Natural Science Foundation of China (Grant No. 82174230) and Translational Medicine and Interdisciplinary Research Joint Fund of Zhongnan Hospital of Wuhan University (Grant No. ZNJC202016). The research funds are mainly used to provide the labor expenses of researchers and the expenses for the publication of articles.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.