Molecular cytogenetics, and particularly the use of fluorescence in situ hybridization (FISH), has allowed deeper investigation of the chromosomes of domestic animals in order to: (a) create physical maps of specific DNA sequences on chromosome regions; (b) use specific chromosome markers to confirm the identification of chromosomes or chromosome regions involved in chromosome abnormalities, especially when poor banding patterns are produced; (c) better anchor radiation hybrid and genetic maps to specific chromosome regions; (d) better compare related and unrelated species by comparative FISH mapping and/or Zoo-FISH techniques; (e) study meiotic segregation, especially by sperm-FISH, in some chromosome abnormalities; (f) better show conserved or lost DNA sequences in chromosome abnormalities; (g) use informatic and genomic reconstructions, in addition to CGH arrays in related species, to predict conserved or lost chromosome regions; and (h) study some chromosome abnormalities and genomic stability using PCR applications. This review summarizes the most important applications of molecular cytogenetics in domestic bovids, with an emphasis on FISH mapping applications.The discovery of the Robertsonian translocation (rob) involving cattle chromosomes 1 and 29 and the demonstration of its deleterious effects on fertility focused the interest of many scientific groups on using chromosome banding techniques to reveal chromosome abnormalities and verify their effects on fertility in domestic animals. At the same time, comparative banding studies among various species of domestic or wild animals were found useful for delineating chromosome evolution among species. The advent of molecular cytogenetics, particularly the use of fluorescence in situ hybridization (FISH), has allowed a deeper investigation of the chromosomes of domestic animals through: (a) the physical mapping of specific DNA sequences on chromosome regions; (b) the use of specific chromosome markers for the identification of the chromosomes or chromosome regions involved in chromosome abnormalities, especially when poor banding patterns are produced; (c) better anchoring of radiation hybrid and genetic maps to specific chromosome regions; (d) better comparisons of related and unrelated species by comparative FISH mapping and/or Zoo-FISH techniques; (e) the study of meiotic segregation, especially by sperm-FISH, in some chromosome abnormalities; (f) better demonstration of conserved or lost DNA sequences in chromosome abnormalities; (g) the use of informatic and genomic reconstructions, in addition to CGH arrays, to predict conserved or lost chromosome regions in related species; and (h) the study of some chromosome abnormalities and genomic stability using PCR applications. This review summarizes the most important applications of molecular cytogenetics in domestic bovids, with an emphasis on FISH mapping applications. The application of cytogenetics to domestic animals emerged about 60 years ago with the study of normal stained chromosome preparations from some cases of domestic animals with reproductive defects ,2,3. HowThis review summarizes the most important applications of molecular cytogenetics in domestic bovids, with particular emphasis on FISH mapping applications.The FISH mapping technique is based on two main principles: the target and the probe. The target can be a whole chromosome (or chromosome arms) or a specific chromosome region. The probe is prepared according to the size of the target and is typically: (a) cDNA ; (b) cosmids with DNA insert sizes of 20–40 kb; (c) bacterial artificial chromosomes (BACs) with DNA insert sizes of 100–300 kb; (d) yeast artificial chromosome (YAC) clones ; (e) chromosome painting probes (obtained by cell sorter or chromosome microdissection techniques) that can visualize parts of or entire chromosomes; and (f) CGH arrays to check for genomic gains or losses. The probes are labeled directly with fluorochromes or indirectly with molecules that bind to the probe via fluorochrome-conjugated antibodies. The probe is specific for the target, based on complementary DNA base pairing, which allows the fluorescence-labeled probes to hybridize and form specific fluorescent signals on specific chromosome regions.The advent of the fluorescence in situ hybridization (FISH) technique, initially applied to human chromosomes ,21, notiThe first study to apply FISH for the precise identification of the chromosomes involved in a chromosome abnormality was published by Gallagher et al. , who disA more complete classification of all chromosome abnormalities studied by classical cytogenetic techniques alone or (in some cases) with other molecular cytogenetic techniques is provided by Iannuzzi et al. .Two examples of the importance of the use of FISH for the correct identification of the chromosomes involved in chromosome abnormalities of cattle were a case of autosome trisomy and two types of Robertsonian translocations. A case of autosome trisomy 28 in an abnormal calf, revealed by both R-banding and FISH mapping with a specific molecular marker , was ideConcerning the studies on meiotic preparations, those performed on the synaptonemal complexes (SCs), especially in spermatocytes, were particularly important for establishing the regularity of the pairing processes during the pachytene substage of meiotic prophase in animals carrying chromosome abnormalities (reviewed in ). RecentFISH mapping was also very important for the definitive establishment of the agreement between various chromosome nomenclatures due to some discrepancies found during the Reading conference  and the The next advance was the application of FISH mapping by two labs that used 31 selected BAC clones (from the Texas Conference) on RBG- and QBH-banded cattle preparations . The chrThe identification of the DNA structure  paved thConsidering the practical impossibility of compiling a complete list of all gene localizations obtained using this technology, some significant examples are listed in Localization sometimes involved a single gene ,129 or aThe mapping of genomic elements by FISH has also been used successfully for the physical mapping of data obtained by other technologies. The first examples concerned the physical anchoring of a genetic map to a chromosome ,154,155 Two main methods have been applied thus far to obtain a FISH mapping comparison between related and unrelated species: Zoo-FISH, which uses chromosome painting probes, and FISH mapping, which uses specific molecular markers of both type I and type II. Zoo-FISH is a molecular technique that provides an easier comparison between related and unrelated species from a macro point of view. The term was first reported by , based oZoo-FISH was first applied in domestic animals when human chromosome painting probes became commercially available. This approach demonstrated the conservation of several human chromosome segments in both domestic bovids  and otheThe use of human-chromosome painting probes allowed the identification of a substantial number of human chromosome segments (around 50) in bovid chromosomes ,218,219.Bovinae chromosome 9 to Caprinae chromosome 14, as demonstrated by both chromosome banding and, in particular, by a molecular marker (COL9A1) mapping proximal to Bovinae chromosome 9 and proximal to Caprinae chromosome 14  is differentiated from the ancestor Bovinae X  by at least three chromosome transpositions and one inversion . Detailiewed in ,223,224.iewed in , indicatThe various FISH mapping techniques developed for human cytogenetics (reviewed by ) includeThe CGH array technology, an evolution of in situ comparative genomic hybridization (CGH), is a method of cytogenetic investigation that emerged in the 1990s to overcome the limitations of common banding cytogenetic analyses, especially those involving the presence of genomic imbalances, such as duplications or deletions ,232. In The publication of animal genomes ,149,250 The genomic sequences produced by the various assemblies can be visualized using one of the available websites available, including Genome Data viewer , UCSC GeThese genome viewers are constantly evolving and contain several tools within them that allow the user to obtain highly relevant genetic data and information. This includes, but is not limited to, the possibility of: (a) identifying the structure of genetic factors (in terms of exon–intron boundaries); (b) identifying SNP polymorphisms in a particular region of the genome; (c) identifying the position of BACs by mapping the BES ; (d) observing the genomic regions expressed in particular types of tissues; (e) analyzing the relationships between different assemblies of the same species; (f) visualizing the relationships between similar regions in different species (comparative genomics); and (g) viewing the repeating regions. In this review, we do not specify a best genome viewer, as this will often depend on personal needs and experience. However, as each genome viewer has its own specific analysis tools, sometimes the best solution is to use all three to obtain more complete information.The availability of genomic assemblages has, on the one hand, limited the interest in the physical mapping of genomic elements, but has, on the other hand, allowed the evolution of a very large number of genetic and genomic analyses. Probably one of the most common uses (even if not directly related to cytogenetics) is to design primers for use in PCR amplifications. This operation can be performed using different software, both available for free and for a fee. Among those available free of charge, the most frequently used is Primer3 . The avaSimultaneously with the publication of the genomes, bio-informatics tools were developed for the analysis of the vast amount of data generated—data that are characterized by both their great variety and their large quantity. One of the main repositories of tools for analyzing genomic data is Galaxy . This rehttps://bacpacresources.org/ (accessed on 2 March 2023)) and INRA (http://abridge.inra.fr/index.php?option=com_flexicontent&view=item&cid=17&id=61&Itemid=202&lang=fr (accessed on 2 March 2023)). Through these two institutes, BACs belonging to different libraries can be obtained.Without a doubt, BACs represent one of the most useful tools for molecular cytogenetics, and, as previously mentioned, their identification in genomes is currently greatly facilitated. However, the current situation would not be possible without the existence of two important institutions that have dedicated part of their activities to the construction, maintenance, and distribution of BAC libraries: the BACPAC Resources Center   is a metIn recent years, PCR-based methods have replaced the classic cytogenetic techniques for detecting chromosome abnormalities and aneuploidy due to greater precision, lower cost, and faster data than are possible with cytogenetic methods, because of the small quantities of DNA (30 ng) required from any stored or fresh biological samples. PCR-based approaches are most commonly used in bovid studies to examine sex chromosomes in early-sex-determination assays to detect aberrations . Telomere assessment is another critical goal of cytogenetics research due to the central roles of telomeres in chromosome stability, aging, cancer development, apoptosis, and senescence. The telomeres consist of thousands of noncoding repetitive sequences of DNA composed of six nucleotide motifs (TTAGGG)n localized at the ends of chromosomes and are responsible for maintaining DNA integrity during each cell division. They are associated with several proteins, with the most abundant being the shelterin complex, which is made up of six different polypeptides. Telomeres also contain other genomic structures, such as T-loops, D-loops, G-quadruplexes (G4), R-loops, and long noncoding RNA (TERRA) . In farm animals, telomere length (TL) did not receive much interest initially due to the difficulty in determining the natural limits of their lifespans. However, a recent study related TL to health, genome stability, and aging in cattle aged between 2 and 13 years and transformed TL into a sensitive biomarker for longevity and wellness , responding to the “One Health” approach  . TL is nApproaches for measuring TL include: (a) telomere restriction fragment (TRF) length ; (b) lenMolecular cytogenetics is approaching its first 30 years of history and during this period, it performed important functions that evolved over time. It therefore seems normal that in the coming years, we will witness further developments; however, some approaches will always be current and irreplaceable. The FISH technology represents, and will represent, the main methodology for the verification of chromosomal anomalies eventually identified with other approaches, just as the CGH array technology that will be increasingly used for the identification of genomic variants linked to a particular phenotype. Molecular cytogenetics could be very useful for the study of those species which have not yet benefited from the genomic revolution, or which are still in its early stages: in this sense, the water buffalo  is the main example. Despite possessing a great economic importance, its genome has been decrypted and made available only recently, and the application of other technologies is very late. A further gap that can be filled is the development of a technological approach that can allow the identification of all chromosomal types identifiable by cytogenetic analyses. A similar approach has already been published , but onlIn the pre-genomic era, FISH technology represented the almost exclusive technology available for the localization of genes in genomes.Prior to the availability of low-cost genomic sequencing, molecular cytogenetics was the only approach for identifying similarities between karyotypes of different species.The technologies of molecular cytogenetics represent the best approach for the characterization of chromosomal abnormalities.Despite scientific progress in similar disciplines, molecular cytogenetics will always find its place and represent an inescapable investigation methodology.The study of the chromosomes of domestic bovids is about to enter its seventh decade, and, as expected, it has undergone a notable evolution along the way. This evolutionary process for this discipline is mainly a result of the appearance of technologies that have significantly increased the potential of applied cytogenetics. Banding techniques, FISH, CGH arrays, and PCR have radically changed animal cytogenetics, making them irreplaceable tools for understanding the genetics of bred animals. Therefore, considering the history of cytogenetics, a quite easy prediction is that even the next evolutions will be dictated by technological advances. Predicting the next technological leap is difficult, but if we were to make a prediction, it would be that long-read genomic sequencing technologies will have important impacts on cytogenetics. Cytogenetics will likely retain its functionality, particularly in the confirmation of genomic results and the characterization of cytogenetic anomalies, as well as in evolutionary studies. This is because the most significant genetic mutations have accumulated at the chromosome level during the evolution of species. Finally, the implication and progresses from animal cytogenetics can be summarized as follows:


Cancer-related hypercalcemia and potential treatments” aimed to collect new advances on the management of hypercalcemia associated with malignancy. The call for submission started at the beginning of 2022 and it was closed on May 2023, finally including six papers written and reviewed by international experts in this topic .The Research Topic “Cancer-related hypercalcemia (CrH), also known as hypercalcemia of malignancy (HCM), is the most common metabolic complication of malignancies affecting between 2% and 30% of patients with cancer, with rates that vary depending on cancer type and disease stage . HypercaAlmuradova and Cicin reviewed the current literature on the mechanisms, diagnosis and management of malignant hypercalcemia. Whatever the cause of CrH, timely and efficacious treatment to control hypercalcemia is critical to minimize morbidity and time hospitalized (Almuradova and Cicin). The mainstay of therapy is represented by intravenous (IV) saline hydration and antiresorptive agents  (Almuradova and Cicin). In severe CrH , intramuscular or subcutaneous calcitonin should be added as the initial treatment, considering the faster onset of action than antiresorptive agents  (Almuradova and Cicin). However, calcitonin use should be limited to 48 to 72 hours due to tachyphylaxis (Almuradova and Cicin). In refractory/recurrent CrH on bisphosphonate therapy, denosumab should be started . Other treatment options for refractory/recurrent CrH are the following: oral phosphorus to treat severe hypophosphatemia that occurs frequently in humoral  CrH, since it binds calcium and then, in the presence of normal renal function, is eliminated and also can be deposited in bone or possibly in extra skeletal tissues ; corticosteroids work to decrease calcium likely via multiple mechanisms, and are highly effective in CrH characterized by calcitriol levels ; furosemide is suggested only in a well hydrated hypercalcemic patient receiving normal saline to transiently determine small reductions of serum calcium . When compared with denosumab, for bisphosphonates dose adjustment and longer administration time  are required in case of underlying renal insufficiency to prevent acute-phase response and worsening renal function . Furthermore, particularly when parenteral bisphosphonates and denosumab are used at an oncologic dosing frequency (monthly to every 3 months), rare but significant adverse effects, such as osteonecrosis of the jaw and atypical femur fracture, can occur .Roukain et al.). The reduction of moderate to severe hypercalcemia due to PC usually requires IV bisphosphonates or denosumab as the initial therapy ; conversely, the calcimimetic cinacalcet is started in case of mild hypercalcemia . These are practical aspects regarding the use of cinacalcet in CrH due to PC, since it often is poorly tolerated due to its gastrointestinal side effects , which are usually dose-dependent, and it has longer onset of action  than bisphosphonates. In this Research Topic there is the paper by Su et al., which is the first systematic review on diagnosis and treatment of liver metastases of PC published to date. Approximately 25%–30% of patients with PC develop distant metastases at some point in the course of the disease. The most common sites of distant metastases are the lungs (40%) and liver (10%), but PC can also spread to the abdominal lymph nodes, bones, pleura, pericardium, and pancreas in rare cases. Since most liver metastases of PC are functional, diagnosis should be suspected when serum PTH and calcium increase. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) can provide valuable support for the diagnosis of liver metastases, but whether 18F-FDG Positron emission tomography (PET)/CT, 18F-FCH PET/CT, or 11C-choline PET/CT can be used as a diagnostic tool this requires further studies. Therapy of liver metastases by PC is palliative and primarily aims to improve symptoms of hypercalcemia through surgery and/or ablation therapies.In case of CrH due to parathyroid carcinoma (PC), the first-line treatment consists of surgical en bloc resection together with the ipsilateral thyroid lobe, even in the presence of metastatic disease, once control of severe hypercalcemia has been achieved . The beneficial effect on hypercalcemia of SSAs is consequence of multiple actions, both indirect  and direct  .When CrH is associated with neuroendocrine tumors (NETs), somatostatin analogues (SSAs) can serve as a further therapy to reduce hypercalcemia, as reported by two case reports in our Research Topic (We enjoyed hosting this exciting Research Topic and we thank all the authors for their excellent contributions.LS: Conceptualization, Writing – original draft. AA: Writing – review & editing. PT: Writing – review & editing.


The number and diversity of phenological studies has increased rapidly in recent years. Innovative experiments, field studies, citizen science projects, and analyses of newly available historical data are contributing insights that advance our understanding of ecological and evolutionary responses to the environment, particularly climate change. However, many phenological data sets have peculiarities that are not immediately obvious and can lead to mistakes in analyses and interpretation of results. This paper aims to help researchers, especially those new to the field of phenology, understand challenges and practices that are crucial for effective studies. For example, researchers may fail to account for sampling biases in phenological data, struggle to choose or design a volunteer data collection strategy that adequately fits their project’s needs, or combine data sets in inappropriate ways. We describe ten best practices for designing studies of plant and animal phenology, evaluating data quality, and analyzing data. Practices include accounting for common biases in data, using effective citizen or community science methods, and employing appropriate data when investigating phenological mismatches. We present these best practices to help researchers entering the field take full advantage of the wealth of available data and approaches to advance our understanding of phenology and its implications for ecology.The online version contains supplementary material available at 10.1007/s00484-023-02502-7. The study of phenology, the seasonal timing of recurring life history events Schwartz , is incrNew sources of phenological data are opening innovative avenues for research. The digitization of museum specimens, historical records, and field data allows scientists to examine phenological events over wider geographical areas and longer time scales than have previously been possible  or combine data from different sources such as citizen science, museum specimens, and remote sensing  that synthesized decades of experience to help researchers new to the field avoid common problems when studying phenology. Working group members frequently encounter these issues when reviewing grant proposals and manuscripts, and even when reading published literature. The working group’s goal was to identify the most common challenges and suggest best practices that researchers could use to overcome these challenges. The working group identified the challenges and best practices based on (1) their own experiences reviewing proposals and manuscripts, (2) a review of the literature, and (3) input from other experts (see Acknowledgements). The resulting best practices are organized generally by activities that occur during planning and data collection (best practices 1–4) and activities that occur during data analysis and interpretation (best practices 5–10). Case studies that highlight practical use of these best practices are included as online supplementary information.Researchers often do not have control over protocols used (previously) to collect the data they analyze . Sampling protocols and effort might change over the data collection period, or metadata may lack key information. For example, exceptionally long-term records of cherry blossom festivals in Kyoto, Japan, suffer from changes in protocols and gaps in data Fig.  Arakawa. And lonWhen collecting data, it is important to follow clear and consistent protocols that are thoroughly documented, readily available, and updated as needed . Errors in recording data may occur more frequently early in growing seasons, when many observers are first learning field methods , microsite variation, the duration of particular phenophases, and extreme weather and other environmental events  should become familiar with the specifics of the data and metadata . Many invasive plant species differ in phenology from native species, leafing out earlier in the spring or senescing later in the autumn  have experienced population declines of up to 90% as a result of temperature-driven shifts in the timing of their insect prey Below is the link to the electronic supplementary material.


In 2021, Canada Health Infoway and the University of Victoria's Gender, Sex, and Sexual Orientation Research Team hosted a series of discussions to successfully and safely modernize gender, sex, and sexual orientation information practices within digital health systems. Five main topic areas were covered: (1) terminology standards; (2) digital health and electronic health record functions; (3) policy and practice implications; (4) primary care settings; and (5) acute and tertiary care settings. In this viewpoint paper, we provide priorities for future research and implementation projects and recommendations that emerged from these discussions. Currently, most digital health systems do not have the capacity to record, store, and use accurate gender, sex, and sexual orientation (GSSO) data . These oIn 2021, people who were affected by and interested in participating in modernizing GSSO data practices engaged in a series of web-based discussions with the goal of sharing the Canadian Action Plan for modernizing GSSO data in electronic health records (EHRs) . The actAlthough the sessions mentioned above took place in Canada, the digital health information systems that are used rely on international terminology standards, such as Systematized Nomenclature of MEDicine-Clinical Terms (SNOMED CT), Health Level 7 International (HL7), and Logical Observation Identifiers Names and Codes (LOINC). SNOMED CT is the most comprehensive controlled health terminology in the world and is an international interoperability standard ,17. ChanSome participants in our sessions and members of the research team were concurrently involved with the work in the HL7 Gender Harmony Project (GHP) . HL7 staFurther community consultation on anatomic and hormone inventories was identified as a priority for future research and implementation planning ,9,12,13.In discussions following this project, the Canada Health Infoway Sex and Gender Working Group (SGWG) has recommended the implementation of patient-centric anatomic and hormone inventories. This inventory approach is currently being discussed by HL7 as part of the GHP balloting process . AdditioSupport for GSSO data in additional languages other than English and perhaps extensions of terminology standards for indigenous populations were also identified as areas for future exploration.Participants noted identity verification and data prioritization as key areas for further exploration ,11. CommParticipants also wanted prioritization of data to be addressed ,11. In sMore work with digital health information system vendors to update existing systems was recommended by participants ,11. ChanFor implementation planning, participants suggested that organizations should perform environmental scans to understand what information is being collected within their information systems and how it is being used and reused within these systems ,11. ThisParticipants also noted that GSSO information modernization cannot be considered in isolation from other types of sociodemographic or clinical information held within digital health systems. Intersectionality is an analytic lens that is used to investigate structural forms of marginalization, such as race, gender, and sexual orientation ,20. A foDiscussions about reuse of data and intersectionality prompted a recommendation from participants for more consultation with affected parties regarding data aggregation versus visibility -14. HistDuring our discussions, participants noted that the variety of practices that exist in health care are dependent upon unique health care contexts. Below, we detail specific considerations for these different health care settings.For primary care settings, participants noted the variety of physical space and environmental design as concerns for GSSO data collection ,15. For For acute care settings, participants noted that the timing and place of GSSO data collection were an important implementation consideration . For exaThe use of remote health care visits requires a greater understanding of best practices for digital care and GSSO data collection and use. In a remote visit, the physical space expands to include the patient’s space, and GSSO policies and practices need to recognize this inclusion ,11. WhilIn both primary and acute care settings, participants noted that referrals may be made for additional screening, diagnoses, or treatments ,15. ThisParticipants recommended further development of use cases for intake, registration, clinical encounters, and referrals in order to understand how and when GSSO data should be collected and used -13. DataPatient portals were provided as a possible example of how patients can control access to specific information when they choose to share portal access with others. However, it was noted that policies regarding the masking of data may be particularly important for youth receiving care, as they may wish to control proxy or parental access to certain types of information within their patient portal ,15.Across the discussions, six evidence-based recommendations were reaffirmed for collecting GSSO data: (1) universality; 2) informed consent; (3) regular updates; (4) confidential processes; (5) relevancy; and (6) provider and staff training  2,22].  informed.  informModernizing GSSO information practices involves many technical, clinical, work processes, societal, and ethical challenges see . The comTechnical challenges include continuous updates to international standards and ensuring that interoperability between digital health information systems within and among organizations is promoted ,11. WhilSome of the clinical challenges that will likely arise with GSSO modernization could include creating and maintaining affirming environments and training and support for clinical staff to have respectful, safe, and meaningful clinical encounters with patients -15. ClinModernizing GSSO information practices will likely also affect work processes within health care environments along the continuum of care. Workflows should be designed with modern GSSO policies and practices for collecting or sharing information in mind ,13. ThesThis work may also pose broader challenges for health care in that it may necessitate a rethinking of the role of patients in regard to controlling their own information and the manner in which different populations are represented in health outcomes reporting ,13. In aAs with any systemic change, one must be vigilant for unintended consequences, and modernizing GSSO information and practices is no different. Our work has limitations in regard to who were invited to and who had the time and energy to participate in our meetings given individual constraints. Although our participant sample may not be fully representative of impacted stakeholders, we included all who expressed interest. While there may be an assumption that GSSO modernization will be beneficial for only some patient populations, the reality is that these types of changes will likely have benefits for all patients as they will receive more individualized care ,21.


The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation.This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals.This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated.Hospitals in SC have been increasingly participating in HIE, improving from 43% (24/56) in 2014 to 82% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals , system-affiliated hospitals , and rural referral hospitals  had higher odds to participate in HIE than their counterparts, whereas critical access hospitals  were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts , difficulty in finding patient health information , adapting different vendor platforms , difficulty matching or identifying same patients between systems , and providers that do not typically exchange patient data .HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers’ addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information. Health information exchange (HIE) has great potential to support patient transitions and achieve substantial financial and societal benefits across the fragmented United States health care system -3. AccorGiven the potential benefits, the Centers for Medicare & Medicaid finalized a rule to promote HIE and set exchanging all “necessary health information,” including courses of illness, treatment, and discharge goals, with health care providers at the next level of care as a condition of participation in Medicare ,11. AlthIn South Carolina (SC), state-level efforts to encourage HIE were funded by the US Department of Health and Human Services during this time. Building upon existing statewide data infrastructure, SC became an early adopter of HIE starting in 2008 . HoweverWe conducted a retrospective, longitudinal analysis of 69 individual hospitals in SC using the American Hospital Association (AHA) Annual Surveys IT Supplement from 2014 to 2020. This survey was sent to the chief executive officer of every hospital in the United States for completion by themselves or by the most knowledgeable person in each hospital. The AHA Annual Survey included questions about organization structure, technology adoption, and other topics about service provision. The AHA Annual Survey IT Supplement database collects data on facility-level adoption and implementation of the US Department of Health and Human Services Promoting Interoperability initiative, including computerized system capabilities, patient engagement, HIE, barriers to HIE and interoperability, and other factors . The resHospitals that responded as having participated in HIE in the previous and subsequent years but did not respond to the survey in a given year were coded as participants.Hospitals reporting no participation in the previous and subsequent years but did not respond to the survey in a given year were coded as nonparticipants.Hospitals that reported no local HIE/HIO or no participation in HIE/HIO in a given year but did not respond in the previous year were coded as nonparticipants in the previous year. For example, if a hospital did not participate in HIE in 2015 and did not report whether they participated in 2014, the hospital would be coded as nonparticipants in 2014.Hospitals that reported having participated in HIE/HIO in the previous year but did not respond in a given year were coded as nonparticipants.The final analytic data set included 69 unique hospitals, but varied by year, ranging from 56 hospitals in 2014 to 66 hospitals in 2020. In 2014, of the 56 hospitals, only 27 responded on barriers to send or receive patient health information and other barriers related to exchanging patient health information. In 2020, of the 66 hospitals, 40 responded on barriers to send or receive patient health information and other barriers related to exchanging patient health information.The primary independent variable was hospital location by rurality, categorized by Rural-Urban Commuting Area codes into urban (primary codes: 1-3) or rural (4-10). We also derived the following factors from the AHA Annual Surveys: number of beds staffed , teaching status, ownership , system-affiliated hospitals (yes or no), primary services code , Medicare payment scheme , ratio of Medicare inpatient days to total inpatient days, and ratio of Medicaid inpatient days to total inpatient days. Furthermore, we set survey year as covariate to examine annual linear trends in the proportion of HIE adoption across SC hospitals.The second outcome variable was barriers to send, receive, or find patient health information to or from other organizations or hospital systems, which was not imputed because the barriers can change over time. To capture the main barriers to exchange and interoperability of patient health information, each hospital was asked, “Which of the following issues has your hospital experienced when trying to electronically (not eFax) send, receive or find (query) patient health information to/from other organizations or hospital systems?” Per the Healthcare Information and Management System Society, interoperability is the ability of different information systems, devices, and applications to access, exchange, integrate, and cooperatively use data, while exchange is the ability to send or to receive information but not necessary to integrate and harmonize data for further use .We first compared hospital characteristics by the status of HIE participation and presented geographic distributions of HIE participation across SC hospitals in 2014 and 2020. We then conducted chi-square tests to compare hospital characteristics by HIE participation status. Cross-sectional multivariable logistic regression models clustered at the hospital level to account for repeated observations and weighted by bed size were used to identify factors associated with HIE participation across hospitals. Additionally, we calculated the frequency of hospitals reporting each barrier related to electronically sending or receiving patient health information or other financial or technical barriers to exchanging patient health information. All analyses were conducted using Stata 15.0 (StataCorp LLC).The University of South Carolina Institutional Review Board exempted this study protocol.In 2014, 24 of 56 (43%) hospitals reported participating in HIE. Private for-profit hospitals, nonteaching hospitals, small hospitals (<100 beds), non–system-affiliated hospitals, and specialty hospitals were less likely to participate in HIE than their peers. In 2020, 54 of 66 (82%) hospitals reported participating in HIE . In 2020As shown in After controlling for other hospital factors, teaching hospitals , rural referral hospitals , and system-affiliated hospitals  had higher odds of participating in HIE, whereas CAHs  were less likely to participate in HIE. Hospitals with greater ratios of Medicare inpatient days to total inpatient days or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation .In 2014, the Office of the National Coordinator for Health Information Technology launched a 10-year road map for the United States to achieve interoperability of EHRs by 2024. In this longitudinal observational study of 69 SC hospitals, we found that federal and state efforts to build an HIE system across all hospitals have been successful in SC, with over 80% of SC hospitals participating in HIE as of 2020; however, there is still a long way to go to achieve Meaningful Use Stage 3 for improved health outcomes. We also found teaching hospitals, system-affiliated hospitals, rural referral hospitals, and hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days were more likely to participate in HIE, while CAHs were less likely to participate in HIE. Yet, key barriers for effective use of HIE for patient care coordination and improved health outcomes remain, including technical, data management, and legal issues. These findings highlight the need to ensure the accuracy of patient information, standardization of health information across various systems, and training of privacy and security regulations to optimize HIE use for data exchange and patient care transition.As of 2020, although over 80% of SC hospitals participated in HIE, our findings suggest that rural hospitals experienced no greater probability of HIE participation. This might be caused by multiple barriers to HIE implementation, including challenges with reporting, workflow, and technology capacity , even with generous financial incentives . Our finMany barriers to HIE implementation and use exist. Despite the HIE functionality, we found that much critical information was missing or hard to find. For example, over two-thirds of HIE-active hospitals reported difficulties locating providers’ addresses to send and receive information or finding relevant patient health information. Even with information availability, some had difficulties matching or identifying the correct patients between health care or EHR systems. On top of the information discontinuity, technical challenges in exchanging across different vendor platforms and the fact that some providers do not typically exchange patient data with outside providers further fuel the structural obstacles to the exchange and interoperability of patient health information across hospitals. In the era of telehealth and HIE across clinicians and hospitals for optimal quality of care ,36, it iLacking provider addresses and difficulties in finding relevant patient health information were the main barriers to exchange in SC hospitals in 2014, suggesting that compatibility issues between EHRs and HIE systems are a significant systematic barrier . TechnicEnsuring usability of information in clinical decision-making and the perception of accomplishing goals is critical for ensuring the sustainability of HIE use across hospitals facing barriers to exchange and interoperability . HoweverThis study has some limitations. First, the AHA Annual Surveys IT Supplement asked about hospital-wide use of HIE via a single item, and the hospitals did not report the extent of use. About 60% of hospitals responded to items on the barriers to exchange and interoperability. Assuming that SC hospitals without HIE tend not to respond to items on the barriers to exchange and interoperability, the current state-level barriers to exchange and interoperability may be underestimated. Second, we did not have data about local HIE needs. Third, the sample hospitals that reported actively participating in HIE may not have exercised HIE to its full potential. Fourth, the AHA Annual Surveys IT Supplement did not collect comprehensive vendor-specific information, and heterogeneity of vendors was not accounted for in this study. Nevertheless, our findings have revealed vendor-specific barriers to exchange and interoperability. Future research is warranted to examine how often HIE has been used across patients or patient visits/admissions and to assess key factors facilitating the optimal use of HIE.Nearly all hospitals in SC participate in HIE. However, barriers to exchange and interoperability remain, including technical, data management, user training and support, and legal issues, highlighting a crucial missed opportunity to improve health outcomes. These findings imply the need to incentivize optimization of HIE and seamless patient information exchange across facilities by facilitating and implementing standardization of health information across various HIE systems and by training HIE stakeholders about privacy and security regulations to ensure smooth, safe, and secure patient care transitions. Future policies and efforts should promote collaborations with vendors to reduce platform compatibility issues and increase user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of patient health information.


P < 0.001; incidence rate ratio [IRR] = 0.982, P = 0.007; IRR = 0.891, P = 0.003). The results of the study demonstrated the importance of combining PHSP and telehealth postdischarge services to improve the efficiency of the health care delivery system and health equity. It is urgent to ensure that PHSs have adequate funding and telehealth infrastructure to support population health.The COVID-19 pandemic has underscored the urgency to focus on the essential value of public health systems (PHSs) in fostering health equity across the US health care delivery system. PHS integration and care coordination can be successfully achieved through health information technology systems. The objective of the study was to examine the association between PHS partnerships (PHSPs), telehealth postdischarge, and racial and ethnic disparities in health care. The analysis used 2017 Centers for Medicare and Medicaid Services Medicare 100% inpatient claims data, the Medicare Beneficiary Summary File, the American Hospital Association Annual Survey, and the American Community Survey. Results showed that compared with those treated in hospitals with neither PHSP nor telehealth postdischarge services, beneficiaries treated in hospitals with PHSP encountered significantly lower Medicare payment and inpatient and readmission rates. Black patients experienced significantly lower cost, inpatient visits, and readmission rates when treated in hospitals with PHSP and telehealth postdischarge services (coefficient = −0.051,  PHSs seek to protect and promote the “health of all people in all communities” by “strengthen[ing], support[ing], and mobiliz[ing] communities and partnerships to improve health,” as well as “build[ing] and maintain[ing] a strong organizational infrastructure for public health.”1The COVID-19 1 Numerous studies and government reports, including the CDC, the National Academy of Medicine, the Healthy People initiative, and the White House have advocated strengthening the role of PHSs.2–5In addition, the Essential Public Health Services framework's recent revision by the Centers for Disease Control and Prevention (CDC) more centrally features health equity. “Remove systemic and structural barriers that have resulted in health inequities” involves “promoting policies, systems and overall community conditions enab[ling] optimal health for all.”7 PHS's activities are more likely to reflect the community health needs9 and improve patients' trust and engagement in health care.11 Indeed, evidence has shown that integrating PHSs with the health care system can improve health care quality,12 care coordination,13 reduce health care cost,14 and reduce racial and ethnic disparities in health care15 and health.17PHSs serve as the center of community-engaged health programs and the major source of health care for underserved populations with limited health care access.During public emergencies, such as the COVID-19 pandemic, robust partnerships between health care systems and PHSs reflect the community resilience not just through resources of health care and social services but also through the trust and social networks that have been embedded in the communities for decades.18–21 The 2020 National Health IT Priorities for Research has acknowledged how HITs can improve the care coordination for vulnerable patients with complex health problems and allow providers better access to health information.22 The partnership between the Mount Sinai Health System and Contessa  shows an example of PHS integration with HIT systems. This integrated system facilitated care coordination and offered home-based care that included home health, hospitalization, rehabilitation, and palliative care at home.23PHS integration and care coordination can be successfully achieved through health information technology (HIT) systems.18 and contribute to “the Quadruple Aim of improving health care access, quality, reducing cost, and improving health equity.”24As Chen et al stated, HITs could promote “both horizontal multi-sector integration  and vertical-level integration ,”The objectives of this article are to examine (1) racial and ethnic disparities in being treated by hospitals with PHS partnership (PHSPs), HIT postdischarge functionalities, and the combination of PHSP and telehealth postdischarge services and (2) the association between PHSP and telehealth postdischarge services and racial and ethnic disparities in Medicare total payment, readmission rates, and inpatient visits. This study focused on hospital-based PHSP and telehealth postdischarge functions among the aging population.26 Given PHS's promise to reduce health disparities as well as improve care coordination and HIT infrastructures, the hypothesis is that PHSP coupled with HITs postdischarge has the potential to improve the efficiency of the health care system through care coordination and system integration and reduce racial and ethnic disparities.Hospital settings provide critical health care resources for the aging and racial and ethnic minority underserved populations. Hospitals can reduce racial and ethnic disparities by providing timely health care, identifying high-need and high-cost patients, and ensuring the continuation of health care in primary care settings postdischarge.The main data sets were 2017 Centers for Medicare and Medicaid Services Medicare (CMS) 100% inpatient claims data and Medicare Beneficiary Summary File (MBSF). These data were linked by beneficiary IDs. Using the Medicare provider IDs, the data were also merged with the American Hospital Association (AHA) Annual Survey to obtain hospital characteristics, hospital-based telehealth measures, and PHSP status. Finally, using beneficiaries' zip codes, this study linked the American Community Survey (ACS) to capture zip-code levels of social determinants of health that were commonly used in the literature.This study focused on community-dwelling Medicare fee-for-service (FFS) beneficiaries aged 65 years and older, and who had at least 1 hospital visit in 2017. Older adults with Medicare Advantage or Medicare and Medicaid dual eligibility were not included. Non-Hispanic White (White), Black, and Hispanic patients were included.Three outcomes were examined. The first 2 outcomes were created based on the measures from the Medicare Beneficiary Summary Cost and Use file: (1) the “total Medicare payments per person per year” is the summation of Medicare payments on major services, including acute inpatient, skilled nursing facility, hospice, home health, hospital outpatient, Part B physician, and Part D Medicare payments, (2) the readmission rate is the total number of 30-day hospital readmissions in the acute inpatient setting per beneficiary in 2017, and (3) the number of inpatient visits is the total number of inpatient visits per beneficiary in 2017.Hospital PHSP was measured using a dichotomous measure defined as 1 if the hospital reported a partnership with local or state public health organizations  or local or state human/social service organizations , and zero as otherwise.Hospital-based HIT measures were obtained in the Facilities and Services section of the AHA Annual Survey. A dichotomous measure of telehealth postdischarge functions was defined as 1 if the hospital adopted telehealth remote patient monitoring postdischarge services or telehealth remote patient monitoring for ongoing chronic care management, and 0 as otherwise.This study focused on whether hospitals had developed a partnership with the PHSs and whether they supported telehealth postdischarge. Hence, PHSPs and telehealth postdischarge services were cross-tabulated into 4 categories: hospitals with PHSP and telehealth postdischarge, no PHSP but telehealth postdischarge, PHSP but no telehealth postdischarge, and no PHSP or telehealth postdischarge.Other independent variables at the beneficiary level included race and ethnicity, age, gender, and health indicators. The Research Triangle Institute (RTI) Race Codes were used for the following groupings: non-Hispanic White, Black, and Hispanic patients. Health indicators included heart diseases, diabetes, hyperlipidemia, hypertension, and asthma obtained from the MBSF. Covariates at the hospital level included teaching status, type of controls , and bed size.Area level variables included rurality index using the Core-Based Statistical Areas, the US Office of Management and Budget. Also, a dichotomous measure of whether the hospital offered the telehealth service was defined as 1 if the hospital adopted telehealth consultation and office visits, eICU, stroke care, or psychiatric and addiction treatment, and 0 otherwise. A dichotomous measure for partnerships was defined as 1 if hospitals had partnerships with other stakeholders, such as nonprofit organizations, faith-based organizations, health insurance companies, or other organizations, and 0 otherwise.Consistent with the literature, the following measures of social determinants of health were included: high school education, poverty as the percentage of people in poverty level for the zip code, and the proportion of Black people in that zip code using the ACS 5-year (2011–2015) average data. Results are presented controlling for these measures of social determinants of health that had been widely used in the literature. Alternatively, models were also tested that controlled for the area deprivation index. Results were similar and available upon request.The unit of analysis was at the beneficiary–hospital level. Approximately 80% of beneficiaries visited the same hospital, 16% were admitted in 2 hospitals, 3% were admitted in 3 hospitals, and 1% were admitted in more than 3 hospitals. Beneficiary–hospital level data were created to account for situations when beneficiaries visited multiple hospitals and adjusted for the number of records in the regression analysis.Likelihoods of being treated in hospitals that have developed partnerships with PHSs and have implemented telehealth postdischarge, and beneficiary-, hospital-, and geographic-characteristics were presented and compared by beneficiaries' races and ethnicities. Multivariate regressions then were applied to estimate the associations between hospital PHSP + telehealth postdischarge and outcomes of interests. The study controlled for the beneficiary-, hospital-, and community-level characteristics already presented and applied state-fixed effect analysis in the regressions. Interaction terms were then used between race and ethnicity (Blacks and Hispanics) and PHSP + telehealth postdischarge in the regressions to test different associations by race and ethnicity.The study employed the generalized linear model with log link and gamma variance distribution to estimate the total Medicare payments and the negative binomial regressions to estimate the rates of readmissions and inpatient visits. The analysis tested different model specifications  and regressions  as sensitivity analyses. Results were similar and are available upon request. This study was approved by the Institutional Review Board of the University of Maryland at College Park.Compared with White beneficiaries, Black and Hispanic Medicare FFS beneficiaries were less likely to be treated in hospitals that provided telehealth postdischarge services . Higher P < 0.001), whereas beneficiaries treated in hospitals with PHSPs but no telehealth postdischarge services encountered lower Medicare payment .P < 0.001) and Hispanic  patients were significantly negative. The interaction terms with PHSP but no telehealth postdischarge and Black  and Hispanic  patients were also significantly negative.In the payment regression, the interaction terms of PHSP + telehealth postdischarge and Black  and readmissions .Results in P = 0.014) and readmission rates . The IRR of the interaction term between PHSP and telehealth postdischarge and Black was significantly lower than 1 , indicating a decreased risk of having an inpatient visit. Similar trends were observed in the number of readmissions .Patients treated in hospitals with no PHSP but with telehealth postdischarge, however, reported higher inpatient  cannot be neglected.Fourth, the race variables provided by the RTI were used. Detailed measures that separate race and ethnicity can be helpful to understand better the health care utilization patterns among the Hispanic population, and future studies should also include Asian and Native patients. Finally, this study focused the overall expenditures. Future studies can further examine the role of PHSP on access and utilization of primary care and preventive services and other services that target whole-person care and population health.33 use shared-risk models to urge health systems to address social determinants of health and focus on whole-person care. Such models have the potential to leverage HIT to partner with PHS to promote population health.Building healthy and sustainable aging-friendly health care structures requires population-based integrated care initiatives at the health care system level. Value-based payment models, such as the Accountable Care Organizations (ACO), and the ACO REACH,34 This ruling includes changes to advance overall value-based care on growth, alignment, and equity for ACOs, including HIT infrastructure and telehealth programs, and centers on accountable care between providers and patients. Passage of such rulings highlights increasing recognition for how shared risk models have potential for better patient care.More recently , the CMS issued the Physician Fee Schedule final ruling, which seeks to promote innovation and care coordination through the Medicare Shared Savings Program, the largest ACO in the United States.Emerging evidence shows that PHSPs can improve the efficiency of the health care delivery system and health equity. Measuring community and PHSPs can be used as one of the quality evaluations and reimbursement incentives. There is an urgent need to understand how to integrate PHSs into the health care delivery system and quantify the cost saving and any cost saving associated with reduced health disparities. It is imperative that PHSs have adequate funding and HIT support to be well prepared and positioned to respond to H1N1 (swine flu), Zika, Ebola, COVID-19, and future public emergencies.


Background: Oral submucous fibrosis (OSMF) is a chronic disorder associated with reduced mouth opening, burning sensation and listed as potentially malignant disorder. The role of mast cells in initiation and progression of this condition has been debated in last few years. It is imperative to understand the definitive role of mast cells and subsequently identify a possible cost-efficient treatment modality for OSMF. This review aimed to study the role of mast cells in OSMF by framing a research question that assessed the mast cell count (MCC), their degranulation and immunohistochemical analyses. We performed a comprehensive search of PubMed, EBSCOhost and general Google search that conceded 26 studies from which 15 articles were finalized for the review. The individual study syntheses revealed increased MCC in OSMF as compared to controls. Also, there was decreased MCC with the progression of OSMF. However, the metanalysis showed high level of heterogeneity as three studies out of eight studies found reduced MCC in disease when compared with controls. There is definite increase in mast cell in OSMF although the cell count falls with the advancement of OSMF. This increases the scope for further research to identify exact mechanism by which mast cells contribute to fibrosis and conduct the drug trials that can inhibit the mechanism. Key words:Oral submucous fibrosis, mast cell count, degranulated mast cells, stages of OSMF.Oral submucous fibrosis, mast cell count, degranulated mast cells, stages of OSMF. Oral submucous fibrosis (OSMF) is a potentially malignant disorder (PMD) affecting oral mucosa and oropharynx and is frequently seen in Southeast Asia, especially the Indian subcontinent. This condition has an obscure etiology and cannot be cured completely, only symptomatic medical management can be rendered. Nonetheless, Areca nut is implicated as the main etiological factor, areca alkaloids strongly involve in the pathogenesis of OSMF ,2. Over Sir Paul Ehrlich 1877) discovered a granular cell of loose connective tissue called mast cells; their functional behavior was almost completely linked to allergic conditions. Mast cells are bone-marrow-derived cells, and their mechanism is found to be complex, well-orchestrated, and multifunctional playing a significant role in the immune system ,7. Mast 7 discoveMast cells are strong contributors in the formation of classical proangiogenic factors like fibroblast growth factor 2, vascular epithelial growth factor, and non-classical factors like tryptase and chymase ,10. The -ObjectivesThe primary objective of the present review was to assess the relationship between mast cell density/count and OSMF. Secondary objectives included if additional parameters like micro- vessel density, stage-wise MCC analysis in OSMF, and comparison with any other PMD or oral squamous cell carcinoma (OSCC) are estimated.-PICOSThe keywords for the systematic review were defined as PICO format:i) Population: “OSMF patients”ii) Intervention: “mast cell density or count immunohistochemistry/serum analysis “iii) Comparison: “healthy controls”, “normal healthy individuals”iv) Outcomes: Assessment of MCC We constructed a primary research question using mentioned keywords: Is there any increase in MCC/density in OSMF? The secondary research questions included: a) “is there any degranulation of mast cells?’ and “is there any variation in the count with the progression of the disease”.A systematic review of data published on mast cell count and the OSMF was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.-Literature searches and Eligibility criteriaThe target population was OSMF patients who participated directly or indirectly  for mast cell counting. PubMed, EBSCOhost, and Google search engines were searched using Boolean terms “mast cell”, and “Oral Submucous fibrosis” or “OSMF”. These terms were specified to “all fields” in the Advanced Search builder for PubMed and EBSCO. The search presented 14 articles from PubMed, 7 from EBSCOhost, and 9 from Google search until December 2021. While four articles were common in PubMed and EBSCOhost searches, those retrieved from Google search were not indexed in major indexing and abstracting systems.-Data collection processThe decision to include the articles was made by reading the article title, abstract, and text containing the search terms and retrieved 26 articles for the review. The inclusion criteria were the presence of search terms, MCC performed between the study group and controls, and any additional data showing the relationship between mast cells and OSMF. The general review articles, prevalence studies, and other molecular studies on OSMF found during the search were excluded from the study.-Data extractionBoth the authors independently extracted the data from each study and included items as the first author, year of publication, staining technique, key features, and inference of the study. Further, sample sizes, means, and standard deviations values of MCCs from each selected study were tabulated. In addition, data for the expression of mast cells in various stages of OSMF, other PMDs and OSCC were recorded. Any disagreement or data extraction errors were settled by reviewing the subtleties of that specific article by following the research question, inclusion and exclusion criteria, and study results.-Quality assessmentBoth the authors critically reviewed the selected articles for clarity of focused question, selection of study populations (no. of cases and controls), and study design. Further, validation of exclusion criteria, comparison of data to establish statistical differences, and applicability of result were assessed among these studies. The relevant information collected was based on the SIGN methodology checklist version 2.0 for case-control studies (Scottish Intercollegiate Guidelines Network) .-Synthesis methodsp-value following the sixth chapter of Cochrane Handbook Guidelines  version 5.4 for academic use recommended by Cochrane Collaboration, 2020 . The staidelines .-Study selectionStudies were selected for two data sets: key salient features exhibiting search terms and fulfilling the parameters of the primary research question. Data were also extracted if the studies further addressed the secondary research questions.-Study characteristicsStudy characteristics included the presence of a comparison of MCC between OSMF and normal tissue. Additional features like comparisons of MCCs with PMDs and OSCCs were also taken into consideration.-Risk of bias in studiesMethodological assessment of studies selected as evidence was based on the SIGN methodology checklist . The che-Results of synthesesA meticulous search yielded a total of 26 articles that were scrutinized according to inclusion and exclusion criteria. We excluded six articles from PubMed , all three from EBSCOhost, and 2 from Google search as they did not match with the PICO format. Thus 15 articles were selected for final analysis as given in the flowchart   Fig. . HoweverOSMF is a chronic progressive disorder of the oral cavity, oropharynx, and esophagus which is induced primarily by betel nut through its alkaloids. The disease exhibits fibrosis that continues to cause difficulty in mouth opening, a burning sensation, and possesses high chance of malignant transformation. There are studies that have described etiopathogenesis through molecular pathways, trace elements, and mast cells ,28,30. Aet al. proposed a possible role of inflammatory cytokines that stimulate the infiltration of the mast cells disease process , histamine, and diamine oxidase. The plasma levels of these molecules can give an insight to the systematic aspect of mast cells in OSMF. Mast cells in subepithelial tissues are considered gatekeepers, the chronic inflammatory response may change them to destructors. As Pujari dalities .From this systematic review, it is evident that MCC is increased in OSMF that decreases with the progression of the disease. But the exact mechanism of action and biomolecular pathogenesis is obscure. There is a lack of data about the variation in MCC in pretreatment and post-treatment setting. Authors believe that there is a need for pre- and post-treatment studies targeting mast cells and correlating the outcomes with the MCC. Further, there is a need to understand the exact mechanism of action by mast cells in initiating malignant transformation in OSMF so that a target drug therapy can be instituted through clinical trials.


This systematic review presents clinical evidence on the association of heart rate variability with outcome prediction in intracerebral and subarachnoid hemorrhages. The literature search led to the retrieval of 19 significant studies. Outcome prediction included functional outcome, cardiovascular complications, secondary brain injury, and mortality. Various aspects of heart rate recording and analysis, based on linear time and frequency domains and a non-linear entropy approach, are reviewed. Heart rate variability was consistently associated with poor functional outcome and mortality, while controversial results were found regarding the association between heart rate variability and secondary brain injury and cardiovascular complications. Heart rate variability (HRV) is a biomarker extracted from continuous ECG analysis and used as a clinical severity indicator in several cardiac and non-cardiac diseases, including heart failure and acute myocardial infarction; sepsis and multiple organ dysfunction; renal disease; respiratory infection; metabolic impairment; as well as in patients with traumatic brain injury and some neurological disorders ,5,6,7,8.Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) are devastating diseases associated with high morbidity and mortality ,11. In pThe HRV analysis has been tested as a possible tool to assess the prognosis of patients presenting with ICH or SAH, but there is no conclusive evidence on the accuracy and value of this approach in the prediction of functional outcome, cardiovascular complications, secondary brain injury, and mortality of these patients or its association with clinical severity.The aim of this systematic review is to focus the available clinical evidence on the possible association between HRV increase or decrease with the considered endpoints in patients with ICH/SAH.The present systematic review has been carried out according to the Preferred Reporting and Items for Systematic Review and Meta-Analyses (PRISMA). The analysis has been recorded in the PROSPERO registry database for systematic reviews .Articles related to the predictive value of HRV in patients presenting with ICH/SAH were searched on PubMed and Google Scholar using the following keywords: “Heart rate variability”, “Heart rate variation”, “subarachnoid hemorrhage”, “intraparenchymal hemorrhage”, “cerebrovascular diseases”, and “outcome prediction”. The screening was extended to the references of the selected studies and considered documents published before July 2022.Studies conducted as prospective randomized controlled trials (RCT) as well as prospective or retrospective observational studies, published as full papers in English in peer-reviewed journals, with ruled participants aged 18+ years, were considered suitable for the present systematic review. Exclusion criteria included preclinical and nonexperimental studies . The disagreement over eligibility was resolved through open discussion.The following information was extracted using a standardized data extraction form: type of study, number of recruited patients, admission diagnosis , characteristics of HRV recording and analysis, and follow-up clinically recorded variables.The HRV recording and analysis methodologies varied among the selected studies, and a description of the details is reported hereafter. Differences in tested domains included an analysis of time-domain, and frequency-domain, and entropy approaches were based on the sequence of intervals between successive R peaks of QRS complexes of the ECG ,17, TablThe literature analysis yielded a total of 2000 studies, out of these 19 were selected as appropriate for the present systematic review . All theVarious aspects of HRV recording  and of the analysis  differentiate the studies selected for the present systematic review . The begThe relationship between HRV and functional outcome was analyzed in five studies ,21,22,23Cardiovascular complications, neurocardiogenic injury (NCI), and neurogenic pulmonary edema (NPE) were analyzed in five prospective observational studies that reported data from a total of 674 SAH patients, Secondary brain injury was reported in five studies on 608 patients as delayed cerebral ischemia (DCI), inflammatory cytokines production, and fever occurrence . DelayedMortality was registered in six studies—five prospective and one retrospective—on 345 patients (298 with diagnosis of SAH and 47 of ICH) ,36,37, TThis systematic review reports original clinical evidence on the relationship between HRV and functional outcome, cardiovascular complications, secondary brain injury, and mortality in patients with ICH/SAH. HRV recording and analysis were carried out with various methodological approaches, based on linear time and frequency domains and nonlinear methods. HRV was consistently associated with poor functional outcomes and mortality. Controversial results were found regarding the association of HRV with secondary brain injury and cardiovascular complications.1 receptors of the myocytes, improve the stress related response. The parasympathetic system, through the vagus nuclei, innervates, and, in particular, the atrial conduction system [The HRV is principally controlled by the dynamic relationship of the sympathetic and parasympathetic nervous systems with the autonomic nervous system . The pren system . Hence, n system  . In any case, the risk of skipping important information is limited due to the comprehensive features of the databases. Another limitation is the restricted number of keywords chosen to launch the literature search, which might have missed the examination of studies potentially related to the present analysis. The retrieved data did not allow a meta-analysis due to the limited number of studies on many issues. Moreover, the included studies present a great variance in terms of their design (prospective and retrospective) and the underlying pathology of the study population (SAH or ICH), which cannot be incorporated in a single analysis. Study endpoints also present considerable variance in terms of the time of assessment.In conclusion, the HRV seems to have promising characteristics in the risk stratification of functional outcome, cardiovascular complications, secondary brain injury, and mortality. In all the studies selected for the present systematic review, the HRV analysis was accomplished offline after recording. Future studies should be designed with an appropriate methodological approach and include an early beginning of HRV monitoring starting from patients’ hospital admission, as well as a standardized analysis of the related characteristics, such as time and frequency domains, which should be extracted in a timely manner in order to test the accuracy of risk stratification. HRV online monitoring might become a useful tool to predict the clinical course of patients with acute brain injury and could be implemented as “routine” support in clinical practice.