Osteoarthritis has the characteristics of degenerative changes in articular cartilage and secondary osteoporosis, and it is a common chronic irreversible joint disease. In addition to affecting articular cartilage, subchondral bone, joint capsule and synovial membrane also undergo pathological changes during the development of the disease. Multiple studies have revealed that patients with osteoarthritis were found to have a significantly increased risk of osteoporosis, which also contributes to the progression of osteoarthritis. However, in the current existing studies, we found that no scholars have used bibliometric analysis in the study of the relationship between osteoarthritis and osteoporosis. From the perspective of bibliometrics, this study summarizes in detail the degree of cooperation between countries, research institutions, authors, and related journals in the field of osteoarthritis and osteoporosis research and their respective influence. In this way, the evolution of knowledge structure, the change of research focus and the hot topics with research potential in the future can be further visualized and analyzed.Search the Web of Science core collection in Science Citation Index Expanded for articles and reviews of research on osteoarthritis and osteoporosis from 1998 to 2021. Bibliometric tools such as VOSviewer, CiteSpace, were be frequently used in our study. They are mainly used to analyze collaborations between countries, research institutions, and publication authors. Meantime, co-citation analysis of journals, co-occurrence analysis of keywords and subject categories will also be reflected in the study.According to the search strategy, 1,078 publications were included during the period 1998–2021. And the number of annual publications on the relationship between osteoarthritis and osteoporosis is on the rise. The United States has achieved the most and contributed the most in this field and the Boston University was the most prolific institution. For the statistical analysis of published publications, Reginster JY had the highest number of publications, while Felson DT had the highest co-citation frequency. Respectively, Osteoarthritis And Cartilage was the most productive journal in this area of research. The keywords “inflammation,” “expression,” and “mesenchymal stem cells” may also be the development trend and research hotspot of the future research direction in this field.In our study, the relationship between osteoarthritis and osteoporosis was analyzed by using literature measurement. These analysis results can lead researchers to learn more directly about the trend in this area and provide guidance for determining popular research directions. Osteoarthritis (OA) is the most common degenerative joint disease. It may affect one or more joints at the same time, including the small joints of the hands and feet and the large joints such as the hips and knees . The iniMost past studies have focused on the inverse relationship between the two diseases because they are thought to rarely coexist in a single individual , 8. But In view of the above aspects. The relationship between OA and OP has attracted the attention of many experts and scholars in this field. At the same time, as mentioned above, some scholars have noted that some common factors influence the development of the two diseases, so these insights may also contribute to the research and development of new therapeutic methods . On the Bibliometrics is an interdisciplinary subject that uses mathematical and statistical methods to quantitatively analyze the knowledge carriers of research. It is a body of knowledge focused on quantification, integrating mathematics, statistics, and documentation. At present, bibliometrics analysts such as Vosviewer  and CiteThe Web of Science Core Collection (WoSCC) is one of the important data sources for obtaining authoritative academic information around the world. It contains more than 20,000 authoritative and high-impact academic journals, more than 200,000 conference proceedings, and abstracts of more than 100,000 scientific and technological books, The Science Citation Index Expanded (SCI-Expanded) of the WoSCC has been used in the scientometric analysis because this platform provides the most comprehensive information needed for bibliometric analysis tools . To avoiThe datasets were imported into CiteSpace software first to remove duplicate data. Then relevant data including publication frequency and citation frequency, distribution of countries and institutions, all authors, funding agencies, publications, and journals, cited articles, and keywords are extracted. The journal information including impact factor (JIF) and Quartile in category  was obtained from the 2021 Journal Citation Reports. Statistical analysis was performed using SPSS20  and Microsoft Excel 2019 .Bibliometric and visualization analyses were conducted by three bibliometric tools. CiteSpace, free Java-based software developed by Chen , was vishttps://bibliometric.com/) for the country collaboration analysis.VOSviewer, another bibliometric software developed by Professor Van Eck and Waltman , VOSviewOne of the main components of Microsoft Office, Excel is a spreadsheet program [a software program that performs numerical and budgetary calculations]. It was the first Office component. Excel has built-in functions that can classify, sort and even chart large amounts of data. We used Excel to calculate the number of publications and citation frequency every year, and made the results into statistical charts to present. Meanwhile, all the tables in this study were also completed by Excel.According to the retrieval strategy, from 1998 to 2021, there were 1078 publications on the relationship between OA and OP, including 935 original articles and 143 reviews. The changes in the annual number of published articles and the frequency of cited articles reflect the development trend and the degree of research focus in this research field . As presthousand five hundred twenty six academic institutions from 66 countries have published papers in the field of research on the relationship between OA and OP. As we could see in the Scholars working in different fields have unique perspectives in their respective fields, and collaboration in this area can facilitate communication between disciplines and unleash new productivity. In addition, the analysis of co-authors helps other scholars understand existing partnerships. The same discovery of relevant contributions by influential researchers can provide authoritative information on certain research areas to help other researchers discover new directions and guidelines. 5527 authors and 19,163 co-cited authors were associated with the relationship between OA and OP. Co-citation analysis is an important part of bibliometrics, which refers to two authors/literature works that appear simultaneously in the reference list of the third literature . Co-citeFor a long time, journals have been an important platform for scientific communication among scholars in various fields. Therefore, the analysis of journal source distribution helps researchers to find the most suitable journals for their articles in a short period. According to preliminary statistics, a total of 318 journals have publications that study the relationship between OA and OP. In 1973, Small and Mashkova proposed that co-citation analysis should be used as a way to assess links between articles , 34. It In the study of scientific knowledge structure, keyword co-occurrence was an efficient bibliometric analysis method, because it can relatively accurately capture the hot areas. We used VOSviewer to extract keywords from the titles and abstracts of 1,078 papers for analysis, and 2,495 keywords were extracted, among which 167 keywords appeared more than 10 times and 22 keywords appeared more than 50 times. As we can see from In this study, we analyzed the research field of the relationship between OA and OP through bibliometrics and visualization, and comprehensively understood the change of the global research trend in this field, including countries, institutions, funding institutions, journals, authors and keywords. It is clear that the field of study has grown rapidly over the past two decades, with the number of publications increasing year by year. We retrieved 1,078 articles in WoSCC according to the designed retrieval strategy. Based on currently available information, we can infer that, as the ceaseless improvement of living levels, the increase of the average life expectancy of the world's population and in turn affected the population increase of OA , that atAs for the spatial distribution of countries and institutions, the United States, China, the United Kingdom, and Australia have played a major role in the study of the relationship between OA and OP. These four countries are the top four most prolific countries, producing more than half of all publications and leading the rest of the world. Among them, the United States, China, the United Kingdom, Australia, and Japan were the first countries to do research in this field, followed by the Netherlands, France, and Belgium. The number of articles published in Western Europe accounted for more than half of the total, 1.41 times that of North America, 2.08 times that of East Asia, and 5.37 times that of Oceania. These data indicate that Western Europe is the most active region in this field. But separately at the national level, the United States has been particularly prolific. In my opinion, the USA as the only superpower in the world has superior conditions in basic and clinical trials, and is ahead of other countries in terms of science and technology, with its professional technology and equipment, full-time researchers, and sufficient scientific research funds, so that it firmly occupies the leading position in the field of research. Of course, as the economies of Asian and European countries continue to grow, interest in this area of research increases, and research led by these countries increases, the gap with the United States will gradually narrow. In 1978, Freeman, an American sociologist, and professor, first proposed intersex centrality as an index to measure the degree to which a point is located in the “middle” of other “point pairs” in the graph . It is mIn the visualization analysis of funding agencies, in vitro. Strontium ranelate reduces the expression of biomarkers of cartilage degradation, thereby reducing the progression and clinical symptoms of spinal OA, which revealed the potential of strontium ranelate in the treatment of knee OA. Reginster JY's greatest contribution is a very detailed review of OA in disease management (For the analysis of the authors with the largest contribution in the field of OA and OP, we ranked the number of published publications and evaluated them in combination with other indicators to provide a more comprehensive perspective on the contribution of these authors , 50. Regnagement , 54, thenagement , treatmenagement –59, and nagement , carriednagement , 62, mannagement , evaluatnagement –66. The nagement –69. But Additionally, the analysis of journals and co-citations can provide information about the journals which are friendly to certain fields of study . This inThe visual analysis of co-citation can be seen in In this study, 2,495 keywords were extracted from all publications and analyzed by VOSviewer. Through the extraction and analysis of keywords, we intuitively conclude from the visualization results that keywords have diversity and variability over time. By analyzing their essence from the surface phenomenon, keyword diversity reflects the complexity of the disease mechanism. Single keywords cannot perfectly summarize the relationship of OA and OP, which indicates that the connection between them is not the connection between a single disease, and they may affect each other and form cause and effect in different development processes through various mechanisms. Mostly we found early keywords at the same time around the disease itself, from a macro level analysis of the relationship between the two, while the late keywords more and more attention to the root cause of the disease-related information, it shows that with the deepening of the research, we are no longer mere attention to appearances, gradually will focus on inflammation causes, inflammatory factors and cellular and molecular levels. As observed in Through visual analysis of bibliometrics, the structure and temporal dynamics of this field can be understood to some extent, but this study also has some limitations that are difficult to eliminate. First, the data set we included only includes data from the WoSCC database, which may leave out some relevant studies from other large databases. However, as the most used dataset in the field of bibliometrics, WoSSC also has sufficient data to illustrate the current status of the research field on the relationship between OA and OP. Second, Second, we excluded non-English language literature, so some contributions to the field using non-English language regions were overlooked. Third, since we set the search strategy until 2021 and the database is constantly updated, the impact of recent publications on the field may be underestimatedWith the help of CiteSpace and VOSviewer, we have a deeper understanding of the current status, cutting-edge hotspots, and future trends of the research on the relationship between OA and OP during 1998–2021. The United States and China are in the leading position. However, there is a lack of cooperation and communication among countries, institutions, and authors, and it is necessary to strengthen the cooperation and communication among them. According to the time variation of hot spots, inflammation, expression, mesenchymal stem cells will be the focus of future studies on the relationship between OA and OP.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.XWan and XWang designed, data analysis, interpretation, and manuscript writing. RP, CX, and WS collected the data. HZ, ZL, and HL revised and approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.


The prevalence of autism spectrum disorder (ASD) increased rapidly in the last 20 years. Although related research has developed rapidly, little is known about its etiology, diagnostic marker, or drug treatment, which forces researchers to review and summarize its development process and look for the future development direction.We used bibliometrics to analyze papers of ASD in the Web of Science from 1998 to 2021, to draw the network of authors, institutions, countries, and keywords in the ASD field, and visualize the results.A total of 40,597 papers were included with a continually increasing trend. It turns out that the research on ASD is mainly concentrated in universities. The United States has the largest number of ASD studies, followed by England and Canada. The quality of papers related to ASD is generally high, which shows that ASD research has become a hot spot of scientific research. The keywords of ASD etiology and diagnostic markers can be classified into at least 7 aspects. The detection of keywords shows that ASD research is mostly based on its subtypes, takes children as the study population, focuses on neurodevelopmental imaging or genetics, and pays attention to individual differences. And ASD research has changed greatly under the impact of Corona Virus Disease 2019 in the past 2 years.We consider the future development direction should be based on the improvement of case identification, accurate clinical phenotype, large-scale cohort study, the discovery of ASD etiology and diagnostic markers, drug randomized controlled trials, and telehealth. Autism spectrum disorder (ASD) is an early-onset, chronic, and heterogeneous neurodevelopmental disorder characterized by social and communication disorders, a narrow range of interests, and restrictive, repetitive, or stereotyped behavior . It inclNearly three-fourths of ASD patients have more than 16 medical, mental, or neurological diseases, such as attention deficit hyperactivity disorder, intellectual disorder, self-injurious behavior, and sleep disorder, making it the main cause of mental disability in children under 5 years old , 10. In Although the prevalence of ASD is increasing gradually, ASD is still one of the frontier problems in scientific research, especially etiology research.Quantitative analysis of ASD research results, combing the historical development of ASD research, analyzing the research hotspots of ASD, and exploring the high studied etiology and diagnostic markers of ASD have some enlightenment for predicting its research trend. At present, bibliometrics, combining mathematical and statistical methods, can evaluate the current situation and future research trends in a field and can guide the follow-up research work . The CitThe article data comes from the science citation index expanded (SCI-E) database on WoS. We searched the WoS with the method: TS = , and the time is from the establishment of the database to December 31, 2021 . As for the types of articles, we include reviews and articles and exclude meeting abstracts, letters, book reviews, etc. We used the CiteSpace 5.8.R3, and set link retaining factor = 2; Look Back Years = 8; Year Per Slice = 3; Selection Criteria = Top50; Prunning method: pathfinder, pruning sliced networks, and pruning the merged network. We used the VOSviewer 1.6.18 to analyze the keywords, and we selected the first 1,000 keywords as our analysis objectives to study the etiology. And we analyzed the diagnostic markers with the same method. The bibliometrics research process is shown in Analyze the change in the number of articles published in the ASD field over time, which represents the degree of attention in this field to a certain extent;From micro to macro, analyze the authors, institutions, and countries in the field of ASD, which reflects the research characteristics of individuals, institutions, and countries in this field to a certain extent;Analyze the journals and references published in the ASD field, which reflect the quality or attention of research articles in this field to a certain extent;Keywords were carried out to analyze the key research directions in this field since 1998, and we focused on the etiology and diagnostic markers of ASD. Keywords with the strongest citation bursts detection were carried out, which can reflect the changes in research hotspots in a certain period;Based on the above analysis, this paper attempts to predict the trend of follow-up autism research.A total of 40,597 articles were included in this study, including 33,489 articles and 7,108 reviews. According to the publication of ASD-related papers The CiteSpace can analyze the cooperation network among authors, institutions, and countries. In the network, each node represents an individual, the size of the node represents the number of individual papers, the connection between nodes represents the cooperation relationship between individuals, different colors of nodes or connections represent different years, and the color from cold to warm represents the year from far to near. The purple nodes in the outer circle of the network represent the most important nodes, which have centrality > 0.1 .molecular psychiatry, biological psychiatry pediatrics, proceedings of the national academy of sciences of the united states of , pediatrics, autism research, etc. The average impact factor is 6.2. We screened all the keywords and got 239 keywords related to the etiology of ASD. We tried to classify these keywords, and found that the etiology of autism involves genes, structural and functional of brain, neurons and related neurotransmitters, immune inflammation, metabolism and nutrition, environmental and social psychological, prenatal exposure, and others The research papers on ASD have increased by more than 20 times in the past 20 years. There is a large amount of financial support and social attention for ASD. For example, since the 21st century, the USA has promulgated several bills to protect the rights and interests of ASD patients. In 2000, The Children's Health Act of 2000 mandated and the National Center on Birth Defects & Developmental Disabilities was established to promote the etiology, diagnosis, and treatment of ASD. In 2006, the Bush administration promulgated The Combating Autism Act, the first law for ASD patients, and spent $945 million on ASD research, treatment, and education within 5 years, which ended after The Autism CARES Act in 2014. In 2007, Congress promulgated a bill on expanding commitments to ASD patients, proposing to provide $83 million for services for ASD and their families in 2008. From 2007 to 2010, many states in the USA successively legislated to require insurance companies to include the treatment and intervention of ASD into the insurance liability, and some states legislated to make sure ASD patients were protected by the mental health laws on a non-discriminatory basis. In addition, the USA has stipulated the rights and interests of ASD patients in many laws, such as the American with Disabilities Act. The network analysis of countries/regions also shows that the USA has the largest number of outstanding published papers in the field of ASD, which is inseparable from the huge financial support of the USA for ASD. Legal support related to ASD has also been provided in China. For example, the China Disabled Persons' Federation included ASD patients in the category of disabled persons and let them enjoy corresponding rights and interests in 2004. The State Council of the People's Republic of China (SCPRC) stressed the rights and interests of ASD patients to receive education in 2009. The Guidelines for Diagnosis, Treatment, and Rehabilitation of ASD were issued to improve the level of diagnosis and treatment for ASD in China in 2010. In 2014, the SCPRC asked each city to help ASD patients with clinical diagnosis and treatment, infrastructure, and education. For the research on ASD, the National Natural Science Foundation of China has funded more than 3,000 projects since 2010, with a total amount of more than 1.6 billion Chinese Yuan.Science elaborated on the dilemma and frontier of ASD etiology research, which attracted the attention of society and researchers. The famous professor Zheng Yi from China was also invited to interpret it and put forward deep opinions on its future development direction  underlie Fragile X Syndrome, which is the most known genetic monogenic cause of ASD . TherefoAccording to the detection results of keywords with the strongest citation bursts , the resBefore 1998: As early as 1926, Grunya Efimovna Sukhareva  from theThe theoretical explanation of ASD etiology also experienced a long development before 1998. In 1949, Kanner described the parents of children with ASD as compulsive, perfectionist, and lacking a sense of humor. He pointed out vaguely that the severe stress suffered in the early stage, such as parental discord, separation, or mothers' depression, is related to autism. Bruno Bettelheim also believed that autism was not born but caused by the mothers' estranged based on his experience in Nazi concentration camps . This th1998–2009: Since Leo  put forw2010–2018: This stage is different from the research before 2010 in all aspects. The generalization of new ASD diagnostic criteria in 2013 reduced the research on ASD subtypes to a certain extent, which can also be seen in After 2019: ASD patients usually suffer from comorbidities including insomnia, anxiety, depression, attention deficit hyperactivity disorder, self-injury behavior, etc. . During ASD patients generally have gastrointestinal symptoms such as diarrhea, abdominal distension, abdominal pain, and constipation , and theThe treatment of ASD is still based on education and behavior training, but there are many candidate drugs for the treatment of ASD in recent years. In 2010, Lemonnier and Ben-Ari  reportedSince Leo Kanner published the case report on early-onset infantile autism in 1943, ASD research has a history of more than 70 years. Although we still know little about its etiology, diagnostic markers, and drug treatment, the increasing ASD research and the introduction of new research methods such as gene research and intestinal flora still make the ASD research develop gradually and have a promising prospect. Combined with the development track of ASD research and the analysis of CiteSpace, we believe that ASD will have such a development trend in the future:a. Improvement of case identification and accurate clinical phenotype: there is no doubt that the diagnostic criteria of ASD are gradually improved from DSM-II to DSM-5. ASD is a pedigree disease rather than a continuum of severity is undoubtedly the result of an in-depth understanding of ASD, which leads to more cases being included in the clinic. However, this diagnosis increases the heterogeneity of the ASD population to some extent, so it also hinders the study of ASD. At present, some researchers  try to ib. Carry out cohort research in combination with genomics and neuroimaging: it is necessary to prospectively adopt larger-scale sequencing technology, behavior, and MRI research for high-risk people with ASD with early medical risk (such as premature birth) or specific genetic background. For example, the Autism Phenotype Project. These measures are of great significance for the study of its etiology and diagnostic markers.c. Treatment: Although there are many disputes about ASD candidate drugs such as oxytocin and bumetanide, as Professor Daniel pointed out , studiesd. Telehealth: In view of the influence of the COVID-19 on ASD patients and caregivers, it is necessary to consider continuous isolation management or public health emergencies. When telehealth becomes the necessary choice, we need to objectively evaluate its reliability, effectiveness, and acceptability in ASD diagnosis and treatment guidance.This study conducted a comprehensive bibliometric analysis of articles in the field of ASD and analyzed the changes in ASD research in three stages. However, this study has some limitations that need to be solved. Firstly, Because of the limitations of the software, we only analyze English articles in the WoS database, which may lead to language and publishing bias. Secondly, the software is mainly used for statistics and visualization, and our discussion on the future may be insufficient.The original contributions presented in the study are included in the article/PR and RM contributed to the conception and design of the study. XZ, HL, and SZ collected data from the database. PR, QF, and XS wrote the first draft of the manuscript. PR, QF, and PG wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.This work was supported by the National Natural Science Foundation of China (No. 82174439) and the Program for Qi Huang Scholar (RM) in State Administration of Traditional Chinese Medicine.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.


He was one of three co-editors of Baja's Principles and practice of surgery, including pathology in the tropics”, which is popularly referred to as ‘BAJA’ after the initials of the editors' surname Professors EA Badoe, EQ Archampong and MOA Jaja. This textbook is a pre-eminent source of information for generations of medical undergraduates, postgraduates and surgeons, especially in the tropics. He was the Dean of the University of Ghana Medical School from 1984 to 1994 and President of the West African College of Surgeons from 1997 to 1999.He was the Editor-in-Chief of the Ghana Medical Journal from 1973 to 1979. Before this time, he was the Assistant Editor from 1969. These years were difficult in Ghana's history, with military coups, uprisings, and social and economic challenges. This period also witnessed tension between professional groups and the military government of the day over the concept of “Union Government”, which proposed to make Ghana a non-party state. Professor Archampong managed the journal successfully and achieved regular publications. During these difficult times, he was promoted to Associate and Full Professor in 1976 and 1978, respectively. In addition, he obtained a Master of Surgery degree (M.S.) from the University of London (1974) by thesis and was awarded the Fellowship of the International College of Surgeons (USA) in 1975.Professor Archampong excelled in his many spheres of endeavour, receiving academic, national, and international awards.He was a recipient of the National Honours of the Republics of Ghana and Senegal. He was considered an astute administrator with a friendly posture.Professor Archampong will be remembered as an icon in the medical profession, a great teacher, an example of dedication to duty, family, and a Christian gentleman.th December 2021 after a well-attended burial service that included the President and Vice-President of the Republic of Ghana.Professor Archampong was laid to rest on 16May he rest in peace.Editorial OfficeGhana Medical Journaleditor@ghanamedj.org


With a year’s delay caused by the Sars-CoV-2 pandemic, the conference series produced by the International Society for Applied Biological Sciences  is reaching its first quarter-century -5. DurinMayo Clinic Short Course in Epigenomics. Here experts, mostly from the Mayo Clinic College of Medicine and Science in Rochester, Minnesota, cover the essentials of epigenomics: fundamental mechanisms underlying the regulation of gene transcription, the molecular basis of epigenetic control, epigenetic states and inheritance, epigenetics in the laboratory, and epigenetics in medicine. This is followed by the pre-conference practical Interdisciplinary Session of the American Academy of Forensic Sciences and ISABS 2022 and ISABS and The Ministry of Interior's Training Course: “Mystery on the Ship – Investigation of Water-Related Crime Scene.” The American Academy of Forensic Sciences and ISABS 2022 session focuses on standards development and progress of the Academy Standards Board, application of ancient DNA methodology in degraded forensic samples, forensic training in crime scene investigation, and aquatic death and dive accidents.The conference is preceded by the In keeping with tradition, the inaugural morning of the conference on June 22 starts with keynote lectures representing the fields covered by the conference: medicine, anthropology, and forensics. Subsequently, yielding to the urgent issues of the time, an afternoon parallel session deals with anthropology and global health in the time of crisis. It focuses on integration of global health, effects of the pandemic on global development, and data management for evidence-based response to the Sars-CoV-2 pandemic and other topics. The other parallel session covers selected topics on the role of genetic variation in disease, forensics, and anthropology.The second day continues with anthropological aspects of global health in the time of crisis covering dietary adherence, the role of sex and geography in COVID-19 variation, etc. A parallel session covers issues of integrated high-definition omics: role of machine learning and artificial intelligence in therapy development, single-cell transcriptomics, and others. This is followed by the already traditional session where Nobel laureates address major issues of our time. This year the speakers are Aaron Ciechanover , Sir Richard John Roberts , and Thomas Südhof . They will address the ethical issues inherent in curing and preventing of pandemics (Ciechanover), the use of biotechnology in combatting hunger and climate change (Roberts), and biological aspects of Alzheimer’s disease (Südhof). This year, the third “Nobel Spirit” will provide the forum to the three Nobel laureates to stimulate public discussion on the role of science in solving global health issues, acute regional problems such as brain drain, demographic decline, as well as cultural and social change.The third-day morning is dedicated to topics from anthropological genetics such as studies of ancient DNA preserved in sediments, a new development in Neanderthal genetics, and others. A part of the day is dedicated to the advancements in osteoarthritis. The second part of the day presents the talks on multi-omics of common and rare diseases as part of the program on individualized medicine.The morning of the fourth day of the conference investigates forensic genetics cases from the one of the notorious Kaspar Hauser to the Romanov family, 9/11 victims, and more. The afternoon revisits individualized medicine through topics from epigenetics to sensitizing cancer cells to DNA damage-inducing agents, anti-tumor immunity, and others. The day ends with the evening address on creativity and artificial intelligence by Gary Kasparov, the unsurpassed former world chess champion and prominent human rights leader.The final day of the conference returns to epigenomics in its interdisciplinary applications. Examples include the use of multi-omics in revealing therapy targets, circadian rhythm, and impact of disordered metabolism in diabetes, epigenetic signatures of psychosocial stress and trauma, and more. The conference will end with the session on the genetics of COVID-19 and pandemics such as the Black Death, as well as other topics.This year’s conference is the first without Moses Schanfield, whom we lost last year . TogetheThis year again, program directors Tamás Ördög and Manfred Kayser invested their creative energy, effort, and time to compile a stellar program. Kudos should be addressed to them; shortcomings and complaints should be addressed to us.


Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, studies have shown that this disease has affected the male population on a significant scale in various parts of the world, making men one of the main risk groups. To analyze the clinical and epidemiological characteristics and experiences of illness in men with COVID-19. A mixed sequential-explanatory study with cross-sectional and exploratory-descriptive approaches. Data was collected from a small municipality located in the central-north region of the state of Bahia, Brazil. Primary quantitative data was extracted from compulsory notification forms from 598 men. Qualitative data from individual interviews of 30 men was analyzed by the Discourse of the Collective Subject method. The findings identified the characterization of reports of suspected and confirmed cases of COVID-19 in men, the organization of the healthcare system, and strategies for the control and combat of COVID-19 directed towards the men of the investigated municipality. They revealed the clinical characteristics based on the collective discourse of men with COVID-19. In men, the individual experience of disease explicitly explains the clinical markers of COVID-19 expressed by the self-reported syndromic approach. Additionally, this understanding also explains the behaviors observed in their search for health care, as well as the adoption of prevention and control measures and therapies recommended by health professionals. Among the population that progressed to a picture of severe acute respiratory syndrome (SARS) caused by COVID-19, until the epidemiological period from February 21st to 27th, 2021, 62,613 cases were registered, with 54.5% of these cases comprising men. The most affected age group from this population was between 60 and 69 years, with a total of 24,775 cases (21.6%). Regarding deaths caused by SARS due to COVID-19 in Brazil, during this period, 16,444 (54.3%) were men, with the most affected age group between 70 and 79 years old, with a total of 7,717 (25.5%).,Several reasons have been suggested in the literature for the difference between sexes in the presentation of COVID-19, which indicate that being male is a risk factor for the new disease. Among these reasons, the influence of hegemonic patterns of masculinities was highlighted. This legitimizes the dominant position of men in society, which can contribute to the neglect of health care, and the disregard and disrespect for measures to prevent and control the transmission of SARS-CoV-2.,There are also factors related to habits such as smoking, abusive consumption of alcohol and other drugs, sedentary lifestyle, and clinical conditions, such as the presence of chronic diseases which occur more often in men. Moreover, new causes have been recognized with the arrival of the pandemic, namely hormonal factors related to testosterone,,Another relevant aspect to be considered that has also been occurring in the context of the pandemic, is that a large proportion of the male population delays searching for healthcare services.When considering the presence of a gap in scientific knowledge in the difference in disease presentation based on sex and gender, and given the clinical and epidemiological context of men with COVID-19, the combination of quantitative and qualitative approaches used in this study is justified. A joint study may contribute to a broader interpretation of the investigated problem, providing better evidence for best practice care for men with COVID-19.To analyze the clinical and epidemiological characteristics and experiences of illness in men with COVID-19.A mixed methods study, with sequential-explanatory type from a transverse and analytical study, and an exploratory-descriptive research with a qualitative approach. In this study design, the quantitative approach was developed first and had the greatest weight; that is, it is the priority stage of the research. Next, a qualitative approach of secondary weight and complementary character was developed. Quantitative data were extracted from COVID-19 compulsory notification forms. Individual interviews were conducted at the qualitative stage. Thus, the data collected in the quantitative stage led and directed the data collection of the qualitative stage,The study population consisted of suspected cases of infection with the COVID-19 in men, notified to the municipal epidemiological surveillance, from February to December 2020.Suspected cases of COVID-19 infection were individuals with an acute respiratory condition, characterized by at least two of the following signs and symptoms: fever (even if referred), chills, sore throat, headache, cough, runny nose, olfactory disorders, or taste disturbances.The study excluded males who passed through the city, were suspected, or were assisted/notified during the data collection period.The quantitative sample consisted of 598 men, notified as suspected cases of SARS-CoV-2 infection from February to December 2020. The qualitative sample consisted of 30 men with a confirmed diagnosis of COVID-19 presenting with symptoms. The men included exclusively accessed the Municipal Center for Coping with COVID-19 and sought care. In addition, we sought participants who only accessed the service to ensure greater sample specificity, considering that it is a rural municipality, with habits, customs, and health behaviors that may have influenced the way they experienced the disease. The municipal health department, epidemiological surveillance sector, and participants agreed to access the data contained in the medical records.Data were collected in the municipality of Quixabeira, Bahia, Brazil, from October to December 2020. During this period, the municipality had 598 notified cases, diagnosed using reverse transcription polymerase chain reaction (RT-PCR) (311 cases) or rapid tests (87 cases). At the end of that period, seven cases were still under monitoring, awaiting test results. Of these, 121 cases were positive: 77 (63.6%) were women and 44 (36.4%) were men. The municipality registered three cases of clinical admissions in a reference emergency care unit, one case of hospitalization requiring assistance in the intensive care unit, and no confirmed cases of death during the investigated period.Excel spreadsheet, and manipulated for structuring the bank, checking for incompleteness and duplication. In the second stage - the qualitative stage - individual in-depth interviews were conducted with the participants.Data collection was conducted in two stages. The first - the quantitative stage - was based on data from the Municipal Epidemiological Surveillance, obtained via access to primary data from the Ministry of Health records of “compulsory notification forms of suspicious of coronavirus disease 2019 - COVID-19 Flu-like Syndromes.” The data were exported from the Google Forms application to an The interviews were conducted by a single interviewer researcher and were audio-recorded in a single meeting, with an average duration of 30 minutes. They were previously scheduled under the support of the Epidemiological Surveillance service and the team of the COVID-19 Combat Center of the investigated municipality. Interviews adhered to health protocols and ensured the safety of the participants and the research team. Additionally, patients were later re-evaluated by a medical professional and given a diagnosis and cure for the disease. Participants were intentionally selected based on the indication of professionals from the Epidemiological Surveillance Service and the municipal COVID-19 Combat Center. An unstructured script was used for the following open questions: Tell us how you experienced the impairment caused by COVID-19? How does COVID-19 manifest clinically? This management was conducted using data surveys in the quantitative stage.For data collection, notification forms were accessed from the health surveillance department after prior authorization. Then, data from the forms were read, organized, and encoded in a spreadsheet in Microsoft Excel application, version 16.0, developed by Microsoft , and submitted to processing in the Statistical Package for Social Sciences (SPSS) software, version 23.0, developed by the International Business Machines Corporation (IBM) .After collecting the qualitative data, the narratives were read line by line, and the data were systematized and coded with the support of NVIVO12 software developed by QSR International . COREQ guidelines were followed to ensure the quality of the qualitative data. The analysis of narrative data was performed using the Discourse of the Collective Subject (DCS) technique,DCS is a category of exposure to the results of qualitative research, with testimonies as raw material, in the form of one or more synthesis speeches written in the first person of the singular. This method consists of pointing out, from each answer, the KEs, which are the CIs of the discursive content expressed by the interviewees.After the analysis of the quantitative and qualitative data, a combination of the data was conducted through the connection and integration of the results. Thus, additional information on the study objectives was identified.Since this research was conducted in the context of the still-in-progress COVID-19 pandemic, ethical requirements in research were fulfilled, which involved biosafety to preserve the participants and researchers. The interviews were carried out with the researchers duly dressed in compliance with social distancing. The application of the Free and Informed Consent Term was associated with the dispensing of alcohol gel and disposable tissues to access the pens made available by the researchers.The study was approved by the Research Ethics Committee (CEP) of the Universidade Federal da Bahia (UFBA) under Opinion No. 4,087,611 on June 15, 2020. Furthermore, we obtained authorization from the Municipal Health Department and Municipal Health Surveillance Department of Quixabeira to access notification forms and patient records.The first part of the results, derived from notifications, describes the clinical and epidemiological characteristics of men with COVID-19. The second part presents data from patient records, relating to clinical and epidemiological features and the control and combat strategies for COVID-19. Finally, the third source of data presents the clinical characteristics from the collective discourse of participants, retrieved from interview audio..This study included 515 reports of suspected COVID-19 infections in men living in the municipality. As shown in ..As shown in ..Data analysis showed that 20.6% of cases were notified eight days or more after the onset of symptoms, causing delays in the surveillance process and possibly in the medical care of these patients. As shown in ..The results also showed that death occurred in older men (≥ 60 years). The men kept in home care, who were negative for COVID-19, had an average age of 19-24 years. Reports of young teens and adult men who had confirmed COVID-19 infections predominantly progressed to cure .The secondary Qual stage of the study involved data from 30 interviews with participants in the first quantitative stage, which was explained in the form of discourse synthesis. Its respective CIs were framed, theoretically, from the fields/variables that make up the “compulsory notification forms of suspicious of coronavirus disease 2019 - COVID-19 Flu-like Syndromes.”Narrative qualitative data presented in the form of DCS of participants were retrieved to further investigate the clinical and epidemiological male health from the perception of users. The following illustrates a Discourse-Synthesis composed of a CI of representation of the collective as a whole regarding the clinical characteristics and experience of COVID-19.The male collective discourse revealed that the clinical characteristics of COVID-19 are demarcated by the presentation of nonspecific symptoms. However, the disease presented its course with clinical characteristics of classic symptomatologic evolution, progressiveness, and worsening of the health status and clinical picture.The clinical trajectory of participants involved access to diagnostic and therapeutic intervening resources used by health professionals, such as nursing technicians, nurses, and doctors, of specialized units for the treatment of disease and subsequent obtention to improve and present complications and/or sequelae. To illustrate the integration of the results of the study, The analysis of clinical and epidemiological characteristics is essential for the planning and execution of strategic and programmatic actions to promote men’s health and prevent diseases and conditions, especially in critical and complex contexts, such as pandemics. Although the clinical findings have indicated satisfactory clinical outcomes - reduced mortality and high cure rate, assuming mild forms of the disease in the investigated period, the data indicate a growing number of investigated cases. This represents the Brazilian and international scenario and indicates that men are more vulnerable to infection and suffering from COVID-19 and are worthy of attention from health professionals and managers.Understanding the clinical and epidemiological characteristics of the male public in research on COVID-19 contributes to the early identification and overview of the reasons that indicate why men are getting sick. The discursive findings reported by men strengthen the understanding of health and disease, the experiences of the patient, the clinical pathways, the therapeutic itineraries, barriers and critical routes adopted by men, and weaknesses in healthcare in the pandemic context, which makes it an effective integration methodology to be employed in the production of evidence for the planning and management of healthcare.-Unlike the findings in our study, the clinical profile of the male population with COVID-19 has indicated a high number of complications resulting from impairment by severe forms of the disease, greater need and length of hospital stay, development of SARS, and death. In our study, young adult men and those with self-reported mixed race/color were the most affected by COVID-19. In the investigated period, vaccination had not yet started in the city, which implies greater exposure of the target population, mainly because in Brazil, the vaccination schedule for COVID-19 includes the young adult population at non-priority levels. Regarding this difference in the clinical-epidemiological profile, epidemiological bulletins in Brazil pointed out in 2020 the impairment of older men, especially in cases of SARS.However, a focused study had already shown a growing number of severe infections in younger men with an average age of 40 years The work environment and occupational relationship of men who were diagnosed with COVID-19 showed a significant relationship with infection. According to the qualitative findings, this may indicate weaknesses in the adoption of individual and collective protection measures, the low quality of personal protective equipment in work environments, and vulnerabilities in access to work, such as in the use of public transport, in addition to failure of institutional protocols for disease prevention and control, as indicated in the literature on the subject.Regarding compulsory notification of the disease, the full completion of notification forms is extremely useful in the assessment of groups at higher risk, which could be prioritized in actions to combat and control the epidemic in states and municipalities. Such professional action in health is legally required throughout the Brazilian territory and, through the Epidemiological Surveillance Service, allows the monitoring and follow-up of cases. In addition, it presents a panoramic status of active, suspected, under treatment, cured, and death profiles.Many small municipalities have greater difficulty carrying out epidemiological surveillance actions because of structural limitations and the small number of professionals involved in the health surveillance system. This can compromise the quality of notifications or lead to underreporting of cases, especially in high-demand situations such as the COVID-19 pandemic.These potential failures in notification systems may occur at the local or national level, and directly impact the conduct of combating actions and delay the collection of knowledge of epidemics. Whether failures occur as a result of the government, or the management and operation of occupational health teams, they can result in episodes of severe disease proliferation, such as what was seen with the COVID-19 pandemic. The exponential increase in new registrations observed corroborates the high number of new clinical cases, giving COVID-19 the status of high transmissibility, even if the estimates of the basic reproductive number reported in the literature vary widely.,The direction of COVID-19 prevention and epidemiological control strategies among the male population must consider the sociodemographic profile, such as race/color, social class, and occupation, and clinical profile related to signs and symptoms, complaints, complications and infection pattern.The increase in the number of home deaths, especially among the elderly, as cited in this study, requires attention from health care managers. It reinforces the importance of ambulatory control of chronic diseases and the need to clarify the safety measures to be adopted by the population regarding the clinical complications unrelated to COVID-19 during the pandemic.,The use of combat strategies focused on health promotion, health education, and communication can be decisive factors in preventing and controlling the spread of SARS-CoV-2 among the male population, considering the pattern of behaviors of greater exposure to the risk of infection, for various reasons. These include construction of masculinity, kind of occupational activity, largest social life in the public environment, incorporated concepts of health and health care, beyond personal beliefs about the health and disease process, social and economic vulnerabilities, level of literacy and health literacy, and difficulties in accessing health services.Government efforts must be directed towards ensuring the reach of COVID-19 epidemic control, with focal investments that reach men more precisely. For this, actions with an impact on health in the workplace are necessary, massive testing drives in places with larger male populations, expansion of opening hours of health services, and investment in social communication, with a gender focus.Finally, with satisfactory effects of the use of these joint efforts, it is possible to reduce the economic impact on the national health system, ensuring greater sustainability of the system before a crisis context. In addition, this will guarantee increased survival and a reduction in male mortality by COVID-19 and secondary complications to the disease, reducing the burden of services and health professionals and will in turn ensure an early and safe return of non-essential daily activities and promotion of social welfare, with positive effects influencing the culture of health care.As a limitation of the study, some of the cases had incomplete information documented in the medical records, and the clinical documentation of the patients was not homogeneous. However, this is a common limitation in analytical studies, considering that data generation is clinically oriented and not systematically oriented.The clinical and epidemiological characteristics of men in the investigation of suspected and confirmed cases of COVID-19 were designed for adult men aged 25 to 29 years, mixed race/color, and who did not work in health care. Compulsory notifications were carried out in the municipality of their residence, with an increase in the period from April to August 2020, representing a peak in notified cases. Fatality and maintenance of home treatment were higher among elderly men, and a progression to cure predominated among adolescent, young, and adult men.The findings in the data pointed to the causal relations of the COVID-19 infection, contagion and transmission, secondary complications generated by the disease, and combat strategies aimed at the male population in the municipal health network. The individual understanding of the disease explains the clinical markers of COVID-19 expressed by the self-reported syndromic approach as well as the search for healthcare in the public service, the adoption of measures to prevent and control illness, and adoption of the recommended therapies by health professionals.


In a recent issue of this journal, we read with great interest the experimental report by Yao and coworkers , focusinIntestinal microecology has been a research hotspot in the field of gut-associated diseases, especially digestive system tumors. Intestinal dysbiosis is the main cause of the formation of hypoxia, low pH, inflammatory and even interstitial high pressure environment, which promotes the formation of tumor microenvironment and provides conditions for tumor generation, progression and metastasis .in vitro and in vivo studies is complementary and necessary. However, it must be mentioned that human studies related to the gut microbiota are often limited. In addition to collecting feces, sampling of small intestine, ascending colon, transverse colon and other parts is limited for normal people. Based on the difficult sample collection process and the tremendous inter-individual variability between samples caused by confounders such as genetic background, diet, health status, lifestyle and environmental conditions , small intestine (digestion process) and large intestine, namely the ascending, transverse, and descending portions of the colon. The first two reactors use fill and draw principles to simulate the different steps of food intake and digestion. The peristaltic pump allows the addition of defined amounts of SHIME nutrient medium, pancreatic enzymes and bile in the small intestine to achieve gastric content transfer. Retention time and the pH of different vessels are carefully controlled to obtain complex and stable microbial communities that are highly similar to those in different regions of the human gastrointestinal tract in structure and function.In intestinal flora research, the integration between nditions , as an anditions , Readingnditions , Simulatnditions , PolyFernditions , etc. Amin vitro model, the SHIME system has certain limitations. First, the SHIME system suffers from the lack of the physiological environment and host responses, such as the absence of oxygen gradients that is released from the blood to the mucus layer in the body. Furthermore, movement and mixing along the gastrointestinal tract is carried out by pumping and stirring rather than by peristalsis (However, it must be pointed out that, like any other istalsis . Meanwhiistalsis , and theIn summary, we completely agree that Yao et al. used the SHIME reactor device to study the important effects of TCM compounds on gut microbial ecology. These data innovatively transforms the research of complex TCM ingredients into the representative of intestinal flora, and are the creative experimental results of using the SHIME system to study the regulation of human intestinal microbiota by TCM compounds. This innovative study mediated by the SHIME model provides a new understanding of the mechanism of TCM compound intervention in the intestinal microenvironment, which is an interesting, encouraging attempt to promote multidisciplinary integration.


The literature reports some experiences regarding the design of integrated healthcare Performance Evaluation Systems (PES) applied in Low- and Middle-income Countries (LMIC). This study describes the design of an integrated and bottom-up PES aimed at evaluating healthcare services delivery in rural settings. The analysis involved four hospitals and their relative health districts in Ethiopia, Tanzania, and Uganda. The evaluation process was undertaken for those indicators that could be evaluated using the same reference standard. The evaluation scores were determined through the international standards identified in the literature or through benchmarking assessment. Both administrative and health data were extracted from the hospitals’ registers and District Health Information Systems (DHIS) from 2017 to 2020. We defined 128 indicators: 88 were calculated at the hospital level and 40 at the health district level. The evaluation process was undertaken for 48 indicators. The evaluated indicators are represented using effective graphical tools. In settings characterised by multiple healthcare providers, this framework may contribute to achieving good governance through performance evaluation, benchmarking, and accountability. It may promote evidence-based decision-making in the planning and allocation of resources, thus ultimately fostering quality improvement processes and practices, both at the hospital and health district level. Health systems in Low- and Middle-income Countries (LMIC), compared to High-income Countries (HIC), are faced with somewhat different intrinsic challenges, which are, in large part, due to interrelated issues of poverty, education, lack of resources, as well as weak leadership .Nevertheless, health systems in all countries, irrespective of income availability, put in place similar policies that aim to improve accessibility, quality of care and equity of healthcare ,3.A wide array of interventions has been implemented so far in order to increase accessibility to healthcare across LMICs, and to guarantee that “individuals that can potentially benefit from effective healthcare do in fact receive it” , thus acDespite crucial differences between health systems in HICs and LMICs, the need to ultimately improve similar aspects of these systems implies that a substantial level of complexity is present across all health systems, irrespective of epidemiological, social and economic context ,8.The last two decades saw an extensive effort to design, develop and implement Performance Evaluation Systems (PES) in HICs to manage such a high level of complexity and improve the performance of health systems ,10. InteThe literature reports only a few experiences regarding the design of PES framework applied to LMICs. When available, they refer to specific services or geographical settings ,16,17, aGiven this premise, the primary objective of this article is to answer the following research question:RQ: What are the features and challenges of designing and developing a bottom-up and integrated approach of PESs in LMICs?For this purpose, the paper describes the development of a PES in four selected settings from three Sub-Saharan African countries, namely Ethiopia, Uganda, and Tanzania. In particular, the PES aims to evaluate and compare the performance of healthcare services delivery of four different healthcare settings, providing policy makers and healthcare managers in LMICs with a specific and scalable framework that can contribute to improving efficacy when assessing performance of healthcare services at hospital and district level.Nowadays, it is common practice for HICs to measure and evaluate the performance of their healthcare systems. Health system assessments have been developed to address the need to face the common challenges of health systems in HICs, such as demographic changes and population aging, limited resources, and rising costs, along with the need to improve quality of care delivery and guarantee equitable access to healthcare services, while ensuring the financial sustainability of the whole system itself ,24. AsidIn this scenario, over the last few decades, the international literature on performance measurement proposed several conceptual frameworks and taxonomies. In 1988, Donabedian developed the first model to assess health services and evaluate quality of care by including three domains: structure, process, and outcomes . This frPartially based on the Donabedian model, a framework developed by the WHO and OECD was created at the beginning of the new century ,27. NeveHowever, it is worth noticing that countries and organisations also adopted different approaches that depend on the specific context, intended use and acceptability . MoreoveEmbedded in this research field is the experience of the PES developed and implemented in a number of Italian regional healthcare systems  and adopMore generally, this generation of “integrated” PESs  is charaTo the best of our knowledge, there are few integrated PESs specifically applied to LMICs, and research and publications are limited ,36. MoreThis paper is based on a constructivist research approach. The approach is widely used in technical sciences, mathematics, operations analysis and clinical medicine, management research ,42,43 asThis approach highlights the principal issues involved in the measurement and evaluation of performance in African hospitals and healthcare districts. It is based on a continuous interaction between the research team (RT) and healthcare managers and professionals of the hospitals and healthcare districts to build up a PES according to their specific needs and requirements.The RT includes four experts in healthcare management from the Management and Health Laboratory (MeS Lab) of the Institute of Management of the Sant’Anna School of Advanced Studies and two medical doctors employed by the NGO Doctors with Africa CUAMM (CUAMM). The constructivist approach entailed a series of meetings and workshops, which took place either virtually or in person, and two site visits in the selected African hospitals and healthcare districts between September 2019 and March 2020. Overall, the design and development of the system involved 5 researchers, 3 public health experts, and 15 professionals on the field. In addition, a panel of 20 experts and professionals was involved in the phase of validation of the PES, as better clarified in As previously mentioned, the methodology used here was inspired by the approach adopted for the design, development, and implementation of the PES of Tuscany Region and the Inter-Regional Performance Evaluation System (IRPES) in place in Italy to measure and evaluate the multidimensional performance of public healthcare organizations across Regional Healthcare Systems ,45. The With regard to the development of the PES system in Ethiopia, Uganda, and Tanzania, The pilot study involved four hospitals and their respective healthcare districts, which are supported by CUAMM through clinical and administrative activities both at hospital and district level.The analysed contexts are embedded within three distinct National Health Systems with specific governance, financing, services delivery models, and different levels of per-capita expenditure ,47,48. FIn all these contexts, the four hospitals analysed have the same institutional setting: they are private, faith based, and not for profit. These private hospitals act in the name and on behalf of the public health system according to specific Private Public Partnerships (PPP) with the Local Health Authorities. Indeed, these hospitals are mainly funded by the regional governments that bear some of the recurring expenses, such as costs of personnel, utilities, and drugs and consumables. The other two main sources of funding are represented by out-of-pocket payments from the patients and refunds from insurance companies. Alongside the hospitals, the health districts are managed by the regional government and are characterized by similar organizational models, featuring a wide variety of healthcare providers at different levels. Primary and secondary care is offered at dispensaries and health centres, which are spread within the reference territory and intended to provide mainly outpatient services, e.g., prevention, health promotion, maternity, and some in-patient curative services. Tertiary care is provided by regional hospitals, which offer more specialized services, including consultation, emergency, and surgical services. These hospitals serve as referral hospitals for the districts. The distribution of facilities across levels of care reflects the healthcare needs of the population, with most cases treated at the district level and more complex cases referred to reference hospitals.The Wolisso catchment area is in the Southwest Shoa Zone, one of the eighteen zones of Oromia Region in central Ethiopia. The catchment area includes five health districts (referred to as a “woreda” in Ethiopia) inhabited by around 633,000 people. In the reference area, primary care is offered by a total of 22 health centres that refer to the St. Luke Hospital—Wolisso Hospital, a private, not-for-profit institution established in the early 2000s. In Tanzania, the Iringa District Council is one of the 158 health districts of the country  and is lAlthough the hospitals and health districts are located in different countries with different environments and epidemiological contexts, they all aim to pursue the three main goals of the healthcare system: better-quality care delivery, guaranteeing equitable access for the entire population, and maintaining the overall financial sustainability of the system ,52.To better realize the relevance of some phenomena and the assessment of the performance indicators, the RT collected data for the years 2017, 2018, 2019, and 2020. As recommended by the literature on the multidimensional character of healthcare performance ,34,45,53The indicators were calculated both at hospital and district level. Hospital-level indicators were extracted from the registers of hospitals’ departments, whilst district-level indicators were retrieved from the District Health Information System (DHIS) of Ethiopia, Uganda, and Tanzania . With reHospitals and health districts datasets were used to collect aggregated data on pre-defined variables (per year of study) and subsequently elaborated into an Excel spreadsheet , which consists of five coloured strips spanning from red to dark green, each of which corresponds to one of the five evaluation bands. The evaluated indicators are represented in the dartboard as white dots. The closer they are to the centre of the dartboard, the higher the performance of the hospital or the health district is .In order to overcome a static representation and provide an integrated and continuous view of the performance across different settings , we alsoAll indicators that could not be evaluated were included in the final list to observe specific and relevant context-related phenomenon.The work illustrated in the present paper produced a total number of 128 indicators over 8 different dimensions and 24 areas. While a total of 88 indicators were calculated at the hospital level, 40 were calculated at the district level. Among these 128 indicators, 48 were evaluated using the abovementioned process, corresponding to around 38%.As already mentioned, the indicators selected for evaluation were indicators that the Tuscany Region was considered feasible evaluate using the same reference standard. All sources of evaluation standards, alternative in terms of dimensions of evaluation to the IRPES standards and benchmarking assessment, were identified through a review of the international literature.For example, bar charts were used in To provide an overall picture of the multiple dimensions of the healthcare services, the RT used the visualization tool of the dartboard, as seen in other studies conducted in Europe ,30,33. FThe dartboard shows the weaknesses and strengths of each catchment area. The dartboard of Wolisso Catchment Area presents a very disperse configuration of indicators, although with a prevalence of indicators scored in the red band as counter to the green and dark green bands. There are very positive performance results relative to all the indicators of vaccination coverage at residence level. On the other hand, there are opportunities for improvement with regard to areas related to Malaria, Tuberculosis, and HIV.Concerning the dartboard of Iringa District Council, the observation of data suggests the need to keep the indicators relative to the vaccination coverage of polio under control. In addition, it is possible to observe a certain degree of inefficiency regarding hospital management, showing potential for improvement in both the Average Length of Stay (ALOS) and the Bed Occupancy Rate (BOR).The dartboard of Napak District shows a high dispersion of performance scores, with a wide prevalence of indicators that fall in the external evaluation bands of the dartboard, and a quite small number of indicators located in the centre of the dartboard. Main criticalities are noteworthy concerning all infectious diseases areas, with particular emphasis on the management of tuberculosis and malaria, while an ups-and-downs trend emerges by observing the areas related to gastroenteritis and HIV.With respect to the dartboard of Oyam District, the graph shows a quite good balance between indicators presenting a good or excellent performance and those presenting poor performance levels. Indicators regarding vaccination coverage reveal poor performance outcomes for all the indicators analysed.Regarding the care pathways, we selected four care pathways based on the relevance of health-related issues in LMICs: the maternal and childcare pathway; the infectious diseases care pathway for two of the most common infectious diseases in Sub-Saharan Africa (tuberculosis and gastroenteritis); and the chronic diseases (HIV/AIDS) care pathway.As mentioned above, each care pathway is represented by a stave  that conThe stave of Wolisso Catchment Area shows quite poor performance in the pregnancy phase, and average and excellent performance scores in the last phase of the care pathway. Regarding the childbirth phase, the results are hybrid, as positive performance is found with respect to the percentage of caesarean sections and the percentage of peri/intra-partum asphyxia, while a quite poor performance can be observed with regard to the percentages of episiotomies and assisted deliveries performed.The stave of Iringa District Council illustrates a high concentration of indicators with excellent and good performance scores in all phases of the Maternal and Childcare pathway. Contrary to the overall excellent performance reported in the Maternal and Childcare pathway, an element of weakness in the hospital performance is represented by the high percentage of caesarean sections performed.In the Napak District, there are potential areas for improvement pertaining to the antenatal care and childbirth phases, with the percentages of supervised deliveries and assisted deliveries at residence level and episiotomies at hospital level performing slightly better than the indicator relative to the peri-/intra partum asphyxia and percentage of caesarean sections. Moreover, there is a weak capability of ensuring care continuity in the first year of new-born’s life and positive evaluation scores relative to the indicators of vaccination coverage.Finally, with regard to the Oyam District, the stave shows difficulties, especially during the antenatal care and care in the first year of new-born’s life. This represents one of the domains that deserve greater attention from the hospital and district managers. However, the indicators relating to the childbirth phase score slightly better, especially the percentage of assisted deliveries and the percentage of peri-/intra-partum asphyxia.This paper is embedded in a stream of the literature which has been enriched by scholars for a long time: healthcare performance evaluation. The contribution of this paper is proposing, with a constructivist approach, a system of hospital and residential indicators for four different African settings. To the best of our knowledge, this is one of the first examples of integrated PES aimed at benchmarking the performance of hospitals and health districts at local level in different LMICs. This PES focuses on the evaluation of the performance of healthcare services delivery within the local health system, which includes several residential health centres and their relative reference hospitals. It also came into existence as the result of a bottom-up and voluntary-based initiative . It was The framework developed in this study resembles the core principles and features of performance evaluation that were mentioned in the theoretical background. In addition, the indicators are reported through three peculiar graphical representation tools, i.e., evaluation bands, dartboards, and staves ,33, whicIf used from a system viewpoint, comparing results in data benchmarking among closer realities may allow the identification of unwarranted geographical variation areas and, in turn, measure horizontal equity at local level . Indeed,In the contexts in which the PES has been already implemented and used, it has proven that the potential use of benchmarking data can be achieved when publicly disclosing performance results, thus making policy makers and managers accountable for their management. Additionally, the experience in using this methodology suggests that the systematic use of benchmarked performance data, paired with effective data-visualization tools, can stimulate local staff motivation by the leverage of reputation. As stated elsewhere, raising professionals’ awareness leads to a “reputational competition” that, in turn, contributes to promote change, and hopefully improvement ,62,63.Additionally, as emerged from the feedback provided by the group of public health experts working in the field  and the performance results do not consider all providers within the same target territory. Therefore, in the hypothesis of extending the analyses to other realities, estimation errors should be considered while defining and calculating indicators.Another main limitation of this research is related to data quality, which depends on the level of development and availability of digital recording systems. The reliability of available data can influence the credibility and robustness of the defined indicators. However, the use of data for evaluation purposes may leverage the progressive improvement of data quality and, in general, the digitalization of information systems. Moreover, since the system has been designed and developed for four different environments, the set of indicators defined are necessarily linked to the data available in these specific contexts. Therefore, as already pointed out by the group of experts, the set of indicators defined does not comprehend all aspects and dimensions that could influence the performance of healthcare delivery in LMICs, e.g., the fees become a barrier preventing access to hospitals’ services. However, this limitation does not invalidate its underlying innovative approach, which can be adapted and adjusted in a fine-tuning process to fit the hospitals and health providers involved, thus respecting the contextual peculiarities evolving within the system.This study investigates the results of a constructivist research study related to the development of a system aimed at evaluating the performance of healthcare services delivery within the local health system.The added value of this study resides in the fact that, to the best of the authors’ knowledge, this is the first experience of this kind found in the literature concerning the design, development, and implementation of an integrated performance evaluation system, aimed at assessing the performance achieved by either the hospital or the health district in rural areas of Sub-Saharan Africa, with a bottom-up approach, using systematic benchmarking to leverage on professionals’ reputation, and by considering the multidimensional nature of healthcare performance.The performance evaluation system presented in this paper represents a useful framework to be shared with actors and professionals involved in the design, implementation, and use of PESs in LMICs. In settings characterised by multiple healthcare service providers, this framework may contribute to achieve good governance through performance evaluation, benchmarking, and accountability. Additionally, thanks to its great potential to strengthen culture of data collection and monitoring, this framework may promote evidence-based decision making in the planning and allocation of resources, thus ultimately fostering quality improvement processes and practices both at hospital and health-district level.From this perspective, future research should explore how the developed PES has been adopted by local decision makers and healthcare managers and the impacts of its use with respect to the improvement of healthcare performance in the long run.There are also opportunities for further research related to the progressive amelioration of the system developed so far. Particularly, there should be systematic and continuous involvement of health professionals in the selection of new and refinement of currently existing indicators. On the other hand, existing indicators should be risk adjusted according to the socio-demographic characteristics of the population and epidemiological and institutional contexts should be observed so as not to neglect possible discrepancies among the analysed settings.These considerations should be undertaken in managerial as well as strategic terms, to provide hints for cooperation programs and NGOs, to identify specific potential areas for improvement for each setting in addition to the individual view of health professionals and, eventually, to make the system scalable in other LMICs.


Your Name from the angle of interest-related community interaction through utilizing online text analysis and Grounded Theory analysis. Based on the interest-related community interaction, we analyzed the elements of interest-related community interaction in cultural tourism triggered by the film, including tourist hotspots, tourism resources, the tourist experience, sightseeing expectations, tourism evaluation and information dissemination, and formulated the orientation pathway of film-enabling cultural tourism. In this study, we aimed to enrich cultural tourism research and provide a reference point and theoretical support for film-enabling cultural tourism in the Internet era by introducing the concept of interest-related community innovation to the scene of film-enabling cultural tourism.The importance of media-induced tourism has increased in the latest decade. The integration and collaboration of film elements is an especially effective pathway for the innovative development and upgrading of the experience of the cultural tourism industry. Existing studies on the mechanism of tourism destinations and cultural tourism development, mainly from the perspective of tourism destinations and tourist experience, have rarely explored the cultural tourism development mechanism from the perspective of interest-related community interaction in the film-enabling context. In this study, we conducted high-frequency word analysis and element category analysis of the online text data of the Japanese animation film  Film caYour Name released in 2016 won a warm response from Chinese consumers. With the continuous upsurge of film popularity, the tourism industry derived from it developed rapidly. After the original filming location of Your Name, Nagano in Japan, was successfully selected as one of the top 10 best tourism destinations by the United States news channel CNN, a vast number of film lovers became fascinated with the place, and the cohesion of the interest-related community was also improved greatly. According to Japanese media reports, Hida City of Gifu-ken in Japan, one of the shooting places, despite its remote location, witnessed an influx of Chinese tourists after the film was released. The number of foreign tourists doubled, and about 80% of them came for the holy land tour mentioned in Your Name. As the data provided by the Hida Tourism Association indicated, the number of tourists in Hida City exceeded 1 million in 2016 (April 2016–March 2017) and reached 1.13 million in 2017, creating an economic benefit of 18.5 billion yen for Gifu-ken where Hida City is located in a short time. There were 6,984 foreigners out of the 1 million tourists in 2016 who stayed for accommodation, up 27.3% year on year. Among them, Hong Kong, China’s Mainland and Taiwan were the top three regions where the tourists came from. Data released by the Japan National Tourism Organization showed that a total of 30 million foreign tourists visited Japan in 2018, 14 percent of whom went to Japan because of the attraction of the anime . Furthermore, in line with the characteristics of tourism activities between China and Japan, combining the film-enabling tourism characteristics from the perspective of the tourist destination hosts and the tourists, this study proposed the elements of the interest-related community interaction of cultural tourism triggered by the film Your Name, namely, tourist hot spots, tourism resources, tourist experiences, sightseeing expectations, tourism evaluation and information dissemination, and finally a film tourism enabling pathway was generated based on the interest-related community interaction, thus providing theoretical support and reference for the exploration of film-enabling tourism mechanism in the Internet era.Given the above consideration, the current study applied online text analysis and element coding of Grounded Theory to conduct high-frequency word analysis and element category analysis toward the text data of the Japanese animation film 2.2.1.Cultural tourism can be defined as “the movement of persons to cultural attractions away from their normal place of residence, with the intention to gather new information and experiences to satisfy their cultural needs”  and invoThe literature has emphasized that earlier cultural tourism emerged from the development and operation of cultural resources, such as heritage tourism, religious tourism, and folklore tourism , p. 680 Cultural tourism has been a core element of the tourism industry for destination marketing and promotion . However2.2.The term “film tourism” originated from the United Kingdom and the United States in the 1990s, originally referring to a new type of tourism formed by combining film and television bases with characteristic tourism , p. 922.In the literature on film-induced cultural tourism, extant research has been dominated by locational shoots in either the U.S. or UK. The early highlight of the western market is partly explained by the dominance of Hollywood in filmmaking , p. 367.Film tourism activities include reenacting scenes, tasting the food and beverages that appeared in the film, and experiencing the culture represented therein , p. 389.2.3.The idea of community is predicated on a collective sense of common interests and purpose. Members of a community are bound together through comradeship and a desire to seek one another out. In the past, communities were based, at least in their conception, on proximity: members lived near one another . The former was finally classified into seven secondary subcategories, which were animation attraction, cultural expression, industrial form, geographical elements, characteristics of the starting place, tourism experience and demand stimulation, and three core categories, which were tourism hotspots, tourism resources and experience demand, as shown in Your Name shows the beautiful scenes of streets, stations, buildings, intersections, mountains, and lakes in Tokyo, Suga Shrine, Gifu-ken, etc., which gives the audience an immersive experience when watching the film and also stimulates the audiences’ intention to travel to the location for sightseeing and other experiences. The improvement and development of Internet platforms have also improved the interaction effect between modern film and television works and scenic spots. The online publicity of scenic spots and interactive communication of tourists have built a community of interest for the supply and demand sides. Tourism destinations should constantly improve the settings of scenic spots, improve the service capacity of the destinations, attract more tourists, and improve the economic benefits of tourism destinations. In such a way, a coupling development mode for film and television industry and tourism industry will be achieved.Given the above analysis of high-frequency words and element categories, the development of film and television tourism should pay more attention to the construction and development of the value chain of the film and television tourism industry from the perspective of the tourist destination hosts. The film and television works are closely related to the shooting locations. When the film and television works show the unique cultural elements of the locations, they will attract social attention and extend the audiences’ demand of watching the film to field visit demand, thus stimulating a series of tourist behaviors. For example, the film Your Name won the popularity of consumers after its first release in the cinema. With the further rendering of social media, the number of tourists going to the location will surge, thus forming a new phenomenon of film and television tourism in the new era. When tourists complete their tour of the tourist destination, they will communicate and share their own tour experience and cultural gains through WeChat, microblog, and other personal social media platforms. A new interest-related community will be formed, and information sharing and dissemination in the community will again spread to a wider range of interest-related communities. As a result, interest-related communities gradually come forth from the perspective of the destination tourists, thus realizing cultural enabling and benefit improvement that films can bring forth to tourism destinations.From the perspective of tourists, the form of “film and television tourism” generated by the interaction between film and television works and tourism destinations can be better spread to attract tourists’ attention. As a new form of tourism, film and television tourism has a strong flow aggregation capacity, aiming to transform film and television audiences into destination tourists. For example, 5.5.1.Your Name for online text analysis and Grounded Theory analysis and explored the film-enabling cultural tourism mechanism based on the interest-related community interaction. According to the research, in the new era of rapid development of the Internet, the emergence and interaction of interest-related community has exerted a positive impact on the sharing of film and television tourism experience and film-enabling tourism and the community effect has been greatly improved. Based on the Grounded Theory analysis, the current research generated the film-enabling tourism characteristics from the perspective of the tourist destination hosts and tourists, demonstrating that under different perspectives of destination hosts and tourists, the focuses of the film and television tourism are different. Specifically, from the perspective of the destination hosts, the focus is put on the driving force mechanism of tourist destination development and the construction and development of the value chain of the film and television tourism industry, namely, the stimulation of tourism hotspots, the excavation of tourism resources, the stimulation and satisfaction of experience demand; Whereas from the perspective of tourists, attention is paid to the guidance of the topic flow brought by the interaction between film and television works and tourism destinations based on the interest-related community, namely, the stimulation of viewing expectation, the guidance of tourism evaluation direction and the improvement of information dissemination effect. In view of the above two perspectives, the overall characteristics of the film-enabling tourism mechanisms are concluded.Overall, with a focus on the topic of “film-enabling tourism,” the current study selected the Japanese animation film Your Name, namely tourism hotspots, tourism resources, tourist experience, sightseeing expectations, tourism evaluation and information dissemination. In such a manner, the current research has directed the pathway of cultural tourism enabled by the Japanese film Your Name based on the interest-related community interaction as shown in Based on the above analysis, and in consideration of the geographical location characteristics of the source of interest-related community discourse, it is revealed that most tourists are from Beijing, Shandong, Shanghai, Zhejiang, Guangdong and Sichuan, and the main tourism destinations are Nagano, Tokyo, Izu Islands and Gifu. Based on the characteristics of film-enabling tourism from the perspective of the destination hosts and tourists, this study has proposed six elements of interest-related community interaction of cultural tourism triggered by the film 5.2.In obtaining the text data with the data crawling software, and adopting the analysis paradigm of Grounded Theory, this study has explored the film-enabling tourism mechanism based on the interest-related community interaction, analyzed the elements of the interest-related community interaction, and put forward relevant measures and suggestions. The current research has broken the limitations of previous studies based on tourism motivation and marketing perspective, innovatively introduced the concept of “interest-related community” into the research of film-enabling cultural tourism, and expanded the research perspective of film-enabling cultural tourism exploration. Previous studies discussed primarily the cultural tourism model of tourism destinations from the perspective of tourism destinations , and rar5.3.This study provides important practical value for the creation of film and television works and image building of tourism destinations in the future. First of all, film-enabling cultural tourism itself is an innovative application of tourism resources, and it inspires us to strengthen the in-depth interaction between film and tourism in the future, tap into the “element resources” in film and television works, highlight the profound cultural heritage of local tourism resources in film and television works, fully use the Internet media platforms to display unique tourism culture, and create the advantages and characteristics of tourism brands, not only to attract tourists to watch films, but also to drive their strong desire to travel to the shooting locations. Moreover, it should be noted that the construction of interest-related community is the key to promoting film-enabling cultural tourism. Therefore, it is necessary to actively build interest-related community, make use of the universality of the community to further promote the film-enabling effect to cultural tourism, and achieve a significant increase in the number of film and television audiences and tourists in the interaction between the film interest-related community and tourism interest-related community. Additionally, it is also inevitable to make full use of tourism destination resources and regional resources to realize the flexible allocation, combination and expansion of tourism resources combined with film elements, open up all-round interaction mechanism between film and tourism industrial chain, and provide tourists with the whole process, full time and space experience to comprehensively cater to tourists’ demand for all-round experience and achieve innovative development.5.4.Your Name and the Chinese tourists traveling to Japan, however, interest-related communities formed by tourists and local residents during the tourism process are not considered. Therefore, future research can attempt to collect data texts including local residents from international social media platforms to further analyze the discourse structure of interest-related communities formed by tourists and local residents to reflect the characteristics of a more comprehensive film-enabling cultural tourism mechanism. In addition, the latest studies in marketing encourage using multiple data sources and methodologies (This study still has deficiencies that need further exploration and improvement. For instance, the data collected are from social media platforms in the Chinese context, and the interest-related communities formed are mainly the audiences of the film dologies , therefoThe original contributions presented in the study are included in the article/supplementary material; further inquiries can be directed to the corresponding author.YL contributed to the empirical work, the writing of the first draft, and the analysis of the results and supported the total work. JZ contributed to the revision and development of the research framework. JL contributed to the overall quality and supervision of the literature organization and empirical work. Authors discussed the results and commented on the manuscript. All authors contributed to the article and approved the submitted version.This work is supported by the Natural Science Foundation of China, Fund No: 72064003, project name: Study on the Regional Dynamic Evolutionary Mechanisms of Intelligent Technology, Factor Substitution and Industrial Synergistic Agglomeration.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.