Safe in COVID-19 are used as an example. Integrated care can only be supported when healthcare data is available and can be sharable and reusable. Healthcare data is essential to support effective prevention, prediction, and disease management. Data available in personal health apps can be sharable and reusable when apps follow interoperability guidelines for semantics and data management. The authors also highlight that not only technical but also political and social barriers need to be addressed in order to achieve integrated care in practice.The lives of millions of people have been affected during the coronavirus pandemic that spread throughout the world in 2020. Society is changing establishing new norms for healthcare education, social life, and business. Digital health has seen an accelerated implementation throughout the world in response to the pandemic challenges. In this perspective paper, the authors highlight the features that digital platforms are important to have in order to support integrated care during a pandemic. The features of the digital platform  The coronavirus disease 2019 (COVID-19) has caused a worldwide pandemic . HealthcDue to the burden of multi-morbidity, which is growing in the European countries, because of the aging population, an increasing number of people find themselves in having to deal with more than one chronic or long-term conditions –10. ThisThis paper presents the authors' perspective on how digital technologies can help make integrated care a reality addressing the needs of governments to efficiently respond to pandemics such as COVID-19. It elaborates on the requirements necessary so that digital platforms can effectually act as outbreak response tools. These include appropriate and effective data management and semantics as well as interoperable personal health apps that address the needs of citizens to effectively support contact tracing while staying safe in the pandemic. In addition, the authors highlight the existing technological, political and social barriers that need to be overcome for the effective digital management of the pandemic.Safe in COVID-19  that offer the ability to document registered isolation and to allow public health to conduct appropriate analysis and research; COVID Symptom Tracker (https://covid.joinzoe.com/us) in the US, that tracks the onset and progression of symptoms to pinpoint virus hot spots and to help slow the spread of the disease; MaladieCoronavirus  in France for symptom checking and self management; Corona-Warn-App (https://www.coronawarn.app/en/) for tracing the spread and providing information; Covid19.es (https://covid19.es/) in Spain for symptom checking and tracing the spread; Helsenorge (https://www.helsenorge.no/) for symptom checking, tracing and information providing; and the software application Go.Data (https://www.who.int/godata), developed by the Global Outbreak Alert and Response Network (GOARN) to manage case-contact relationships and the follow-up of contacts. Go.data has been deployed to over 35 countries in support of the COVID-19 Pandemic response. In addition, several countries, such as France, Croatia, Germany, and Norway have already developed e-government apps for their citizens, under the direction or with the endorsement of public organizations  a web application for public health authorities to give a complete picture of the status regarding the spread of the disease at a national level and the measures taken by healthcare services; (ii) a web application for healthcare professionals that supports online communication with registered patients in order to provide personalized information and coaching and instant access to patient reported symptoms related to COVID-19 disease for monitoring their health status; and (iii) a mobile application (Android/iOS) for citizens that allows recording on a daily basis their health status and communicate synchronously or asynchronously with healthcare professionals in order to receive personalized instructions for managing their health. Certainly, web apps could be used instead of using smart phones for the citizens. However, we believe that packing the app as a mobile app makes it easier for users even without appropriate digital skills to navigate and enjoys additional integration with their mobile phone (push messages etc.).The Safe in COVID-19 framework is based on and significantly extends a fully-fledged, state of the art PHR system, it includes the personal health records and user profiling out of the box. However, specific modules have been customized for COVID-19. The symptom module has been extended to include specific symptoms of COVID-19, and the communication module has been extended to enable continuous communication with the healthcare team. Other modules such as the position tracing and the recommendations have been implemented specifically for addressing the COVID-19 outbreak. All collected data are stored in the data lake, enabling visual exploration through the application tier. Different levels of care and health services are brought together through online interaction with national digital health portals that provide secure application programming interfaces for patient, healthcare professional and insurance organizations applications. Typical services include access to national EHR services, ePrescription and national registries with COVID-19 patients.This tier includes the necessary services for handling the logic behind the graphical user interface. More specifically as the Safe in COVID-19 framework does not store specific patient identification data, but only unique codes generated randomly by the system and shared with the health authorities. In addition, those codes can also be generated by the health authorities for the confirmed COVID-19 cases. Data processing has been minimized only for the persons who need it whereas, all data is encrypted in order to further increase security and privacy. Further, every data access is recorded, whereas the necessary consent is also granted by the citizens with full information about the intended processing of data. In order to verify legitimate users  users may need to receive appropriate codes when entering data into the app to be confirmed by the server. Position tracking is legitimized by relying on a voluntary adoption by the users for each of the intended purposes.Handling personal health data requires specific attention to the security and the integrity of the collected data. As such, the Safe in COVID-19 framework goes beyond simple data dashboards, by providing intelligent dashboards that enable the multidimensional exploration and filtering of the available data. Internally we have (a) external data directly ingested in the data lake (b) the database of the adapted PHR-C (the schema is based on the Open EHR). All data are mapped to an ontology, which enables the semantic uplifting of the available data and their homogenization and integration. The ontology currently used is an extension of the MHA semantic core ontology  a public health system with a comprehensive national epidemiologic strategy (ii) a technology and architecture model that promotes interoperability for data sharing, and data re-use; (iii) widespread connection with mobile devices, and (iv) the appropriate regulatory and legislative conditions for the use of integrated digital solutions for all stakeholders safeguarding safety and privacy for all.To leverage the individual benefits of mobile apps and other digital technologies it is important to have an interoperability layer to enable the various such solutions to exchange data. A unifying layer will facilitate the exchange of meaningful data in the appropriate format and needs to be implemented on top of the individual proposed solutions. All collected data should be made immediately findable and accessible through fully anonymization and publishing on the web using digital object identifiers (DOIs) and other permanent identifiers. This process is called data FAIRification.Relevant ontologies, such as the MHA semantic core ontology , and othSafe in COVID-19 FHIR architecture, since they can publish patient laboratory results for COVID-19 tests into the FHIR Server. Available applications then will be able retrieve the test results from the FHIR server and present them to the end users.The use of fast healthcare interoperability resources (FHIR) can enable and facilitate interoperability with existing hospital health systems. FHIR should be used for the representation of the medical data related to COVID-19 . COVID-1Privacy and trust are key concerns for individuals considering the adoption of personal health systems. As data are expected to be directly shared upon their creation appropriate anonymization techniques should be enforced for sharing information among patients, and their relatives, doctors, researchers, policy makers and governments. Digital solutions need to provide appropriate explanations to citizens, highlighting the importance of sharing health information for “flattening the curve” and explaining all measures taken to ensure anonymity and confidentiality.Extending existing digital services with novel solutions can increase public value. Efficiency and effectiveness are facilitated through the use of wider range of available tools such as the provision of legitimate user orientation, high level of participation, legality, and equity. Responses to COVID-19 have largely not been integrated, leading to adverse outcomes. Innovative digital solutions can exhibit their highest impact when they integrate and interoperate with existing healthcare services and infrastructures.Safe in COVID-19 platform was used to illustrate in practice what the healthcare ecosystem can gain form an integrated innovative digital service, demonstrating the components that should be available and the challenges for adopting them in practice.Digital platforms can act as disease outbreak support tools when they are able to integrate within existing digital health services. This paper presented the overall requirements and conditions that are essential in order to develop digital platforms that can be useful to all healthcare stakeholders including public health authorities, healthcare professionals and citizens . The SafProviding the means to securely link reliable data has the potential to support care anywhere at any time. When coupled with advanced analysis, then digital systems can be transformed into smart systems to better support integrated care. Of course, relevant challenges linked to organizational, financial, legal and interoperability issues will always need to be properly addressed at different configuration settings.Integrating novel digital solutions can provide opportunities to support and strengthen health systems in the diagnosis, treatment, monitoring, citizen empowerment through information, public health surveillance and epidemiology , 12, 32.Foreseen benefits for public health authorities include decongestion of healthcare units, provision of real-time information on the evolution of suspected, candidate and confirmed cases, online monitoring of the spread of the virus, and effective decision-making regarding required measures. Benefits to healthcare professionals include support in managing patients, reduced time for direct contact with patients, more efficient case management, and improved working conditions. Benefits for citizens include systematic recording of symptoms, self-assessment, access to personalized information, and instructions and reminders based on their overall health status.Safe in COVID-19 offers an example of an integrated platform offering multiple benefits for the users in alignment with relevant national eHealth initiatives. It can operate efficiently under the appropriate regional or national infrastructures with links to medical and diagnostic centers around the country and the size of the population under consideration. Such platforms can support the return to the “new normal” with less stress and more security for individuals, more direct and safer management of patients by physicians, and better possibilities for monitoring the epidemic by public health authorities.The healthcare systems can act as drivers of change and facilitate the adoption of similar eHealth technologies based on need. As technology adoption barriers have decreased due to the current pandemic , digitalDigital solutions can help support integrated care in the era of COVID-19, on a larger scale. Healthcare systems need to focus on flexibility and interoperability to achieve sustainability and to realize the vision for healthcare at the point of need. Turning vision into reality requires taking the responsibility to act now to ensure health systems and people continue to benefit.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Excessive muscle tension is implicitly caused by inactivity or tension in daily activities, and it results in increased joint stiffness and vibration, and thus, poor performance, failure, and injury in sports. Therefore, the routine measurement of muscle tension is important. However, a co-contraction observed in excessive muscle tension cannot be easily detected because it does not appear in motion owing to the counteracting muscle tension, and it cannot be measured by conventional motion capture systems. Therefore, we focused on the physiological characteristics of muscle, that is, the increase in muscle belly cross-sectional area during activity and softening during relaxation. Furthermore, we measured muscle tension, especially co-contraction and relaxation, using a DATSURYOKU sensor, which measures the circumference of the applied part. The experiments showed high interclass correlation between muscle activities and circumference across maximal voluntary co-contractions of the thigh muscles and squats. Moreover, the circumference sensor can measure passive muscle deformation that does not appear in muscle activities. Therefore, the DATSURYOKU sensor showed the potential to routinely measure muscle tension and relaxation, thus avoiding the risk of failure and injury owing to excessive muscle tension and can contribute to the realization of preemptive medicine by measuring daily changes. The rapid aging of the population and declined birthrates as well as advanced medical technology and increased medical requirements have rapidly increased medical costs and demand for nursing care. In addition, the number of young people in the workforce is reducing. Therefore, protecting the lives of the elderly and their families as well as coping with the rising burden of medical costs are becoming major issues. To address these issues, a new direction of medicine has been proposed as preemptive medicine, which aims to diagnose and predict diseases with a certain probability, and to provide therapeutic intervention in the early stage of disease onset, when there are no clinical symptoms and no abnormalities in the usual examination findings . The aboIn this study, we developed a wearable device that realizes measurement of the muscle state, especially excessive muscle tension (co-contraction), as a state of daily motor function, and also realizes muscle relaxation, which is a cognitive avoidance of muscle tension based on biofeedback. Excessive muscle tension is often implicitly caused by inactivity and tension in daily life, leading to increased joint stiffness and vibration, which in turn causes decreased performance in sports, breakdowns, injuries, and defects and diseases in daily activities, such as contractures and tremors. Therefore, the measurement of the muscle state, including excessive muscle tension, is effective for injury prevention and performance improvement .However, the measurement of muscle state in daily life has not yet been realized owing to several technical issues. For example, in commercially available wearable devices, vital sensing techniques, such as the heart rate, respiratory rate, and blood pressure, have been developed by pulse oximeter-based measurement technology ,4,5,6. HWith this background, this study aims to directly measure muscle states, including excessive muscle tension (co-contraction), in a cross-modal manner. The muscle has several characteristics, based on its physiological structure and mechanism of activity. During activity, the muscle contracts by overlapping actin filaments and myosin filaments, and the cross-sectional area of the muscle belly increases during the activity owing to this physical phenomenon. However, relaxation softens muscle and makes it more susceptible to deformation in response to external forces and inertial forces. We focused on these deformations related to muscle activity and relaxation, and then estimated the muscle state in a cross-modal manner by measuring the circumference of the muscle. In this approach, there is no problem of electrical contact impedance between the body surface and electrode as described above, and no problem of power consumption because the sampling rate of general motion  is sufficient for the measurement. Furthermore, it is possible to estimate excessive muscle tension owing to direct measurement of the muscle state.In this study, we developed a DATSURYOKU sensor that realizes a measurement of muscle state that involves tension as well as stable relaxation. The DATSURYOKU sensor is a capacitive sensor in the form of a wearable belt. It includes the dielectric of a silicone elastomer sandwiched between stretchable electrodes prepared by the flocking of silver-plated fibers. It can convert the change in the circumference of the wearing part into a change in capacitance. We validated the estimation of the muscle state by conducting human subject experiments using the DATSURYOKU sensor and conventional measurement devices to measure the muscle state in a multimodal manner. In this experiment, we measured motion using an optical motion capture system, floor reaction force by a force plate, and muscle activity using EMG. The muscle state is measured multimodally during excessive muscle tension (co-contraction) and walking. The analysis results show a high interclass correlation between muscle activity and circumference, and we showed that the DATSURYOKU sensor has the potential to estimate the muscle state that involves tension and relaxation.This paper is organized as follows: In this section, we describe the features and development of the DATSURYOKU sensor, as well as human subject experiments for validation.We developed a prototype wearable sensor that can measure the change in the circumference of a human thigh in real time. The sensor was designed to have two conductive layers that can be stretched and shrunk, and a dielectric layer sandwiched between them. The aim of the design was to output the change in length as a change in the capacitance of the dielectric layer. The core of the sensor is a stretchable conductive layer, which is formed by the flocking of silver-plated fibers that have been cut into short lengths. The conductive layer can maintain its conductivity even when stretched, as previously reported by Nobeshima et al. .The fabrication flow of the DATSURYOKU sensor and a schematic diagram of the cross-section to be fabricated are presented in The fabricated sensor was incorporated into a commercially available belt to provide wearability. The belt was made of nylon fiber and had hook-and-loop fasteners and hardware. The belt was cut into two pieces, and the end of the sensor was glued to each piece. An insulated nichrome wire was soldered to two terminals made of copper tape prepared during the fabrication of the sensor, making it possible to connect to the measurement device. The length of the nichrome wire was sufficiently long (5 m), such that it cannot interfere with human movement in the experiments described in The sensor was connected to an LCR meter , with To validate the DATSURYOKU sensor developed in the previous section, we conducted experiments on a human subject using the DATSURYOKU sensor and conventional measurement systems to measure the muscle state in a multimodal manner . In thisOne healthy male, 29 years old, participated in this study. The subject was not injured at the time of data collection. The protocol of this study was approved by the review committee of the local research institute in accordance with the guidelines described in the Declaration of Helsinki (1983), and informed consent was obtained from the subject. A split-type treadmill with a built-in force plate  was used for the measurements. Two force plates installed on the treadmill were used to measure the contact force between the participant and the floor. Each force plate measured the contact force and momentum in six axes at a rate of 1 kHz. In addition, the activities of the vastus lateralis (VL), rectus femoris (RF), vastus medialis (VM), biceps femoris long head (BFL), and biceps femoris short head (BFS) muscles of the right leg were recorded at a rate of 1 kHz using a wireless EMG system . A data acquisition device  and a motion capture system  were used to record three-dimensional marker positions and analog data, including contact forces and muscle activity data synchronously. The DATSURYOKU sensor was connected to a data acquisition device and a motion capture system via an LCR meter . The circumference was recorded using a data acquisition device and motion capture system, synchronized with data from other conventional measurement devices.Here, the participant performed a single maximal voluntary co-contraction of the thigh muscles for 10 s in the static standing and sitting positions, and passive extension and flexion of the knee joint 5 times in the sitting position to monitor the characteristics of the sensor. Data during walking (4 km/h) and running (12 km/h) for 2 min on the treadmill were also collected during conscious co-contraction and neutral and conscious relaxation. In addition, a series of five maximal voluntary co-contractions in the sitting position and five squats were performed as movements with and without explicit co-contraction.The recorder circumference data from the DATSURYOKU sensor were low-pass filtered at 10 Hz using a second-order Butterworth filter. The recorded GRF data were low-pass filtered at 50 Hz using a second-order zero-lag Butterworth filter . The EMG−3 mg/mm2, because the area of the flocking was 15 mm wide and 150 mm depth. The sheet resistance of the conductive film measured by the four-terminal method was 1.2 ± 0.1 Ω/sq. This electrical resistance is comparable to that in our previous report [The appearance of the fabricated sensor is shown in s report . Compares report ; moreoveL (mm)) is expressed in terms of its capacitance (C (nF)), which results in Equation (1). From these results, we succeeded in developing a stretchable sensor that measures the change in length from the change in capacitance with good wearability.Here, we outline the results of multimodal measurement of muscle state in human subject using the DATSURYOKU sensor and conventional measurement devices. In each graph in i-th muscle activity , and accurate comparison with EMG. Another limitation is that the DATSURYOKU sensor measures the effect of all muscles involved in the circumstance and cannot measure the independent muscle activity. We would solve this limitation by considering the musculoskeletal model and estimating this identical muscle activity by solving the mathematical optimization of somatosensory information estimation. Several directions remain for future work. Current DATSURYOKU sensors are meant for measurement in laboratory. We are working on the development of a wireless and wearable measurement with Bluetooth connection and on-tip data acquisition for the daily routine measurement. Another direction for the DATSURYOKU sensor is to realize the large-scale muscle state dataset from its daily routine measurement. We plan to apply machine learning techniques for injury risk estimation and sports performance improvement. Another direction is to apply the DATSURYOKU sensor only on the young subject. With further experimentation, we plan to validate this sensor for elderlies and children whose muscle properties are different from young people.


The issue of malnutrition is perhaps the most important public health determinant of global wellbeing. It is one of the main causes of improper mental and physical development as well as death of many children. The Mid Upper Arm Circumference (MUAC) rapid text setup is able to diagnose malnutrition due to the fact that the human arm contains subcutaneous fat and muscle mass. When proportional food intake increases or reduces, the corresponding increase or reduction in the subcutaneous fat and muscle mass leads to an increase or decrease in the MUAC. In this study, the researchers attempt to develop a model for determining the performance of MUAC in predicting Child malnutrition in Ghana. It focuses on the Joint Generalized Linear Model (Joint-GLM) instead of the traditional Generalized Linear Model (GLM). The analysis is based on primary data measured on children under six years, who were undergoing nutritional treatment at the Princess Marie Louise (PML) Children’s Hospital in the Ashiedu Keteke sub-metro area of Accra Metropolis. The study found that a precisely measured weight of a child, height, and albumen levels were positive determinants of the predicted MUAC value. The study also reveals that, of all the variables used in determining the MUAC outcome, the hemoglobin and total protein levels of a child would be the main causes of any variation between the exact nutritional status of a child and that suggested by the MUAC value. The final Joint-GLM suggests that, if there are occasions where the MUAC gave false results, it could be a result of an imbalance in the child’s hemoglobin and protein levels. If these two are within acceptable levels in a child, the MUAC is most likely to be consistent in predicting the child’s nutritional status accurately. This study therefore recommends the continued use of MUAC in diagnosis of child malnutrition but urges Ghana and countries in Sub-Saharan Africa to roll out an effective nutrition intervention plan targeting the poor and vulnerable suburbs so that the nutritional status of children under five years of age, who were the focus of the current study, may be improved. Malnutrition remains an important public health issue all over the world. It is seen by many stakeholders to be the main cause of improper mental and physical development of children. Studies have shown that whereas about a quarter of the children less than five years of age are stunted worldwide, about 9% of the children in Sub-Saharan Africa have moderate acute malnutrition with about 2% of them having severe acute malnutrition , and neaThe reason for use of the Mid Upper Arm Circumference (MUAC) in the diagnosis of malnutrition lies in the fact that the human arm contains subcutaneous fat and muscle mass. When proportional food intake reduces, the corresponding reduction in the subcutaneous fat and muscle mass leads to a decrease in the MUAC. Many researchers have therefore continually recommended the use of this rather very simple-to-use and low-cost tool in screening for malnutrition among children less than five years of age ,6,7,8).,7,8.6,7,Even though MUAC is used as a rapid indicator for screening for acute malnutrition in children, its cut-offs remain controversial among researchers and other stakeholders. In their recent study, Fiorentino et al.,  tried toThe agreement between MUAC and weight-for-age also appears to vary within different groups of children . It is tThe use of MUAC to identify children for admission into nutritional treatment has been well explored ,13 as weThis study is relevant in both design and purpose. In design, the choice of statistical modeling in the study of an important public health issue shall enable us to identify the key variables relevant for the adequate description of a given subpopulation by the reliance upon some mathematical expressions representing their distributions. Most important to this study is our interest to identify possible sources of discrepancy in the MUAC’s ability to predict malnutrition in children under five years of age. The study therefore explores the Joint-GLM approach to elicit the two main objectives of this study. In purpose, this study adds to the ongoing discussion on malnutrition in children under five years of age with the aim of contributing to the knowledge on the possible occasions where the MUAC may give false results.Data for this study were obtained from a cross-sectional survey conducted between December 2018 and May 2019. The study setting was the pediatric unit of the Princess Marie Louise children’s Hospital (PMLCH) in the Ashiedu Keteke Sub-Metro of the Accra metropolitan assembly. In all, a sample of 163 malnourished children were used for our analysis and reporting. Variables measured include MUAC as the dependent variable, with a child’s age, height, weight, hemoglobin level, total protein, and albumen as independent variables. Data cleaning and editing was done daily.Two trained personnel assisted in the process of data collection; one collecting data on MUAC, age, weight, and height, while the other assisted in recording clinical data  that were made available to us by the laboratory department of the hospital. Recumbent length was measured for children less than 24 months while standing height was measured for children 24 months to five years. The Schorrboard  was used in measuring length and recordings were made to the nearest 0.1 centimeter (cm). In the measurement of weight of a child, the Seca 874 scale  was used. Weights were recorded to the nearest 0.1 kilogram. MUAC was measured to the nearest 0.1 millimeter (mm) using the Johns Hopkins University MUAC tape.Ethical approval was sought and obtained from the PML children’s hospital. Informed consent was sought from the mothers and caregivers of each participant. The right of participants to decline participation was strictly emphasized and respected throughout the study data collection. Data have been and would continually be treated with absolute confidentiality.The R-console statistical software was used in analyzing the data and generating all diagnostic plots. Descriptive analysis was used first to summarize the data, then correlation analysis was done to explore the relationship between the variables under study.In theory, the traditional generalized linear model (GLM) is obtained from classical linear models by two extensions, one to the random part and another one to the systematic part . By thesy-axis are known as outliers. Discrepancies amongst the data and the fitted values generated by GLMs fall into two main classes; isolated or systematic , j = 1, 2, 3, …, 6 [number of independent variables] on which the expected value A linear function of the regressors called the linear predictor,An invertible The method used in this paper follows the Joint-GLMs of Lee and Nelder . By theip-value <0.2 in a preliminary exploratory backward elimination procedure. Correlations among independent variables (multi-collinearity) were examined and we can report that independent variables used in this analysis are not collinear.Model selection was done by computing and assessing three very useful criteria in statistical modeling; the Akaike Information Criterion (AIC), the conditional-AIC (cAIC), and the Bayesian Information Criterion (BIC). These criteria enhance the exploratory power of statistical models while penalizing model complexities. As a rule, when the three criteria disagree on the best-fit model by generating varying values, we choose the model with the lowest AIC. This is done to guard against false negative models. In this study, therefore, the best model shall be adjudged to be that with the lowest value for the Akaike information criterion (AIC), the Bayesian Information criterion (BIC), and the conditional Akaike information criterion (cAIC). The data-driven statistical bias was minimized by the rigorous selection of variables selected only upon securing a minimum This study measured height (length) and weight of children as well as the MUAC and other biomedical indicators used in malnutrition determination . The desSimilarly, the weight of a child is highly correlated with the MUAC and the height of a child, the values are 0.768 and 0.773, respectively. Our dependent variable MUAC, however, showed a moderate correlation with all the dependent variables except for the weight of a child. Similarly, the weight of a child is highly correlated with the MUAC and the height of a child, the values are 0.768 and 0.773, respectively. Our dependent variable MUAC, however, showed a moderate correlation with all the dependent variables except for the weight of a child. From the parameter estimates , the fitBefore applying the distributional results for inference, it is always necessary to check that the model meets its assumptions well enough to be sure that the results are likely to be valid. Similarly, On all the three bases for best model selection see  the AkaiAge is found to be highly determinant for the accuracy of MUAC (coefficient = −2.477) but it does so inversely. This implies that, as you grow, the ability of the MUAC to accurately predict acute malnutrition reduces. Fiorentino et al.  recommenFrom the dispersion model in In the anthropometric study of Grellety and Golden  in some There are several strengths of this study. Data for the study came from a population-based sample hence providing a useful representation of the Ashiedu-Keteke sub-metropolitan area as whole. Misclassification was minimized significantly with the use of standardized data collection tools and triplicate measurements of anthropometric indicators. Again, whereas many models used in Child malnutrition studies are unable to establish a causal relationship between the observed dependent and independent variables, our Joint-GLM is able to establish such a relationship demonstrably well, thereby improving the quality of the model. Our model is able to identify sources of discrepancy in reaching accuracy, making it possible for policy makers to determine the fate of such variables in the future. However, one notable limitation of this study includes the sample size, which was admittedly small to examine moderate to severe acute malnutrition. Some previous studies ,22 have An imbalance hemoglobin level is an indication of an iron-deficiency anemia usually resulting from low consumption of fish, meat, vegetables, and also due to general low intake of proteins. For the two determinants (hemoglobin and protein) to be accounting for this discrepancy, policy makers may wish to address the possible food insecurity likely to be the main underlying cause of malnutrition for households from where these children are coming. Intervention strategies aimed at improving knowledge of caregivers on the subject of nutrition as well as food supply to these caregivers from poor socio-economic homes. The time for an effective nutrition intervention plan targeting the poor and vulnerable suburbs in Ghana has been long overdue.In addition, this study identifies hemoglobin and protein as the key clinical factors that might trigger the all useful MUAC to be unreliable. These two clinical factors will assist in the proper allocation of health resources aimed at improving child nutrition at both the individual and community levels; most especially in poor socio-economic homes.On the basis of the study outcomes, the ministry of health and the government of Ghana need to critically consider formulating and implementing community-based interventions to improve child health. At the individual level, caregivers especially mothers should be adequately educated in basic nutrition and the need to frequently visit health facilities to be sure of the child’s nutritional status. In addition, mother–child programs should be made readily accessible to women in poor communities across Ghana by our health care system. It is our hope that these interventions, if considered by Ghana and countries in Sub-Saharan Africa, may go a long way to improve the nutritional status of children under the age of five years, who were the focus of the current study.This study selects seven key determinants of the accuracy of MUAC in the determination of malnutrition of children under the age of five years. They include age, height, weight, and their interactions , albumen level of a child. More importantly, the model suggests that, if there are occasions where the MUAC gave false results, it could be a result of an imbalance in the child’s hemoglobin and protein levels. If these two are within acceptable levels in a child, the MUAC is most likely to be consistent in predicting child nutritional status accurately.We again conclude that even though the traditional GLM is still a satisfactory mean model, modeling the mean and dispersion (Joint-GLM) improves the quality of the models significantly and also provides two very important pieces of information; the value of discrepancy, and the actual variables causing it. Once any variable is found to account for a discrepancy, policy makers can then decide what should be done in respect of the particular disturbing variable. They may decide to re-measure, modify, or even ignore depending on the nature of the discrepancy they introduce.


Globally, lower respiratory infections (LRTIs) are one of the most common infectious diseases whichaffect majority of the population and as a result of inappropriate antibiotics practices lead to antibiotic resistance (AR). An individual randomized control trial will be conducted in the post-conflict areas of Swat, Pakistan, through a random sampling method. Patients aged > 18 years will be recruited from five community pharmacies and assigned to equally sized groups to receive either pharmacist-led education interventions or usual care with no intervention. A total of 400  patients will be included, with prescriptions comprised of antibiotics for LRTIs. The outcomes measured in both groups will be a combination of treatment cure rate and adherence, which will be assessed using the Morisky Medication Adherence Scale and pill count. The trial comprises pharmacist-led educational interventions to improve treatment outcomes for patients with LRTIs. This study might establish the groundwork for pharmaceutical care of LRTIs patients with antibacterial therapy and the future delivery of a care strategy for the improvement of LRTIs treatment outcomes in post-conflict, remote areas of the third world and LMICs. Trial registration: Chinese Clinical Trials Registry, identifier: ChiCTR2000040453, registered on 28 November 2020.Lower respiratory tract infections (LRTIs) are a type of acute sickness that lasts for 21 days or less and is characterized by the presence of at least one other lower respiratory tract symptom, in addition to the main symptom of cough , with no other suitable explanation  ,4. The LNonetheless, antibiotics are still used for the treatment of LRTIs, resulting in the development of antimicrobial resistance ,13. AntiEducational interventions could increase appropriate antibiotic prescription, dispensing, and/or use, which are commonly employed multimodal interventions ,21,22. EThe post-conflict areas (Swat) of Pakistan have witnessed extensive militancy since 2007. This has continued for many years, as the majority of the population of rural areas were displaced and migrated to the safest areas of the country . During Therefore, this study aims to determine the adherence to prescribed antibiotics through educational interventions in post-conflict rural areas of Pakistan.The main objective of the current trial is to test the adherence to LRTI treatment in the local/rural villages of Swat, Pakistan. The secondary objective is to assess the improvements and the success rate of the therapy. First, the quantitative part will be completed; then, a qualitative interview will be conducted.The primary hypothesis is; the intervention group will gain knowledge of, and adhere to, the prescribed therapy for LRTIs at a higher rate than the control group at 2 and 7 weeks. The secondary hypothesis is as follows.Post-assessment will be conducted in the second week and endpoint evaluation at the end of seventh week; participants who received the intervention are expected to report positive changes in terms of their adherence to the medication and a reduction in antibiotic storage. After the seventh week, those in the intervention group are more likely to stick to their prescribed medication. Following the quantitative phase of the research, a qualitative assessment will be conducted to determine its acceptability.This is a two-arm, single-blind, individual, randomized, controlled trial that will determine the effectiveness of pharmacist-led educational interventions for the patients who approached pharmacies with LRTI prescriptions. The present study will be conducted in a community-pharmacy setting in the rural region of Pakistan. The iRCT will be favored to reduce possible contamination between the two groups. The standard protocol items; recommendation for interventional trials (SPIRIT) used in the current trials are presented in Swat, formally known as the ‘Yousufzai State of Swat’ (1849–1969), has a population of 2.3 million at present, and is one of the rural districts in the northern region of the Khyber Pakhtunkhwa, Pakistan. About 86% of the total population lives in rural areas ,27. SwatThe data collector team will be comprised of healthcare workers . The trained pharmacists will select pharmacies  to recruit participants, with their full consent . LeafletThe data collector team will have the required qualifications, and the pharmacist must be registered with Pakistan Pharmacy Council (PPC) . The phaThe pharmacists and other healthcare members must be trained for the counseling sessions with participants at community pharmacies. Effective training in communication skills will be held before the execution of the trials, and pseudo-patient training will be arranged to assess their counseling skills at community pharmacies. Finally, the principal investigator will approve the trained team for the trial.We have designed educational interventions and a brief, telephone-based intervention strategy will be developed for the EATSA based on WHO/CDC evidence-based guidelines for antibiotics adherence. Before its implementation, a period of formative and contextual work will be adopted, especially training in the intervention materials, to the study population in rural areas of Pakistan.Firstly, at the community pharmacy, a trained pharmacist and team will provide written information to the intervention group participants about the use of antibiotics and adherence to the prescribed antibiotics therapy for LRTIs, and discourage the storage of antibiotics at home. An educational leaflet will be designed, containing information based on ‘Get Smart: Know when Antibiotics work’ by CDC . The wriAfter the educational interventions at the community pharmacies, a follow-up will be continued up until the 7th week. The first telephone call will be made at the start of the second week and the therapy success will measure the rate of adherence to the prescribed antibiotics. Then, a follow-up with a brief educational strategy will continue throughout the study period, and a 3rd, 4th, 5th, and 6th call will be made to enhance the participants’ knowledge related to proper antibiotics use. The 7th week of the trial will be the assessment week and will measure the overall knowledge as a primary and secondary outcome.Participants in the intervention and control (arms) groups will continue to receive pre-planned, routine telephone calls on an individual basis and the care would be considered enhancement care. The primary care, the antibiotics therapy, will not involve any placebo, and the focus will adhere to the prescribed treatment. The usual care will consist of: (i) primary healthcare provider, pharmacists and assistants trained in interaction with and supervision of treatments with antibiotics; (ii) providing feedback results to all participants about their assessment; (iii) information will be provided about the options for appropriate care and treatment through the nearest tehsil headquarter hospital (THQ) or tertiary care facility.Both arms are equally free to BUC through their routine health providers. Finally, on the 7th week, the strength of the services will be measured. The evaluation will be carried out and reported in a timely manner.The previous literature will serve as a guide for calculating sample size, based on the effect of the prescribed antibiotics and pharmacist-led educational interventions on successful adherence to therapy ,32. A saOnce their complete consent has been given, patients diagnosed with LRTIs  will be Using a computer-generated random digit number, a biostatistician will construct a random allocation order that is independent of/blinded to participants and trial size. For every participant that is recruited, a sample 1:1 is used to allocate them into control and interventional groups. Finally, ten pharmacists will be randomized to the intervention and control arms 1:1 and the permuted method will be used. This will be accomplished by the study teams exchanging a list of pharmacists, each of whom has a unique number assigned to them. The status of allocation will be conveyed to the research team coordinators, who will notify individual pharmacists as soon as the participants’ agreement to trial participation is obtained by research teams.Before preceding to random allocation into either the control or intervention arm of the study, an informed consent/agreement ascertainment and eligibility will be obtained. The allocation will not be known to research assistants, participants, or trial representatives (pharmacists) until the point of randomization. Interventional households will only be known to research assistants. The participants will be introduced to the interventional arm facilitator individually, by mobile phone call. If the pharmacists and research teams are allocated to the control arm, they will continue to regularly contact the allocated UC.At first, data from patients’ medical records reporting LRTIs  would be collected by trained pharmacists at community pharmacies, and the pharmacist team will remain blinded to the outcomes. A complete booklet of educational written information will be provided to participants in each interventional arm. The booklet will include materials that are relevant to antibiotic use, such as graphical leaflets, antibiotic dosing regimens kept on sticky notes, adherence, and prevention of antibiotic storage in the home. Following this textual counseling, oral/verbal counseling will be delivered in the patient’s usual area of counseling at a pharmacy. The patient’s information will be transferred to pre-determined data collection forms and stored securely. For the follow-up phase, patients’ valid mobile phone numbers will be collected and retained for future contact and follow-up. The trial team members will contact the participants through their mobile phones in both union councils. After one week, patients will be asked to exhibit their prescribed antibiotics, and the first therapy outcomes will be checked at the beginning of the second week. Finally, in the final session of the trial, a qualitative interview will be scheduled for the 7th week of the study. To keep data quality high, data collection should be current and dependable. As a result, at least three meetings will be held for the field assistance members (pharmacists) to keep the records up to date. The lead investigator will collect all data once a week, as in Blinding is impossible in the present intervention, due to its educational nature. However, to reserve a certain level of blinding, to maintain and protect the bias sources, some measures have been taken. Detailed information related to blinding is shown in To control the attrition rate among patients, pharmacists will contact all intervention study participants that were enlisted via phone or text message before their scheduled follow-up session. LRTI patients who have some issues or are not prepared for a follow-up visit will be revealed, and the self-actualization survey will be completed via call if possible. The appointment can be moved to an alternate day, but the one-week treatment outcomes must be reported through mobile phone. The outcomes of the study will be based on measures of primary and secondary outcomes.The primary outcome for individuals with LRTIs will be measured through the beliefs about medicine questionnaire (BMQ), purely to observe the participant’s beliefs about AB . The BMQThe measure of adherence to the prescribed therapy for LRTIs will be a secondary outcome. MMAS-8 combined the adherence endpoint scale and (% age) rate of pill count; this will be used to assess the AB adherence in LRTI patients. The first seven items of the MMAS-8 adherence scale must be answered with a yes or no (dichotomous) response, while the next five questions are on a Likert scale ,36. The The trial team will conduct over 20 semi-structured interviews with a random subset of participants. The trial will include individuals with same number of dropouts and completers, and a semi-structured interviewing guide that covers a topic relevant to each respondent category. Through a mobile phone call, all interviews will be recorded (audio) through a mobile phone recorder with prior consent ,39. To aData will be managed per established norms. Monitoring will be required at all stages to gather true, authentic, and verified data. Every day, the principal investigator’s field office will save the data on a paper evaluation study booklet with a participant’s given codes. The data will be checked by the lead investigator, with all highlighted queries being rectified as soon as possible, and any discrepancies being resolved by a third data entry person. Following the creation of electronic files, all data will be password-protected, and only authorized individuals will have access to the database, which will be backed up every day. The participant’s information will remain confidential to maintain quality and data secrecy. Only pharmacists will be aware of the private information in the intervention; all data forms will be kept in closed filing cabinets. The trial team will monitor the trial progress on a daily basis.According to the Consolidated Standards of Reporting Trials (CONSORT) for RCTs, all the findings will be reported as per the given guidelines . Data wiThe information collected from patients, after statistical analysis, would be given to the allocated principal investigator in the field staff, who will serve as independent witnesses. The information from the research meetings in the study will become the property of the trial ethics committee, and they may request to discuss the individual information of the LRTIs patients in order to evaluate their therapy improvement. Authorship of the journal publication will be decided according to the guidelines described by the International Committee of Medical Journal Editors (ICMJE).All the events related to adverse drug events (ADEs) occurring as a result of anti-infective therapy will be recorded by field staff. The ADRs will be observed and within 48 h, it will be decided whether the event occurred due to the antibiotics or other medicines. Trial staff will determine the appropriate action if necessary. The principal investigator will be in contact with the trial participants and ethical approval bodies.The authors are not aware of a theory that can be utilized to support the development of interventions aiming to enhance adherence to prescribed antibiotics and discourage the household storage of antibiotics in Pakistan. Hence, the overall goal of this study is to assess whether an intervention by authors with educational leaflets will enhance adherence and reduce the storage of unused antibiotics in households taking antibiotics. There is a possible association between adherence to prescribed antibiotic use and general beliefs about antibiotic storage. This study is based upon the existence of evidence that people use antibiotics in the wrong way. This is the most ignored area in the country at the community level. Additionally, the present study aims to contribute, on a humanitarian level, to the existing knowledge, along with the related factors regarding the inappropriate use of antibiotics.Pakistan has a high rate of excessive use of medications compared to other low–middle-income countries (LMICs) with irrational prescribing, high amounts of injectables (antibiotics), costly drugs, inappropriate dispensing, and weak regulations for community pharmacies . Policy In conclusion, once antimicrobial drugs were considered curative and lifesavers. At present, due to the global emergence of AMR, the value of these agents is under pressure. Many factors are leading to the storage of antibiotics at home, and this can raise rates of misuse, increase antibiotics’ resistance, increase wastage, and cause patients to fail to adhere to therapy.


Background: Pregnancies that follow perinatal loss are often associated with mental health disorders, which are not usually treated or even identified. Objectives: The main study aim is to identify the prevalence of symptoms of post-traumatic stress disorder and complicated perinatal grief at different stages of pregnancy following a prior gestational loss. Methods: This descriptive longitudinal study will be conducted with a twelve-month follow-up. The study variables addressed will include sociodemographic data  together with clinical data on complicated perinatal grief and post-traumatic stress disorder scores. Results: The results obtained are expected to provide a new perspective on the healthcare approach to perinatal loss and subsequent pregnancy. Conclusions: We seek to optimise comprehensive healthcare in cases of pregnancy following previous perinatal loss and to evaluate options to minimise possible risks. Perinatal loss can be defined as that which takes place at any time from the moment the pregnancy becomes known until the first month of the child’s life . ConsequKennell, Slyter and Klaus (1970) were the first to identify mothers’ reactions to the loss of their newborn and to explore the strength of the bond between the mother and her unborn baby . The ackPerinatal loss can be a traumatic experience with significant repercussions that are not only physical but also have psychological and social consequences. Although perinatal loss, especially when it is early, has little social recognition or consideration, a growing body of evidence suggests that its effects can be as shocking as any other loss and should be acknowledged as such .It is estimated that up to 25% of pregnancies end with perinatal loss, and that 50–80% of women who experience perinatal loss conceive again . AccordiThe relevance of this work is oriented to the study of the symptoms of perinatal grief and post-traumatic stress disorder (PTSD) in pregnancy after a perinatal loss and the analysis of related risk factors. Although there have been numerous studies on PTSD and perinatal grief after perinatal loss, there are fewer studies that address these symptoms during the course of a subsequent pregnancy and its evolution over time. In view of these considerations, the study presented is intended to extend our understanding of the consequences of perinatal loss on the parents’ mental health and of how related problems may arise even after the successful outcome of a subsequent pregnancy. The ultimate treatment goal in this area of healthcare is to improve the status of those involved following a gestational loss and to ensure the necessary resources are available to provide the services needed.The study aim is to identify the prevalence of symptoms of PTSD and complicated perinatal grief at different stages of pregnancy following a previous gestational loss.To identify possible differences in the incidence of complicated perinatal grief and PTSD in the different types of gestational loss.To identify risk factors for the development of complicated perinatal grief and PTSD during pregnancy subsequent to gestational loss.To identify possible gender differences in the prevalence of complicated perinatal grief and PTSD during pregnancy after perinatal loss.Specific goals:This quantitative study protocol is based on an observational, descriptive and longitudinal design, with a 12-month follow-up. The reference population for the study is that of all women in the province of Malaga (Spain), together with their partners, who have become pregnant after suffering a previous perinatal loss. They will be recruited through the pregnancy consultation, which is a health program for low-risk pregnancies included in the National Public Health System of Spain. Pregnant women attend this consultation early in pregnancy. Collecting the clinical history, the obstetric formula will identify those women who have suffered a perinatal loss before . All women and their partners who attend the Pregnancy Programme consultation at any of the health centres in the province of Malaga and meet the following inclusion criteria: of legal age, have suffered a previous perinatal loss , and who agree to take part will be invited to participate in the study.Persons who do not understand Spanish, the language in which the questionnaires are presented, will be excluded. To determine the prevalence of complicated perinatal grief, for a total population of 13,434 women with full-term pregnancy resulting in live birth , with an alpha value of 0.05 and a precision of 8%, the participation of 112 couples is needed to enable a prevalence of 25% to be detected .To determine the prevalence of PTSD, for a total population of 13,434 women with full-term pregnancy resulting in live birth , with an alpha value of 0.05 and a precision of 8%, the participation of 99 couples is needed to enable a prevalence of 21% to be detected [To determine the relationship between complicated perinatal grief and PTSD, the participation of 103 couples is needed to enable a minimum correlation coefficient of 0.60 to be detected, with an alpha value of 0.05, a power (1-beta) of 0.95 and a null correlation hypothesis of r = 0.35.To achieve these three objectives, we will therefore obtain a sample of 115 couples.During the follow-up period, the participants will be contacted by email, once during each trimester of the pregnancy and once at the end of the puerperium, i.e., ≥40 days after delivery.The scale proposed in 1989 by Potvin, Lasker and Toedter  and adapThe Davidson Trauma Scale , presentSociodemographic data will be collected via an ad-hoc questionnaire.Sociodemographic variables: age, sex, education, marital status, employment status.Obstetric history: probable date of delivery, number of pregnancies, number of perinatal losses, number of children, type of perinatal loss, gestation week in which the loss occurred.Perinatal grief score: according to the Perinatal Grief Scale.PTSD score: according to the Davidson Trauma Scale.Study data will be obtained by means of self-administered questionnaires, available via forms on an online application.Descriptive statistics will be derived by exploratory analysis and frequency distributions by determining the normality of the distribution of variables (using the Kolmogorov–Smirnov test) and by the analysis of asymmetry, kurtosis and histograms.Bivariate analysis will be performed and differences evaluated using Student’s t and Wilcoxon tests, according to the normality of the distributions. Chi-square tests will be performed to determine the relationships between the qualitative variables considered.The relationship between PTSD and perinatal grief will be determined by calculating Spearman’s correlation coefficient, with the corresponding 95% confidence intervals.Finally, multivariate logistic regression models will be constructed to evaluate the factors associated with the appearance of perinatal grief and PTSD.All analyses will be carried out using SPSS 25  GPower  and Epidat 4.1 software .This study has been approved by two Research Ethics Committees. During its implementation, all applicable standards of good clinical practice and the ethical principles established in the Declaration of Helsinki will be applied at all times. The current regulations on data protection and privacy will be complied with. Signed informed consent will be obtained from all participants. All participant data will be anonymised by assigning an alphanumeric code. The data processing will be for research purposes only. Although the question of perinatal loss has drawn increasing attention, the situation of persons experiencing another pregnancy after such a loss is rarely considered in clinical practice . In paraIn Spain, in particular, little is known about the impact of perinatal loss during subsequent pregnancy. To our knowledge, no systematic interventions in this respect have been conducted, despite the valuable findings reported from studies elsewhere ,18,19. TIn relation to our objectives, in previous studies we can observe that Callister uses the term "incongruous grief" to refer to gender differences in the experience of perinatal loss, arguing that mothers tend to exhibit longer and more intense periods of grief, and they are more emotionally expressive . Men, onIn agreement with another of the objectives, the available literature classifies perinatal grief as an important predictor of PTSD symptoms . EngelhaRegarding risk factors, Armstrong, Hutti and Myers 2009) examined depression, anxiety, and post-traumatic stress disorder experienced during pregnancy and the postpartum period in couples who had previously suffered perinatal loss. These authors found significant correlations between depression, post-traumatic stress disorder and anxiety. Greater intensity of grief was associated with higher levels of PTSD . This co examinedThe main limitation envisaged concerns the recruitment of participants . This recruitment will have to be carried out in the health centres involved and will require the cooperation of the personnel in each case. Another possible limitation may be due to not considering the mental health history of the participants. Furthermore, the longitudinal nature of this study means that a certain percentage of losses to follow-up must be taken into account. Accordingly, in calculating the necessary sample size, an estimated 15% of losses to follow-up are included.As the main outcome from this research, we expect to obtain data confirming the existence of significant levels of PTSD and symptoms of complicated perinatal grief during pregnancy after prior gestational loss. We aim to identify the risk factors for these conditions and to determine their possible evolution over time. The overarching goal is to facilitate the adaptation of comprehensive care for persons in this type of situation and, from a psychosocial perspective, evaluate possible healthcare interventions to enhance outcomes and minimise risks.


Unmanned aerial vehicle-based remote sensing technology has recently been widely applied to crop monitoring due to the rapid development of unmanned aerial vehicles, and these technologies have considerable potential in smart agriculture applications. Field phenotyping using remote sensing is mostly performed using unmanned aerial vehicles equipped with RGB cameras or multispectral cameras. For accurate field phenotyping for precision agriculture, images taken from multiple perspectives need to be simultaneously collected, and phenotypic measurement errors may occur due to the movement of the drone and plants during flight. In this study, to minimize measurement error and improve the digital surface model, we proposed a collaborative driving system that allows multiple UAVs to simultaneously acquire images from different viewpoints. An integrated navigation system based on MAVSDK is configured for the attitude control and position control of unmanned aerial vehicles. Based on the leader–follower-based swarm driving algorithm and a long-range wireless network system, the follower drone cooperates with the leader drone to maintain a constant speed, direction, and image overlap ratio, and to maintain a rank to improve their phenotyping. A collision avoidance algorithm was developed because different UAVs can collide due to external disturbance (wind) when driving in groups while maintaining a rank. To verify and optimize the flight algorithm developed in this study in a virtual environment, a GAZEBO-based simulation environment was established. Based on the algorithm that has been verified and optimized in the previous simulation environment, some unmanned aerial vehicles were flown in the same flight path in a real field, and the simulation and the real field were compared. As a result of the comparative experiment, the simulated flight accuracy (RMSE) was 0.36 m and the actual field flight accuracy was 0.46 m, showing flight accuracy like that of a commercial program. Owing to the recent breakthrough in unmanned aerial vehicles (UAVs) or drones, their applications in the agricultural field, such as in crop monitoring, detection of crop diseases, digital surface modeling (DSM), sowing, spraying, irrigation, and mapping, have significantly reduced working hours and labor requirements, greatly improving the efficiency of agricultural work. In particular, they are widely used for remote sensing ,2. CurreIn general, UAVs are widely used for farm work, such as crop monitoring, control, and sowing, which are required for agriculture. As UAVs use batteries as their main power source, a single UAV has limited operating time, taking considerable time to cover large areas. Multiple images taken from different directions are required for the precision maps used in precision agriculture, and field phenotyping requires high accuracy . Thus, tIn general, in the case of UAVs applied to agriculture, scanning is carried out over a large area. Such remote sensing can be used to accelerate the arduous process of performing crop inventory and yield estimates for large areas. Area sizes typically used for remote sensing in agriculture, ranging from 5 to 10 hectares, are used for remote sensing and generating field phenotypes . HoweverMany studies have been conducted on measuring field phenotypes (crop height) using drone-based remote sensing. Christiansen et al. created a point cloud by combining the GNSS and an inertial measurement unit with LiDAR data. The created point cloud was mapped and analyzed using the functions of ROS and Point Cloud Library. Based on the analyzed crop height and volume, it was possible to estimate crop yield and nitrogen concentration . Torres-can time . Howevercan time  and plancan time  are consMany studies are underway to reconstruct the 3D phenotype models of crops using images taken from multiple perspectives ,36,37,38This study aimed at developing a system for the collaborative driving of multiple UAVs to improve the accuracy of field phenotyping using UAV-based agricultural remote sensing, thus optimizing the cost, efficiency, and productivity, while reducing the impact on the external environment. The specific purposes of this study were: (1) to design, build, and test multiple UAVs; (2) to develop an algorithm to enable the collaborative driving of multiple UAVs; and (3) to verify the multiple UAV collaborative driving algorithm thus developed and optimize the variables, with a comparative verification experiment conducted by comparing it with the commercial GCS system in the simulation environment and the real world.In this study, two unmanned aerial vehicles were produced, and a cooperative driving algorithm and collision avoidance algorithm were developed for stable swarm flight to improve phenotyping. After optimizing and verifying a number of unmanned aerial vehicles to which the developed algorithm is applied in the simulation environment, the same algorithm was applied in the real field to compare the simulation and real-world performance. In addition, a performance comparison with commercial programs was conducted. Flight accuracy and total flight time were used as indicators for algorithm evaluation and performance comparison.The UAV’s status information, location/attitude information, and control commands are transmitted and received between each UAV and the GCS (PC) through wireless communication (telemetry radio). Because telemetry radio supports only universal asynchronous receiver–transmitters , parallel communication is difficult. To use the UAV monitoring and control programs simultaneously in this study, the UART communication was changed to user data protocol (UDP) communication using the micro air vehicle link (MAVLink) router. MAVLink is a protocol for communicating with small, unmanned devices and different internal components within itself, and provides reliable data exchange . The traThe GCS developed in this study receives the status and location information of the UAV through wireless communication (radio receiver), and converts the transmitted and received information into the UDP format through the MAVLink router. Each UAV is given a unique IP address and a port number, and each UAV’s status and location information are transmitted through the UDP based on the MAVLink protocol. The GCS developed based on MAVSDK uses the received location and status information of the UAV received via the UDP to implement and operate real-time UAV monitoring, the collaborative driving of multiple UAVs, and the avoidance algorithm. GCS development and operation were constructed in the Ubuntu 18.04.6 environment, and it was confirmed that GCS and UAV were wirelessly connected to each other for monitoring and control. In the operation of multiple UAVs, a unique flight path must be generated for each UAV. Many variables  must be considered to generate flight paths that are optimized for the image acquisition area and multiple UAVs. To create a waypoint, the image size and overlap ratio among both forward and side directions were considered, as shown in Multiple UAVs fly by following individually entered flight paths. The developed collaborative driving algorithm facilitates the following mechanism: the location information of each UAV is synchronized with the GCS; therefore, if external environmental factors (wind) or flight latencies of other UAVs occur, the UAVs can overcome them and fly according to the set paths while maintaining a certain distance and altitude. Condition 1.Current location of UAV–target waypoint location ≤ LBO .The path needs to be updated for the UAV to fly along the path to the last waypoint while updating the waypoints. Waypoint updates are included in the algorithm for multiple UAVs. As shown in The collision avoidance function of a general commercial unmanned aerial vehicle is designed mainly for obstacles. However, the risk of collision is very high because multiple UAVs fly in close proximity as a swarm along the crop row. Usually, the possibility of collision is small, but considering the possibility of two UAVs colliding due to external disturbance (wind) or GPS error, an algorithm to eliminate the risk was developed and applied in the collaborative driving of multiple UAVs: it avoids collision automatically when two UAVs are close enough to collide with each other. The developed algorithms were verified, and a virtual environment was constructed that could conduct a number of unmanned aerial vehicle simulation flight experiments under various conditions. GAZEBO 9, an open-source robot simulator, was used for the simulation environment. The algorithm  developed in this study was checked and optimized. As the multiple-path generation algorithm and the collaborative driving algorithm of multiple UAVs are operated in conjunction, they were checked and optimized together. Optimization was performed for the size of the LBO and the maximum flight speed, which have the greatest influences on the driving algorithm. For the collision avoidance algorithm, virtual collision paths were generated to check whether the UAVs operate normally according to the algorithm.The size of the LBO is the variable that has the greatest influence on the waypoint updates. If the LBO is large, the waypoint is updated quickly, but the flight location error would be large, as the path is updated far away from the waypoint. In contrast, if the size of the LBO is small, the waypoint update takes more time, but the location error is small because the path is updated close to the waypoint. Because it is difficult to fly under the same conditions every time in the field, the LBO size was set to 0.2 m intervals in three steps  in the flight simulation environment, and the flight log was analyzed after completing the flight. Then, the size of the LBO was selected considering the total flight time and position error.The maximum flight speed is a variable that affects the path updates, such as the LBO, as well as the total flight time. An appropriate maximum flight speed needs to be set based on the distance interval between the waypoints. Basically, the UAV decelerates the flight speed as it approaches the waypoint. However, if the maximum flight speed is too high, the deceleration time will be high and the UAV will pass by the waypoint, resulting in a loss of flight time. In contrast, if the maximum flight speed is too low, the total flight time will increase, resulting in reduced flight efficiency. In the simulation environment, the maximum flight speed was set at an interval of 2.0 m/s in three steps , and the flight log was analyzed after the flight was completed. After that, the optimum maximum flight speed was selected in consideration of flight position error and total flight time.Conducting a collision experiment with the initially developed collision avoidance algorithm in a real-world environment would involve a very high level of risk. Hence, the algorithm was firstly tested in the developed simulation environment. Multiple UAVs were configured to fly normally along the paths and then collide with other UAVs by arbitrarily modifying the paths. Here, the flight logs of multiple UAVs recorded in the simulation were analyzed to check whether they avoided collisions normally and returned and landed at home according to the collision avoidance algorithm.Communication latency is unavoidable in long-distance wireless communication. Therefore, the experiments were conducted on long-range wireless communication between GCS and UAV in real field environment. In this study, a Telemetry Radio V3 433Mhz (the same communication device used in this study) and an additional microcontroller were attached to the UAV to measure the loss rate and latency in radio communication. The flight experiment was conducted by applying the multiple-path generation algorithm and the collaborative driving algorithm of multiple UAVs—which were checked and optimized in advance through simulations—to the real field. The experiment was conducted on the sports field (open field) of the Kangwon National University Medical School, and The flight experiment was conducted by applying the collision avoidance algorithm, which was verified in advance via simulation, to the real field. To perform collision verification arbitrarily, the collision path was generated as shown in Currently, an improved QgroundControl is being developed that enables more efficient mission planning than the existing commercial program (QgroundControl) and allows operators to build complex missions . In geneA comparative experiment was conducted for the cooperative operation of multiple UAVs in a flight simulation environment and in a real field. The simulation was configured to be as similar to the real field experiment as possible by adding an operation latency corresponding to the actual measured wireless communication latency time. All flight parameters, including the optimal flight parameters  found earlier, and multiple flight paths were set using the same conditions . After cMultiple paths were generated with the multiple-path generation algorithm developed in this study. Prior to flying, all parameters required for the flight path generation were input to generate a path for each UAV. Variable optimization for the multiple UAV collaborative driving algorithm was performed in the simulation environment developed for this experiment. In the variable optimization, nine variable combinations were used, with three levels  of speed (m/s) and three levels  of LBO (m). As shown in In the simulation environment, a large number of UAVs flew along a modified path, and different UAVs were induced to randomly collide. As shown in As a result of flight comparison experiments in the simulated environment and real field with the optimized flight variables (an LBO size of 0.4 m and a maximum flight speed of 3 m/s), the flight trajectory was as shown in As a result of the collision avoidance verification experiment in the actual field, using the collision avoidance algorithm verified in the simulation environment and the arbitrarily modified collision path, collision avoidance was normally performed, as shown in This paper developed a system for the cooperative driving of multiple UAVs to improve the accuracy of on-site phenotyping and to reduce external environmental influences when using UAV-based agricultural remote sensing. As depicted in To minimize phenotypic errors by allowing multiple UAVs to simultaneously acquire images from different viewpoints and improve digital surface models, this study developed a novel system for the cooperation of multiple UAVs to optimize the cost, efficiency, and productivity, while reducing the impact on the external environment. The GCS developed in this system communicated wirelessly with different UAVs using MAVLink, and the loss rate and communication latency were 0% and 334 ms, respectively, which were similar to those of the common wireless communication method of UAVs. A GAZEBO-based simulation environment was developed to optimize the flight parameters of the collaborative driving algorithm and conduct the preliminary verification experiment prior to the field test. Through the simulation, the optimal parameter values  were calculated. In field experiments conducted based on these parameters, it was found that two UAVs performed autonomous flight stably. The flight time and flight accuracy of the developed GCS were 185 s and 0.08 m, respectively, which increased the flight time by 58 s compared to the previous program (QgroundControl), but the flight accuracy was improved by 60%. The collaborative driving system developed in this study facilitates the collaborative driving of multiple UAVs, which cannot be performed by the existing commercial programs. Furthermore, because different UAVs are synchronized and fly autonomously by updating waypoints simultaneously, it is possible to acquire the images required for field phenotyping from multiple perspectives simultaneously, which can reduce errors in field phenotyping.


Bowling is an immensely popular, but scarcely researched sport associated with overuse injuries in its participants. The purpose of this study was to investigate and report on the incidence of common upper extremity complaints in elite bowling athletes.All Malaysian national level bowlers (n=39) were evaluated via questionnaire on their upper limb symptoms. A focused, relevant clinical examination was performed on each subject to exclude de Quervain’s tenosynovitis, tennis and golfer's elbow, carpal tunnel syndrome and trigger finger. The athletes were then allowed to resume bowling for two hours before completing another symptom-related questionnaire.Pain was the predominantly observed symptom, with a predilection for the wrist, ring and middle fingers, and thumb. De Quervain’s tenosynovitis was found in 53.8% (n=21) of the subjects, with 52.4% and 42.9% of them experiencing pain during and after training, respectively. Other repetitive injury-related disorders were also considerably more common than in their non-playing limb and the general population.The incidence of de Quervain’s tenosynovitis was exceptionally high in this population. Further studies on sports kinematics are needed to prevent long term morbidities in these athletes. In a game of tenpin bowling, a weighted ball that is gripped using only the thumb, middle and ring fingers, is swung and subsequently launched at speed along an 18m long alley, in an attempt to knock down as many of the pins as possible, thus accumulating as many points as possible. When performed repetitively, these movements could result in overuse injuries in the elbows, wrists and hands of its participants. As well known as the sport is, and despite the tremendous amount of research dedicated to the field of sports medicine, little effort has been devoted to investigating the ill effects of this sport on the musculoskeletal health of its players.3. Based upon the kinematics of tenpin bowling as a throwing sport, the game places its participants at risk of these musculoskeletal disorders. However, literature describing the relationship of competitive bowling to musculoskeletal ailments has, to our best knowledge, been few and far between. An example of this is an article by Kerr et al in 20114. The epidemiological study described bowling related injuries in patients presenting to the emergency department in 18 years. Finger injuries were the commonest predicament, followed by injuries to the trunk and the wrist. Details of these injuries were, however, vague and non-specific; they were mainly attributed to 'soft tissue injuries' and 'sprains or strains'. Furthermore, the commonest mechanisms of injuries described in the article, of tripping and falling, or being hit by the bowling ball, and injuries as a result of dropping the ball, are less likely to occur in more seasoned athletes and do not represent or occur as a result of, repetitive stress4.Approximately 3% to 25% of sports related injuries were reported to involve the wrist and handThis study was carried out to investigate, describe and report the incidence and symptomatology of common upper limb pathology in elite bowling athletes.This observational study was reported according to the STROBE guidelines. A universal sampling technique was performed: all present Malaysian National Elite Team and National Back-Up Bowling Team, coached under the same standard national elite training programme, were recruited. The bowlers were initially cross-sectionally interviewed via a questionnaire to ascertain their demographic information, bowling styles, bowling history and upper limb musculoskeletal symptoms.Parameters to determine each athlete's characteristic bowling style included their handedness and bowling handedness, preferred bowling ball weight and ball gripping methods. The weights of bowling balls were classified as light (4.5 kg to 5.0 kg), medium (5.1 kg to 6.0 kg), or heavy (6.1 kg to 7.0 kg). Ball gripping methods, on the other hand, were categorised either as 'conventional', where the ball is gripped up to the proximal interphalangeal joint or as 'fingertip', where it is gripped up to only the distal interphalangeal joint.The total period of active bowling for each bowler was recorded in the bowling history and was defined as the accrued duration, in years, spent training as a national athlete. The number of sessions of bowling and the average number of hours per session were also noted. The cumulative hours of bowling, defined as the total number of hours spent on bowling, was then derived from this data. The presence of previous and/or current upper limb musculoskeletal symptoms throughout their bowling career and the specific nature and duration of each symptom, viz. subjective pain, swelling and stiffness, were subsequently noted for both elbows and wrists and the digits of each hand.Next, a targeted clinical examination of both the upper limbs of each athlete was carried out. Tests performed were: the Finkelstein, Eichhoff and the wrist hyperflexion and abduction of the thumb (WHAT) tests for the diagnosis of de Quervain’s tenosynovitis; the Durkan test, Tinel sign, and numbness in the median nerve distribution in the digits for the diagnosis of the carpal tunnel syndrome; tenderness along with the A1 pulley and observed triggering of the digit for the diagnosis of a trigger finger; the Mill and Cozen tests, and common extensor origin tenderness for the diagnosis of a tennis elbow; and common flexor origin tenderness and pain on passive wrist flexion and forearm pronation for the diagnosis of a golfer's elbow. Each set of tests was performed only when the relevant symptoms were registered on the questionnaire. The Finkelstein, Eichhoff and WHAT tests were only performed when the subject had symptoms of wrist pain. A clinical diagnosis was made if at least one of the tests was positive for each respective pathology.The athletes were then allowed to resume bowling for two hours of their routine training sessions before another questionnaire-based evaluation of their symptoms of pain if any, was conducted. The presence of pre-game, in-game and post-game pain and their respective pain scores were recorded for the wrist and elbow pathologies of de Quervain's tenosynovitis, tennis and golfer's elbow.Data collection was led by a senior orthopaedic hand surgeon, and every member of the team was well-versed in the techniques of clinical examination of the hand and upper limb. All questionnaire and clinical examination data were transcribed and analysed using the SPSS version 25 software. Descriptive statistics were used to report demographic data and incidence of musculoskeletal symptoms. The Fisher’s exact test was used for comparison of symptoms between playing and non-playing limbs.This study was approved by our institutional ethics committee .There were 39 members in the present Malaysian National Elite Team and National Back-Up Bowling Squad, and all were recruited as subjects In terms of topographical involvement , the wriIn the ball-playing limb, wrist pain was reported to have lasted between one to 6 months in 10 (25.6%) subjects and beyond 12 months in only one (2.6%). Thumb and middle finger pain were found to have lasted between one to 6 months in one subject and beyond 12 months in another 5. Ring finger pain was reported to have lasted between one to 6 months and more than 12 months in 2 and 6 subjects, respectively. When a subsequence analysis was performed to evaluate the correlation between the two ball gripping methods In the targeted examination section 5, and even so, it was more routinely found in older age groups6. Other diagnoses of tennis and golfer's elbow, carpal tunnel syndrome and trigger finger were less prevalent but were still much more common when compared to the non-playing limb. The incidence of these disorders was also higher in comparison to the average population9.Malaysian Elite tenpin bowlers suffer from pain involving the wrist, ring finger, middle finger and thumb of the ball-playing limb. This was frequently accompanied by symptoms of stiffness and swelling of these parts of the body. Those complaining of wrist symptoms were found to have de Quervain’s tenosynovitis 80% of the time, which was the commonest diagnosis on clinical examination, with an incidence of 54%. This incidence is considerably higher than in the average population; only 0.49% of the population were reportedly affected by de Quervain’s tenosynovitis in one recent study10; this requires releasing the ball exclusively via a wrist action, which increases the work and hence repetitive strain around it. Another obvious contributing factor would be the awkward and unnatural ball-gripping technique involved, where only the thumb, middle and ring fingers are fitted within the gripping holes of a ball; the statistics in this study where many of the subjects recorded symptoms in their thumbs, middle and ring fingers, and where none of them recorded any symptoms in the index and little fingers substantiate this. The 'conventional grip' method where the ball is gripped up to the proximal interphalangeal joint by which individual bowlers prefer to grip their ball, was also found to be associated with slightly more frequent symptoms here. Although a similar comparison cannot be made in the subjects here, in view that all of them utilised the same weight class of balls, it can be asserted that the use of a heavier bowling ball would likewise increase the risk of musculoskeletal afflictions due to the increase in force required to handle and launch them.These findings can quite clearly be attributed to a few aspects of how the game is played. In order to produce a greater ‘pin action’ to generate a domino effect on the other bowling pins, players nearly always attempt a ‘hook’ to create a spin on the bowling ball12. This was reflected by the fact that a good number of these athletes bowled on, despite the awareness of their symptoms, some lasting for longer than 12 months, and that a few of them even continued training despite experiencing pain before, during and/or after their game.Another factor that should be taken into account would be the amount of time these athletes spent in training; most were observed to spend an average of two and a half hours per practice session five times a week. This may seem a fair amount given that bowling may be their primary priority as professionals, but such high frequencies of training could also precipitate an injury or pathology and/or prevent its healing14, long term morbidities or may even end careers if left untreated. It is therefore paramount that initiatives are taken to identify, diagnose and treat them at an early stage as these conditions are known to respond favourably to both non-operative and operative management. Awareness programmes, more personalised training schedules and modern training methods, an improvement in throwing technique, and the development of highly individualised equipment may help retard or deter their occurrence. The area of further research should be focused on assisting in the formulation of other preventive strategies and to improve the athletes' performances whilst protecting them from trauma.These musculoskeletal disorders may ultimately result in poorer performance, days of work lostThis study is not without limitations. The small sample size of 39 subjects precludes more complex statistical analyses and thereby the ability to arrive at more reliable and credible conclusions. This was however unavoidable as the subjects of this study constitute the entirety of the national bowling squad bowling at the highest level in our country. The questionnaire data heavily depended on the comprehension and mental recollection abilities of the subjects, and therefore may not be precise. The deployment of an experienced team to the task of data collection and of performing the targeted clinical examination may have reduced but not eliminated the possibility of data reporting errors. Lastly, many other common overuse injuries and conditions were not investigated within this observational study; an example of which is hand osteoarthritis, which was initially planned as a part of this report but only to be excluded due to the lack of radiographic support for diagnostic confirmation.Elite tenpin bowling athletes are at an increased risk of developing musculoskeletal disorders of the upper limb. The incidence of de Quervain’s tenosynovitis was exceptionally high in this population. The pathogenesis of these disorders may be linked to the kinematics of the sport and should be investigated further to improve the performances and prevent long term morbidities in these athletes.