The ultimate goal of the New Rural Cooperative Medical Scheme (NRCMS) is to improve physical and psychological health and aim to provide equitable, affordable, cost-effective healthcare services for all rural people. One of our major concerns from the perspective of policy outcome is whether middle-aged and elderly can benefit from the insurance to improve self-rated health. The main objectives of this study are to answer the questions that the reimbursement rate of the NRCMS is a possible explanation of why and how rural middle-aged and elderly shift from non-medical service inputs to medical service to produce health based on a family production theory.Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2018, which involved 1,030 rural adults aged 45 years and older, and ordinal logistic regression estimator and two-step regression were used to examine these assumptions. Our approach controlled for the health status of those people at the same administrative level of the hospital.p < 0.01) greater for those with higher reimbursement levels than for their counterparts with lower reimbursement. Third, the odds ratios of inpatient care visit, outpatient care visit, and physical examination among policyholders of NRCMS are also 1.116, 1.628, and 1.08 times greater, respectively, than their counterparts who are not satisfied with these local medical services.Our study shows some interesting results. First, the reimbursement rate of NRCMS predicted a higher level of SRH among rural middle-aged and elderly, but that all of the indirect effect of it on SRH could be explained in total by satisfaction of local medical services utilization (ab = 0.0492). Second, the results further showed that the odds ratio of satisfaction from affordable, convenient, high-quality medical services is 2.402 times (Our results concluded that generous insurance reimbursement can reduce the price of healthcare and costs of utilization that both had a dramatic effect on SRH among middle-aged and elderly when their demand for medical treatment is incurred. The government should focus on the healthcare cost, utilization, and health benefit calculations of health insurance policy options at the stage of rapid aging in rural China. Rural China is facing an increasingly serious population aging problem. At the end of 2019, the population of elderly people aged 60 years and older increased to about 253.88 million, accounting for 18.1% of China's total population  in 2003 . At its A key issue in the recent debate over preventing chronic disease in China is whether the extensive coverage of insured individuals by the NRCMS promotes their health . Some stThus, many studies have found that NRCMS is closely associated with individual health status through healthcare utilization because it can eliminate the gap in access to health care services and the financial burden of disease in vulnerable groups . HoweverIn this paper, we aim to examine how the NRCMS's reimbursement rate impacts SRH, applying the Becker family health production model as the theoretical framework . AlthougFamily health production theory states that preventive services are the best input into the production of health but generous health insurance can lower the out-of-pocket price of curative inputs relative to the price of preventive inputs and thereby distort the choice of inputs. We can conclude from those certain conditions above, rising insurance reimbursement rates may simultaneously bring the out-of-pocket medical price down and then increase the quantity of medical care demand. Thus, the insured has much less input of healthy lifestyle into the production of health. The conclusion is consistent with Ehrlich and Becker to a certain extent that the healthy people covered by generous health insurance are often not producing health in the best ways such as going to the gym, early detection of diseases or taking preventive care . HoweverTherefore, the public health insurance among the household may remain attractive because the purchase price of social health insurance is less than the other health inputs, and there is a higher probability of curing illness completely through healthcare utilization. Grossman found that although people inherit an initial stock of health that may be increased by health input, that initial stock depreciates over-time at an increasing rate . He asseOur research is different from that of others. This study assumed that the reimbursement rate of NRCMS (RRN) impacts SRH among rural middle-aged and elderly through the satisfaction of affordable, convenient, and high-quality medical services based on family production theory as the underlying framework . First, Although some studies found that the NRCMS implementation failed to reduce total and out-of-pocket (OOP) medical costs and improve access to healthcare for low-income groups such as rural middle aged and elderly people , other shttp://charls.pku.edu.cn/index/en.html). The inclusion criteria of the participants in our analysis were: (1) rural household registration and; (2) aged 45 years and older and;(3) enrolled in NRCMS or Urban and Rural Resident Medical Insurance (URMI) and; (4) no missing value in all variables. This study removed those samples with missing values because the samples of the CHARLS are large enough. Ultimately, 1,030 respondents were selected, with 837 and 193 in the NRCMS group and URMI group, respectively. All the respondents in the CHARLS provided informed written consent that was in accordance with the Declaration of Helsinki. This paper is a retrospective study based on CHARLS, in which the Ethical Review Committee of Peking University provided ethical approval of the survey .This article is a retrospective study based on the China Health and Retirement Longitudinal Study (CHARLS) in 2018 to explore the relationship between the reimbursement rate of NRCMS and SRH in a national sample of rural adults aged 45 years and older. CHARLS is surveyed by the Institute of Social Science Survey of Peking University in China, with the purpose of reflecting a large-scale national, biennial household, and representative survey of China's health, retirement, and population  represents the place where subjects received healthcare services and it is the key independent variable in our analysis. Two items were used to represent the concept of the reimbursement rate in CHARLS. The two items include total medical costs of hospitalization and out-of-pocket costs in CHARLS. First, total medical costs of hospitalization only include fees paid to the hospital, including ward fees but excluding wages paid to a hired nurse, transportation costs, and accommodation costs for yourself or family members. Second, the “out-of-pocket” part was investigated by this question “how much will you pay out of pocket for the total medical costs of hospitalization, after reimbursement from insurance?” Third, we know that total medical costs of hospitalization minus out-of-pocket medical costs equal the reimbursement for medical costs of hospitalization. Thus, RRN = [1- ], which scores on the RRN were coded from 0 to 1.It should be noted that the mediating variable is adopted in this study to answer the question, “how does RRN impact SRH in rural middle aged and elderly people?”. The mediating variable is scored with 5 points is the utilization of local medical services, are you satisfied with the cost, convenience and quality of local medical services when you visited local medical facilities? This item was scored as follows: 1 signified “not at all satisfied”, 5 signified “completely satisfied”. Three binary variables—whether you have been hospitalized in the past year, whether you visited the medical facility for outpatient care last month, and whether you had a physical examination since the last interview—are employed to reflect healthcare utilization incurred.Our analysis also controlled for a set of factors that may affect respondents' health conditions and access to healthcare. These included variables for individual social-economic demographics, health status, type and level of health facilities among the respondents, for social-economic demographics, including age, gender, education, marital status, etc. The correct identification of our statistic model that relates an outcome y (SRH) to an independent variable (RRN) relies on the assumption that there is the same or approximate health status among middle aged and elderly people in our sample. Because the scores of activities of daily living (ADL), numbers of disabilities, numbers of chronic conditions, depression, and lifestyle may be proxies for current health status, these sets of covariate variables were controlled in our study. Furthermore, in the context of Chinese medical systems, simpler health needs are handled in the rural local medical facilities and more complex cases are triaged up to the more tertiary hospitals. An obvious concern in our context is critical illness, since patients who received less reimbursement are those who went to the downtown tertiary hospital. Some of these may be more severe cases, and therefore may have reported worse health status. Thus, the second series of binary covariate variables in our study measure whether the subject incurred critical illness, such as stroke, cancer, heart disease, emphysema, etc. In addition, we also controlled the level of this medical facility and the type of this medical facility which patients visited, so, the object of our study is the rural older patients who visited for last medical care at the same type and level of health service facility.Because NRCMS, characteristic of local medical service, healthcare utilization, and SRH are usually discrete variables that are not applicable to stepwise regression referred by Baron and Kenny . The two*b represents the indirect impact of RRN on SRH. Two-step logistic regressions estimate the parameters a and b, used to test the indirect effect (mediation effect). In addition, Tofighi et al. . The product of regression coefficients ai et al.  recommenean of b .M = aX+ε1 The first step In a nonrecursive three-variable causal model above, Zhao et al.  identifiAs shown in p < 0.01) greater than their counterparts with lower reimbursement. Furthermore, model 4 to model 6 in The analysis in the theoretical framework stresses that the RRN and SRH usually are not directly connected, but are indirectly related through healthcare utilization. Our results are consistent with most of the studies that lower medical cost was associated with the probability of healthcare utilization and with a higher level of perceived health among the rural older enrollees. As shown in p < 0.01)greater for middle-aged and elderly who are satisfied with local medical service than those unsatisfied with it, regardless of health status.These results supported the family production theory that the generous insurance reimbursement reduces the price of medical care at the point of being ill, so the insured would rather use more medical care than utilize nonmedical services to produce health, when controlling for health status. We discovered that the increase in RRN increased the probability of reporting their good health among rural middle aged and elderly people by controlling health status and health outcomes. In family theory, the quantity of health demanded often declines as healthcare prices rise. This result is consistent with the experience that generous health insurance reduces out-of-pocket expenses for medical care; then, rural middle aged and elderly people covered by generous NRCMS prefer to shift from expensive non-medical services to cheaper medical care when curing diseases is a top priority. In rural China, the probabilities of reporting good health are 1.26 times  with Diagnosis Related Group Systems (DRGs)-based reimbursement to achieve dual goals: cost containment and maximization of health output. Second, the reimbursement rate of hospitalization expenses should be increased in middle aged and elderly people at a disadvantage of health and economic status after the NRCMS merged with URMI came into effect. Third, the government should devote its attention to providing more affordable, cost-effective, convenient, and equitable health insurance for middle aged and elderly people who would like to use more medical services to produce health when their medical treatment is incurred in rural China. Last but not least, the government not only needs to focus on the NRCMS' design, implementation and reform, but also emphasize the fact that the health care costs and utilization are the vital nexus between the NRCMS and SRH that is a very important policy mechanism to produce health in a public health system. How to reduce the burden of disease and produce better health for rural middle aged and elderly people by bringing the NRCMS benefits of the package is one of the key priorities of rural China's public health insurance reform at the stage of rapid aging of the population.http://charls.pku.edu.cn/pages/data/2018-charls-wave4/en.html.The dataset supporting the conclusions of this article is available in the All the respondents in the CHARLS provided informed written consent that was in accordance with the Declaration of Helsinki. This paper is a retrospective study based on CHARLS, in which the Ethical Review Committee of Peking University provided ethical approval of the survey .XX conceived, designed, and conducted the original research, who acquired and analyzed the data. Drafting the work or revised it critically about nearly 70% was a substantial contribution to XX. YH contributed to the methods, collection and interpretation of data, and proofreading of final paper together. Both authors contributed to the article and approved the submitted version.This study was funded by General Projects of the National Social Science Fund of China from 2018 to 2021.YH was employed by West China Hospital, Sichuan University. The remaining author declares 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.


The concentration of the world’s population in coastal areas means an increase in pressure on the environment and coastal ecosystems. The impacts of climate change affect natural biophysical and ecological systems and human health. Research has been developed to create coastal monitoring with Unmanned Aerial Vehicles (UAVs) that allow data to be obtained and methodologies that integrate computer vision algorithms for 3D and image processing techniques for analysis, combined with maritime information. The Valencian oval is located on the Spanish Mediterranean coast and registers significant coastal erosion. It is a densely populated area, with high economic relevance and tourist activity. The main goals of the developed research in this coastal area include creating a methodology of data collection that identifies environmental indicators significant to community health and uses in the coastal areas, to test progression of interventions and to assess coastal erosion detection and monitoring. The final objective is to aid in decision-making and coastal management. Sediment characterization was obtained, and continuous maritime information was collected. The dynamic evolution of coastal areas was researched by using UAVs on the Spanish Mediterranean coast. This technique is suitable for measuring medium to small coastal changes. Flight planning was carried out using the grid mode and adapted to areas in order to obtain a homogeneous pixel size and precision. This monitoring program takes advantage of technological development with very low economic costs and is a good tool for making decisions that must be based on scientific information. With the monitoring work, an annual erosion between 12 and 6 m was detected. The monitoring program has evidenced the shoreline trend as a result of the impact of rigid structures, mainly ports and groins, in promoting down-drift erosion processes in the area. The impacts of climate change affect natural biophysical and ecological systems and human health ,2,3,4. CSince the 1950s, coastal areas have steadily increased in population . The conResearch on the evolution of cities and coastal agglomerations between 1945 and 2012 established that the number and size of cities, and the populations living in them, are continuously increasing. As a result, the concept of city and coastal agglomeration (CCA) is considered as referring to those with more than 100,000 inhabitants located less than 100 km from the coastline. In turn, however, there are two other characteristics to consider: dispersion of the population and conurbation of two or more cities. Mechanisms to determine the relationship between various ecological, geographic and socioeconomic factors and urban development on the coast have been analyzed ,14,15,16Coastal erosion is a process that degrades coastal profiles and mainly occurs due to natural factors  and overcrowding  . While tManagement strategies must be based on scientific information. Monitoring data provide adequate tools to understand coastal processes and the analysis of what is happening during each period. Remote sensing techniques, which use satellite imagery to measure the morphology and scale of sandbars, have been introduced. Tracking techniques based on Landsat and Sentinel 2 images with the use of geographic information systems (GIS) and terrestrial surveys can be achieved to obtain indicators on coastal areas by using landmarks, global positioning system (GPS) light detection and ranging (LiDAR) and tri-dimensional (3D) scanners. However, the shoreline detection problem has still not been solved, since there are no algorithms that can be used without taking into account the objectives and characteristics of remote sensing images . The resMore recently, coastal zone surveys, including foreshore, backshore and dunes, have acquired and processed high-resolution data obtained by vertical take-off and landing (VTOL) drones, also known as UAV with cameras ,38,39. RThe objectives and goals of the developed research for the region are to assess the state of coastal erosion by using integrated systems to provide a comprehensive and complete model for coastal erosion detection and monitoring and to promote a clear pathway that will serve for decision-making and coastal management.The Valencian oval is located on the Spanish Mediterranean coast  and regiThe total population of the Valencian coast is 4.64 million inhabitants, and it has increased by almost 2 million in the last 50 years. The central region of Valencia extends to the north and south of the city and has a continuous conurbation of more than 2.9 million inhabitants. Currently, the central coastal area has a population density of 1238 inhabitants per square kilometer. It is an area with high tourist use and very important economic activity. Valencia’s port specializes in container traffic and has become a Mediterranean leader in this field, with the metropolitan area being a relevant logistic center. The effects of occupation and increased use, urbanization, degradation and destruction of coastal spaces, construction of port infrastructure and other infrastructure for land transport and hydraulic regulation have produced important sedimentary imbalances and an alteration of coastal dynamics with the consequent modification of coastal morphologies ; these accumulations are the result of sedimentation and changes in profiles. Erosion in many coastal areas has increased due to the complex effects of climate change. Rising sea levels and changes in weather patterns have intensified the frequency of extreme events occurring on our planet ,35,36.An evaluation of the situation of the sedimentary balance, determining zones in accretion and others in erosion throughout the last 15 years, was obtained for the stretch of coast between the south port of Castellón and the port of Sagunto. Recently, to define interventions in areas with coastal erosion, topographical and bathymetric surveys have been developed in Almenara and the Sagunto beaches. This is a coastal area with extensive sandy beaches and dunes and is only interrupted by ports and small river mouths. Charadrius alexandrinus, a bird included in some catalogues of endangered fauna species in the vulnerable category. The coastal regeneration works have had to consider the nesting period in a very special way. For this reason, this project must stop during the spring period.In September 2021, the stabilization works of the La Llosa and Almenara coastline began; these are based on a construction project that aims to stabilize the coastline in this area. The actions planned in this project focus on the beaches of La Llosa, Almenara and to the north of Sagunto, undertaking, among other things, the transfer of winnowed gravel from the Malvarrosa beach to the south of the Gola de Queralt, as well as the extension of jetties. From the point of view of fauna in the dune coastal area, it is worth mentioning the importance of the nesting In order to assess negative effects on beaches, especially those located in the northern area of Almardà, Corinto and Malvarrosa beaches, the monitoring of coastal areas needs to consider whether or not there is coastal erosion as a result of these regeneration works on Almenara beach. The follow-up will focus on analyzing the evolution of the Sagunto beaches and coastal area. This monitoring was extended for three months, from November 2021 to January 2022.This study aims to utilize a multidisciplinary approach by combining different analyses of maritime information, coastal processes and monitoring technologies to establish the causes of coastal erosion. An integrated analysis offers advantages in obtaining comparisons and simulations of dynamic situations in order to explore possible strategies to overcome erosion and, consequently, sustain public health and uses, economic growth, minimize population risk and maintain biodiversity in coastal ecosystems. The methodology in this study aims to achieve coastal erosion management and coastal erosion research, especially on vulnerable areas, which could be based on a risk assessment ,34,37,38There is no periodic information on the geometry of the coast and its temporal evolution available. There are some assessments of advances and retreats of the coastline, but they are not systematic, nor do they take into account the position of the sea level and its effects; they are also not correlated with the maritime climate between each observation period. For this reason, it is necessary for the purposes of this study to correctly carry out these controls of the resulting geometry. To this end, determinations were made in the field through the use of surveys, which are described in detail later. The sources of information on coastal geometry and coastal sediments that were used have the methodological purpose of allowing comparisons to be made between different periods of time, so that the behavior and evolution of the beaches and the coastal area can be deduced, and sedimentary movements quantified.Sedimentary materials present on the beaches and contributions and movements made;Geometry of backshore, beach face and surf zone profile;Sea level in the period of observation and survey;Maritime climate data, especially having regard to wind and wave regimes in the monitoring period;Analysis of storms and their effects in the monitoring period;Anthropic actions taken, such as works, occupations, etc.To monitor the coastal–littoral area under investigation, it is necessary to develop a complete methodology ,35 that Sea level, through the analysis of tides provided by the Network of Tide Gauges ;https://www.puertos.es/oceanografia/Paginas/portus.aspx (accessed on 2 December 2021).Storm surges, based on prediction data, real-time records and an analysis of historical data from the State Ports Public Agency  program through the link In addition, it was necessary to carry out work and analyze the granulometric characteristics of coastal materials, both native and those that may have been contributed. The collection of information in this regard must be as broad as possible, especially with regard to the implementation period. Surveys were performed over three months. For the purposes of monitoring and controlling the effects to be analyzed, continuous maritime information is being collected regarding the following:To obtain sediment characterization, which allows for the establishment of potential sediment sources to characterize coastal conditions in the study area, sediment samples were taken and analyzed in the laboratory. Sediment sampling was performed at a central point of each of the three beaches: Malvarrosa, Corinto and Almardá beaches . Granulohttp://marine.rutgers.edu/po/index.php?model=roms, accessed on 9 November 2021). Relationships between the different sea reference levels were considered. Wind conditions  were determined, obtained through dynamic downscaling using the WRF-ARW 3.1.1 model  from the ERA-interim atmospheric reanalysis [The sedimentary transport by waves and storm surges was estimated. The wave climate in the area was established ,42,43,44analysis , develop0, significant wave height in deep water depths. Angle between wave crest and shoreline is α0. Coefficients, Kp, Kg, correct the probability of the wave height and direction, and the geometric configuration of the sector with the capacity to generate transport.Aerial and satellite views were also analyzed ,45,46. Thttps://icv.gva.es/es/cartografia-tematica (accessed on 5 November 2021). All this allowed us to start the monitoring works.To monitor the geometry of the coast, the first task carried out was to establish control areas and points: stretches of coastline and profiles. Then, the downscaling of the information obtained from the Sentinel Hub satellite images, which is a cloud-based GIS platform for the distribution, management and analysis of satellite data, was addressed. Annual orthophoto images of the study area were obtained from the regional government of Valencia through the Institut Cartogràfic Valencià link, For precision monitoring, field work was launched with the aim of carrying out monthly large-scale geometric surveys using drone systems. The processing of different images allows for remote sensing on shoreline detection and for the monitoring of coastal areas ,37,39. AFor photogrammetric flights for geometric purposes, a global navigation satellite system (GNSS) base belonging to the air system was used to provide precise georeferencing in real time kinematic (RTK) to the images captured from the air. Flight planning was carried out in grid mode and adapted to the existing terrain in order to obtain homogeneous pixel size and precision.The GNSS base of the aerial system is located in topographical bases. Precise XYZ coordinates were previously given to these bases, relying on the reference framework that defines the Spanish official reference system (which is the ETRS89 in UTM projection).These coordinates were measured using a dual-frequency GNSS system with an accuracy of less than 1 cm.In each flight, a series of support and control points (SACP) were also mediated with the dual-frequency GNSS system in order to provide precision guarantees. A precision report was delivered in each of the photogrammetric flights for the geometric analysis of the areas it has flown over. Flights were carried out with a professional drone (DJI Phantom 4 RTK and DRTK Base) and the GNSS system used to measure the SACP was a multi-constellation Spectra with a Trimble TDC600 controller . Once thThe planning parameters are to fly at a height relative to the ground of 36 m to obtain a pixel size or ground sample distance (GSD) of 1 cm/pixel, with the drone’s camera oriented completely from above so that the photo capture overlaps 80% longitudinally and 90% horizontally and transversely. Subsequently, the images captured by the drone are downloaded and processed using the drone’s native software to enable precise georeferencing with respect to the data measured by the drone’s GNSS system. This was performed post-process, whereby the position given by the GNSS base in the fraction of a second that the camera captured each of the aerial images was synchronized.Next, Pix4D software is used to process all the georeferenced images in order to obtain the necessary metric products. These are the 3D Point Cloud, orthophotography and digital terrain model (DTM). From these products, other cartographic products can be obtained ex post in any format, including both raster and vector.Finally, the zero line (ZL) is defined along the entire coastline using GPS methodology. The study area does not have a significant tide. Small time scale sea level changes are mainly due to wind set-up, storm surges and wave conditions. The swash zone forms the land–ocean boundary at the landward edge of the surf zone, where waves runup and rundown the beach face. The ZL is defined by runup and rundown interpolation in the swash zone. This method allows us to precisely define the edge of the beach. It can be complemented with the correction of the sea level by astronomical or meteorological tides and wave oscillation. The data collection is extended up to the −1.00 level in profiles taken between 25 m. Consequently, detailed information can be obtained from the most exposed and dynamic sections of the submerged beach profile. The total length of the stretch of coast to be monitored with the ZL is 4530 m long. All the obtained information must be analyzed throughout the monitoring time with information on the maritime climate.50 = 0.25 mm sand and occasionally gravel close to river mouths. Many bathymetric studies have detected submarine materials, mainly composed of fine sand of D50 = 0.11–0.15 mm [The northern part of the Spanish Mediterranean coastline is generally in the direction of S60°E; it is fairly straight and low-lying without natural indentations. There are a large number of port infrastructure and coastal protection systems, including jetties, dykes and breakwaters. It suffers considerable erosion. The coast, especially in the Valencian oval, registers significant erosion due to the north–south movement of materials and the absence of sediments from the north, which is mainly due to the presence of docking installations and other construction. Beaches are mostly composed of D–0.15 mm .Problems of erosion have been occurring in recent decades. The effects of occupation and increased use, urbanization, degradation and destruction of coastal spaces, construction of port infrastructure and others for land transport and hydraulic regulation, etc., have produced significant sedimentary imbalances. The Valencian oval coast, particularly between the port of Castellón and the port of Valencia, has intensively recorded these effects. Along this coast, longitudinal protection, groins, detached breakwaters and many artificial beach nourishments have been built. All these structures, especially the ports and groins, have produced significant effects on littoral transport rates.50 of sediments on these beaches varies between 0.19 and 0.29 mm , erosion, accumulations due to sedimentation, changes in profiles, etc. The vulnerability of the coast is rapidly increasing due to climate change. Vulnerability is manifested via increases in flood levels, beach profile changes, erosion, increases and changes in coastal morphology, variations in littoral transport rates and coastal erosion. Ports can create coastal erosion by altering wave patterns. The research that was carried out attempts to clarify environmental effects in managing port-induced coastal erosion occurring at beaches, which are extensively used by the population.Changes in weather patterns due to climate change produce an intensification of the frequency of extreme sea events. Beaches in this area are showing coastal sedimentary movements that lead to the appearance of gravel and its propagation towards the south in very significant magnitudes. This has been very noticeable after recent extraordinary storms in September 2019 and the Gloria storm in January 2020.On the Spanish Mediterranean coast, more than 90% of the sand and gravel comes from rivers, torrents and streams, while the rest comes from erosion materials from cliffs, in addition to vegetable matter. Granulometric results show that sediment beaches along the Sagunto and Almenara coast are a mix of sand and gravel. Until a few years ago, Almenara and Sagunto beaches maintained a sand cover, giving the impression of sandy beaches. Recently, erosive processes in this coastal area have displaced the sand and exposed the gravel .The obtained shoreline change rates show that problems in the coast between the ports of Castellón and Sagunto are the result of general degradation of natural conditions, resulting in a fragmented coast with sedimentary imbalances generated by ports and other infrastructure, human use and invasive urbanization of coastal spaces. River regulation and sediment reduction supplies to the coast and the effects of climate change have increased erosion. At the same time, to correct the situation, there have been no investments made according to environmental, natural and socioeconomic values. ICZM under the principle of sustainability is needed. The current result is a degraded and fragmented coast, which requires management and intervention through coordinated action and sustainability.Over the years, the imbalance in sediment and transport, which is strongly influenced by port constructions and groins, has been sought to be mitigated through the building of various defense works. The entire area under investigation here has been altered from its natural initial dynamic. The areas with the greatest problems are those in which strong transport and urban areas coincide. The current situation is attributable to successive transformations that have taken place over time in an initially continuous coast, with an area of lagoons and incipient dunes. The construction of the ports of Sagunto in 1902, Castellón in 1915 and Burriana in 1932 reduced littoral transport rates, and a significant volume of sediments were retained upstream of these ports. The urbanism developed over the years, which was more intense from the 1960s/1970s and affected natural conditions, especially in dune areas. Solutions given to these problems were local, with coastal defenses mostly developed in front of urban centers, which gave rise to even greater sedimentary imbalances, forming important concavities downstream .The diagnosis of sections between the port of Burriana and the port of Sagunto recommend a reanalysis study on all the currently existing defense works, taking into account climate change and extending to critical points with serious current erosion. With the start-up of the stabilization works on the coast of Almenara and Sagunto, it was possible to develop a monitoring system that provides data on coastal evolution on an appropriate time and space scale. Dunes and beach changes were evaluated. Coastal management requires us to define its characteristics and evolution. The task of continuously collecting information is a basic necessity for proper management and, in addition, today there are increasingly powerful and accessible technological means for it.ICZM is a key element for the sustainable development of the coastal areas. One of the consequences of climate change is the increase in global coastal erosion and the loss of valuable coastal areas. A large number of development activities, such as construction of ports, urbanization, massive tourism, overexploitation of aquifers and the presence of dams, are increasing the vulnerability of coastal areas. Due to extraordinary storms on the coast, there is a great urgency for ICZM. Action must be addressed with a robust system based on coastal monitoring and the evaluation of results. Recent trends in coastal erosion mitigation are addressing towards soft and innovative methods, since hard methods have important impacts such as high cost and down-drift erosion. The debate on coastal sustainability must consider the effectiveness and adequacy of necessary investments, consolidating them into conservation plans and ICZM.To act against coastal erosion and correct the current situation affecting dunes and beaches, it is necessary to promote soft and innovative solutions such as sand bypassing, dune rehabilitation and dune vegetation. These solutions will also work to prevent coastal erosion due to stronger storms caused by climate change. During the stabilization works of a coastal area on the Spanish Mediterranean coast, a monitoring investigation was developed based on the use of UAVs and maritime and sediment information. Coastal monitoring provided appropriate information because of its spatial and temporal dimensions and data quality to strengthen scientific knowledge and sustainability.This monitoring program made it possible to manage very precise information, and high-resolution images can be processed to detect changes, both from the works in progress and from natural changes due to the action of winds, waves and tides. This monitoring program is a good tool for making decisions that must be based on scientific information and takes advantage of technological development with very low economic costs.


Accreditation is important for all medical laboratories, particularly public health laboratories in developing countries. Several laboratories in Ghana implemented the requirements of the International Organization for Standardization (ISO) 15189 but were unable to proceed to accreditation. This article describes the challenges faced by the Pathology Division Laboratory of the 37 Military Hospital, Accra, Ghana, during the acquisition of ISO 15189 accreditation and suggests solutions for a better approach.Following ISO 15189 accreditation in 2017, an online survey was conducted between 01 and 30 March 2020 among the laboratory staff. Respondents were required to grade, on a scale of 0 (least) to 5 (most), the extent to which 16 key challenges influenced the process of obtaining accreditation. Key informant interviews were also held with laboratory personnel who were directly involved in the establishment of the quality management system in the laboratory and the accreditation acquisition process.p = 0.11).Documentation, laboratory safety measures, laboratory management support, and reagent unavailability were estimated as the challenges that most affected the acquisition of laboratory accreditation. Challenges such as poor communication, staff apathy and workload had the least effect on the accreditation process. There was no difference in challenges identified between persons who worked in the laboratory before or after accreditation (To surmount the anticipated challenges, there is the need for national strategic direction for laboratory accreditation, hospital and laboratory management support for the accreditation acquisition and maintenance processes, and sufficient technical assistance in the form of training and mentorship. Even for laboratories that have attained accreditation in other countries, weak hospital management support, inadequate documentation, inefficient equipment, irregular supply of reagents, little mentorship, and high staff turnover have been identified as bottlenecks to attaining and maintaining accreditation.11 As several African countries within the sub-region, including Ghana, pursue healthcare reforms to achieve universal health coverage, the need for national accreditation policies and systems has become a priority for several ministries of health.12Between the years 2010 and 2013, Ghana enrolled 15 public sector medical laboratories in the Strengthening Laboratory Management Towards Accreditation programme to develop laboratory systems towards accreditation readiness and subsequent accreditation.8 Learning from its experiences and challenges, the laboratory has maintained its accreditation status over the years while gradually expanding its scope to include other departments in the division. The Microbiology Department also subsequently obtained International Organization for Standardization (ISO) 15189:2012 accreditation in 2019 from the Southern African Development Community Accreditation Service.The Pathology Division Laboratory of the 37 Military Hospital became the first public sector laboratory to be accredited for methods in chemical pathology and haematology in Accra, Ghana, in 2017.This article describes the challenges faced by the Pathology Division Laboratory of the 37 Military Hospital in Accra, Ghana, in the pursuit of ISO 15189:2012 accreditation and suggests solutions to the identified challenges.Ethical clearance, with reference number 37MH-IRB/DS/IPN/417/2020, was received from the Institutional Review Board of the 37 Military Hospital, Accra, Ghana. Participants were required to respond to a consent section before voluntarily completing the online questionnaire. To protect the privacy of participants, no personal information was collected.The study was conducted in the Pathology Division Laboratory of the 37 Military Hospital in Accra, the capital of Ghana, West Africa, which received ISO 15189 accreditation for haematology, chemical pathology, and microbiology test methods between 2017 and 2019. The laboratory also operates other departments, including histopathology, serology, and a blood transfusion service.Key informant (KI) interviews were conducted with personnel who were directly involved in the establishment of the Quality Management System (QMS) of the laboratory and the accreditation acquisition process. These KIs included the officer-in-charge of the division, laboratory manager, quality manager, and heads of department for the haematology, chemical pathology, and microbiology departments. The KIs were coded  to maintain confidentiality. Interviews were digitally voice recorded after securing interviewee consent. Interviews were conducted in English, transcribed verbatim immediately thereafter, and then reviewed by members of the research team to ensure their validity. The main themes explored covered personnel, documentation, and management.10 and the laboratory’s observed experiences during the ISO 15189 implementation phase. These covered challenges related to documentation, laboratory management support, laboratory safety, reagent availability, equipment availability, mentorship, support from doctors, hospital management support, staff attrition, staff qualification, staff strength, laboratory information management system, support from nurses, workload, staff apathy, and communication.An electronic questionnaire was sent to all laboratory staff between 01 and 30 March 2020 to obtain staff opinions on the challenges with the laboratory’s accreditation acquisition process. The key challenges were selected based on other studiesn = 104] multiplied by the maximum score applicable [n = 5]).Participation in the study was voluntary. Participants were required to grade, on a scale of 0  to 5 , the extent to which 16 key challenges impacted the accreditation acquisition process of the Pathology Division Laboratory. The three most challenging and three least challenging aspects of the accreditation process were identified. The maximum score attributable to each challenge is 520  and Stata IC/16 . Summary descriptive statistics were used to describe the characteristics of the data set obtained from survey respondents. The number of responses on each challenge to accreditation was also represented as percentages for each score category. A multivariate regression model was used to compare the scores of key challenges between personnel who joined the Pathology Division Laboratory before accreditation versus after accreditation, adjusting for employee type, education, gender, and awareness of the accreditation status of the pathology division. A total of 106 of the 110 personnel working in the laboratory completed the structured questionnaire, representing a 96.4% response rate. There were two non-responses on time of joining the laboratory (before or after accreditation) and five non-responses on job title. More respondents  were present throughout the laboratory’s accreditation acquisition process compared to respondents  who joined the laboratory after the accreditation in 2017 .The pathway to ISO 15189 accreditation is marked with several challenges, especially in resource-limited environments. This, however, does not make it an improbable cause. Notable among the challenges to the accreditation process were laboratory personnel attrition, personnel attitude to change, service interruptions and logistic constraints, documentation, continuous external assessment outcomes, and size and complexity of the laboratory .10 Challenges such as nurses’ support, doctors’ support and staff qualification were rated among the least challenging.Documentation, availability of reagents, workload, and staff strength were among the highest-rated challenges. These challenges are consistent across different laboratories.8The role of laboratory management in ensuring that the requirements of the international standards are understood by laboratory personnel is important to ensure collective buy-in and conformance. Where such inadequacies exist, mentorship would be needed to complement management roles in the application of the relevant standards.13 When staff are committed and involved in the accreditation process from the beginning, good commitment is more likely to persist throughout the life cycle of the laboratory.When controlled for employee type, education, gender, and awareness of the accreditation status of the pathology division, there was no statistically significant difference in responses between respondents who joined the laboratory before or after accreditation . This isCritical among the challenges to the accreditation process was laboratory personnel attrition. KI-1 acknowledged:‘As a military facility, military personnel are moved every now and then on military and allied duties resulting in significant reduction in staff numbers and consequent increase in workload on the remaining personnel.’ As a result, persons trained and deemed competent in the quality system were lost and new persons introduced. This can be described as a ‘brain drain’ of laboratory personnel. According to KI-2 , ‘between 2014 and 2017, five out of eight members of the laboratory quality steering committee members had been changed’. This certainly increased the amount of work the few remaining personnel had to do to support the quality system. To address this situation, the laboratory developed and deeply integrated a staff orientation and training programme to consistently update old and new staff with the status quo and requirements of the laboratory QMSs. Additionally, for every key appointment  there were two assigned deputies. Although these deputies had technical roles, they also understudied the key officer in preparation for taking over when one was moved. The attrition of personnel may constitute a significant form of brain drain in a laboratory that has built the capacity of its personnel to implement the requirements of the QMS. The effect of attrition is felt when the quality system is established around personalities and not as a functional system. Establishing a functional system is to ensure that developed policies and procedures are followed as required. However, there is the need to maintain a good level of stability of key personnel such as the quality manager and the quality team players to maximise the human resource capacity.The attitude of personnel to changing work routines was another challenge that was apparent during the application process. According to KI-4:‘Laboratory personnel considered the accreditation process and its requirement as additional work burden which added very little immediate financial benefits to one’s pocket hence the lack of enthusiasm towards the process.’ We opine that the general perception among personnel is that the implementation of a quality system towards accreditation is entirely different from the ‘regular’ laboratory work. Hence, staff are more likely to go about their routine duties and only implement quality system requirements if they remember to do so. Both KI-3 and KI-4 emphasised:‘The same personnel who are deployed on technical bench duties and processing of samples were the very staff involved in the numerous administrative and documentation tasks. They are simply overwhelmed with tasks and had the right to complain.’ 2The routine duties of laboratory staff and the quality requirements associated with ISO accreditation are more interconnected than mutually exclusive as perceived. The perception of the two being separate stems from the situation where too much emphasis is placed on getting documentation done to the detriment of patient care or vice versa. Additionally, lack of motivation coupled with the extra duties increases that perception gap. Personnel are originally employed by their managers to run patient samples and churn out results. Therefore, any additional duty is expected to come with some extra, usually financial, remuneration. Where this fails to occur, as is the case in most public sector laboratories because they do not manage their own budget, enforcing such a change is met with firm resistance or indifference. This situation is however contrary to a study done in Lebanon where accreditation was found to be an impetus for better performance.It took several one-on-one mentorship and coaching sessions and in-house continuous education on ISO 15189 accreditation, the improvement process, the requirements of the Stepwise Laboratory Improvement Process Towards Accreditation checklist, good clinical laboratory practices, and laboratory QMS to get a lot more personnel on board with the process. According to KI-2:‘The concerns of laboratory personnel regardless of how often or how much they complain is good feedback. Though we knew that indeed they were overwhelmed, everyone was overwhelmed. However, we initiated a staff of the month award scheme to motivate personnel.’ This ‘staff of the month’ award included a lunch package for the winner and a crate of drinks for the entire department, as well as the display of the winner’s photograph at the front desk.Interruptions in the continuity of laboratory service was considered one of the challenges to the accreditation process. KI-1 explained:‘Service interruptions usually occurred as a result of delays by suppliers to deliver reagents and other consumables, as well as bureaucratic procurement processes. These mostly resulted in reagent stock-outs. Most of the reagents and consumables required for testing are imported and are very capital intensive. Due to the amount involved and the foreign exchange transaction policies of the government of Ghana, it became even more difficult to carry out such procurement.’ KI-1 acknowledged as a solution:‘To ensure a more regular and continuous supply of reagents and consumables, some level of financial autonomy was given to the laboratory. An accountable imprest was also set aside for the laboratory. This brought to the fore the level of support offered by the hospital management.’ The level of support and trust provided sufficient drive for the staff and management of the laboratory to improve their interest in the whole process and secure the coveted accreditation.All KIs agreed that the absence of a dedicated budget for procurement of laboratory logistics was the main reason for the service interruptions occurring in the laboratory.In preparation for accreditation, self-checks and external assessments are needed to ascertain the readiness of the laboratory for the final accreditation assessment. According to KI-1:‘We were subjected to several external assessments; however, it was as if the outcomes did us ‘more harm than good’. Despite the efforts put into preparing for external assessments, the scores were low and staff were demoralised. Different assessors almost reported different findings for the same requirement.’ All KIs agreed that assessments  are critical as required by the standard but that it is important to focus on managing the quality system rather than on the numbers or scores of an assessment.Constant documentation of activities is one of the key requirements of accreditations in general. The ISO 15189 standard requires the generation of evidence of the implementation of laboratory policies, processes, and procedures. KI-3 said:‘It is like you have to document everything you do or do not do, this is hard, this is not something we are or were used to, hence the massive resistance.’ In a time of evidence-based laboratory medicine, it is only imperative to document all activities as proof that they were carried out as required. The key role of conformance to documentation in any quality system cannot be overemphasised. KI-1 commented:‘It is not possible for any laboratory to implement a quality system when the personnel who are the direct implementers of the system are not committed to the process. No matter how good the policies and processes are, if the people do not conform to it, it is useless.’ This represented one of the biggest challenges to manage in an environment where documentation and conformance are not part of the culture. Group training and consistent one-on-one coaching with staff on the importance and benefits of documentation were conducted. Most importantly, results of documentation  were periodically reviewed and communicated to staff to help them appreciate the need for and benefits of keeping quality records.KI-5 (laboratory scientist) stated that ‘the medical laboratory, to the ordinary person, may be perceived as a small space within which simple tests are performed’, and further opined that the converse rather is true, stating that ‘the laboratory is a large complex network of several units and departments involved in an interconnected series of test activities’. This was a major challenge. The laboratory has five testing departments, collectively performing over 100 test panels and generating results for over 300 analytes. ‘At a point we were confused, not knowing exactly what was going on because they were just too many’, KI-2 (laboratory manager) said. The initial attempt to get all methods accredited at once was not working. The burden of work was overwhelming due to the size and complexity of the laboratory. Therefore, the laboratory adopted a stepwise approach to attaining its much-desired accreditation. This phased approach implied prioritising the methods to be accredited and working at accreditation in smaller chunks. Chemical pathology and haematology were therefore chosen for the initial accreditation process, with the subsequent addition of microbiology a year later.All KIs acknowledged that the accreditation of a public sector laboratory in Ghana was considered highly improbable. This made it even more difficult for laboratory staff to be convinced that it was possible to be accredited as a public sector laboratory. As explained by KI-2:‘Staff always made reference to other bigger hospitals in Ghana and in the West African sub-region that if those facilities were not accredited though better placed to be, how was it going to be possible for the military hospital which is resource-stricken be accredited.’ However, it was clear that although there was no historical precedence, with the needed guidance and mentorship, it was possible to meet the requirements for accreditation.According to KI-1 and KI-5:‘Effective mentorship is a pivotal element for any public sector laboratory seeking accreditation. In the absence of a historical precedence, our mentorship program guided the development of policies and process and further assisted in the implementation, conformance and the review process.’ 14 The inadequacies in the national support for accreditation result in the inadequate dedication of resources  towards attaining and maintaining accreditation. While a national focus is required, hospital management support, including support from other healthcare workers such as doctors and nurses, cannot be overemphasised.8 Management support plays a key role in the accreditation process in resource-limited settings, and the engagement of hospital management with laboratory management accelerates the accreditation acquisition process.In a country where the motivation of the government towards laboratory accreditation is weak, securing accreditation for any public sector laboratory is usually a huge challenge.Perspectives about the challenges with securing accreditation vary between laboratory personnel and management staff. While laboratory personnel identified excessive documentation, weak laboratory management support, and inadequate safety as the main challenges to accreditation, management personnel identified staff attrition, personnel attitudes, and the size and complexity of the laboratory facility as the main challenges. However, both groups of personnel identified excessive documentation and service interruption as key challenges. There is a need for constant feedback across levels of hierarchy to get everyone on the same page in the quest for accreditation. That way, the resources, although limited, can be better apportioned to address common challenges.The study was limited to staff of the Pathology Division Laboratory so the perspectives of hospital management, other hospital staff and clients were not solicited. The KI interviews did not include personnel whose testing activities were not within the scope of accreditation. Some bias may therefore be inherent in the responses.To make laboratory accreditation more relevant and, consequently, surmount the anticipated challenges, there is the need for national strategic direction for laboratory accreditation, hospital and laboratory management support for the accreditation acquisition and maintenance processes, and sufficient technical assistance in the form of training and mentorship.


Modeling and prediction of traffic systems is a challenging task due to the complex interactions within the system. Identification of significant regressors and using them to improve travel time predictions is a concept of interest. In previous studies, such regressors were identified offline and were static in nature. In this study, an iterative joint clustering and prediction approach is proposed to accurately predict spatiotemporal patterns in travel time. The clustering module is tied to the prediction module, and a prediction model is trained on each cluster. The combined clustering and prediction are then iterated until a chosen metric is optimized. This orients clusters of data towards prediction while enabling model development on subsets of travel time data with similar prediction complexity. The clusters created using the joint clustering and prediction approach confirmed to the real-world traffic scenario, forming clusters of high travel time at busy intersections and bus stops across the study stretch and forming clusters of low travel time in the sub-urban areas of the city. Further, a comparison of the developed framework with base methods demonstrated a decrease in prediction errors by at least 22.83%. This indicates that creating clusters of data that are sensitive to the quality of predictions using the joint clustering and prediction framework improves the accuracy of travel time predictions. The study also proposes criteria for choosing the best predictions when cluster-based predictions are used. Modeling of traffic systems is essential for the development of new road networks, analysis of existing ones, prediction of their future performance, and planning measures for improvements. The modeling of traffic systems is challenging due to their inherent complexities and associated uncertainties. Traffic systems are influenced by human, vehicle, road, and environmental characteristics and their interactions with each other. These characteristics make it difficult to identify suitable variables that can capture the temporal and spatial variations in the system.Travel time is an important traffic variable that is widely used to characterize the traffic system. Travel time data exhibits both temporal and spatial variations; it may vary depending on the day, time, location, etc. The high variability in the system must be considered for accurate prediction of travel times. Earlier studies have predicted travel times by offline identification of significant regressors based on the assumption of fixed patterns . HoweverWhile modeling complex systems, it is common to consider a set of local models and analyze the system in parts instead of using a global model. This technique is called multiple model learning . Here, iThe choice of the prediction technique can be based either on process knowledge or the end-use. Historical averaging, linear regression, linear and non-linear time series models, and machine learning-based approaches such as Artificial Neural Networks (ANN), Support Vector Machines (SVM), and Deep Learning (DL) are commonly used for travel time predictions. The goal of the present study was not only accurate prediction of travel time, but also meaningful interpretation of data. Techniques such as historical averaging, linear regression, and time series modeling, although easier to interpret, could compromise the accuracy of predictions. On the other hand, with increase in accuracy, the model may lose transparency and interpretability of the results. For example, DL approaches may afford high accuracy at the expense of transparency.Many studies have used clustering as a pre-tool for the prediction and estimation of traffic variables –7. HowevThe ability of ML approaches to solve complex and non-linear problems makes them a suitable prediction strategy for the prediction of traffic state variables. Artificial Neural Networks (ANN) is a popular ML technique used in predictions. , 8–16, hk-means clustering algorithm [k-means, hierarchical, and Kohonen SOM clustering algorithms in predicting bus travel times were compared by [k-means clustering was found to perform best.Clustering has been used in the past as a pre-tool for the identification of significant regressors and the prediction of many traffic variables. Important clustering algorithms used for the prediction of traffic variables include the lgorithm –24, hierlgorithm –28, and lgorithm –31. The lgorithm  assumed pared by . The k-mThe review of literature shows that clustering-based multiple model learning for data understanding and prediction have hitherto been explored largely for homogeneous traffic conditions. In addition, the clustering and prediction modules have been studied independently, without considering their effects on each other. The question arises whether clusters can be formed such that they improve the prediction accuracy.  used a pThe study reported herein aimed to address these gaps in literature through the design and testing of a novel joint clustering and prediction framework. The reported approach created meaningful clusters of data that correspond to real-world traffic conditions and was sensitive to the quality of predictions. Another significant contribution of the study is that the proposed framework is agnostic to both the domain (prediction of travel times in this study) and the model used for prediction (ANN in this study). Thus, this umbrella framework can be applied to prediction exercises regardless of the domain and the prediction model used.The developed joint clustering and prediction framework was applied to predict travel times on an urban arterial road. The study also systematically analysed the changes in the clusters across the iterative steps and the effect of feature vectors on prediction strategies. In addition, the predictions made by the framework were compared with those made using base data, data with fixed clusters and data-derived clusters to assess performance.Yt,s)k denote the travel time of section s for trip t in the kth cluster, where t = 1, 2, …, T; s = 1, 2, …, S, and k = 1, 2, …, K where T, S, and K are the total number of bus trips, the total number of sections across the study stretch and the optimum number of clusters, respectively. Given k, the study aimed to predict the travel times of trips t = T+1, …, T+Δt. Clusters were formed by partitioning the data such that C1 ∪ C2 ∪ … ∪ CK = Y, the whole set of travel time measurements. The clustering algorithm aimed to find K clusters in the data such that the within-cluster sum of squares is minimized, as shown in A joint clustering and prediction approach was formulated, in which, clusters of data were identified, and accurate predictions of travel times were obtained using an iterative approach to minimize errors. Here, the input to the clustering algorithm was from the prediction module and vice versa. Let th iteration were used as feature vectors for clustering. The process was terminated once the error metric stabilized. This ANN was chosen as the best predictor and was used to predict the testing data set. The developed joint clustering and prediction approach is summarized in In this study, an iterative training procedure was chosen to train the predictive model, and the variation of cluster membership in each iteration was studied. The input space partitions were chosen such that a further increase in iterations did not reduce training prediction errors. The framework of the developed joint clustering and prediction approach is shown in w method . For eveK predictions could be obtained using each of the K ANNs. Choosing the appropriate prediction model from these K options was a challenging task. To address this, two approaches—a selection- based approach and a fusion-based approach were proposed.On completion of training, the ANNs were used for testing. The challenge lay in associating a section travel time in the testing dataset to a specific cluster since the future was unknown. For example, for each test section travel time, The first approach, a selection-based criterion, involved the exploration of the features of the clusters, as shown in K predictions was used. The algorithm for the fusion-based strategy is provided in In the second approach, a fusion-based criterion was devised, in which, a weighted average of all the The data used for the study were collected using the GPS units fixed on the Metropolitan Transport Corporation (MTC) buses in Chennai, the capital city of the state of Tamil Nadu, India. The 19B bus route was chosen as the study stretch. The route spans a length of 29.4 kms and connects Kelambakkam, a suburban area of the city, to Saidapet, a major commercial area of the city. The northbound 19B route was chosen for the analysis. The GPS data were collected every 5 seconds from the GPS units fitted in these buses. A total of 1,231 trips were collected for 45 days. The obtained GPS data included the date, timestamp, latitude, and longitude of the bus location. The distance between two consecutive GPS points was calculated using the Haversine formula . For anaThe joint clustering and prediction approach was implemented, and travel times of 500 m sections were predicted using ANN. The prediction accuracy was quantified using Mean Absolute Percentage Error (MAPE), Mean Absolute Error (MAE), and Normalized Root Mean Square (NRMSE). 75% of the data points were used for training, and the remaining 25% were used for testing. The characteristics of the clusters formed, and the prediction performance were analyzed in detail and are presented in the following sections. The results from the joint clustering and prediction approach are then discussed, followed by a performance comparison with the base methodologies.x. Once the points similar in magnitude and predictability were grouped within a cluster, the change in MAPE and cluster memberships became minimal. The process was terminated after the xth iteration. However, it must be noted that this case was only for this particular dataset. Any other dataset may require a different number of iterations to stabilize the MAPE and cluster memberships.In joint clustering and prediction, the variation of MAPE was used as the decision criterion to terminate the iterative training. The MAPE of the trip with the highest prediction error was plotted, and the iteration was terminated when the change in MAPE was negligible. x iterations, there was no significant change in the predictions, and hence the training was terminated. The K ANNs trained in this iteration were selected for further testing.xth iteration were analyzed to better understand the nature of clusters formed. xth iteration. The plot is color-coded to represent the cluster memberships. Data points that belong to the same cluster are shown with the same color. Using the Elbow method, the value of the optimum number of clusters K was found to be four. The four clusters are arranged in increasing order of average travel times as blue, green, yellow, and red, with blue indicating data points with least average travel times and red indicating data points with highest average travel times. Descriptive statistics of the four clusters are presented in Clustering is an unsupervised learning technique and has no associated labels. It is therefore challenging to evaluate the correctness of the partitions created. The clusters are commonly validated using visual inspection and prior knowledge about the system under consideration . In thisThe heat map shown in The clusters were further analyzed, both spatially and temporally. In the spatial analysis, the primary objective was to identify sections that exhibit similar behavior with respect to the magnitude of travel time and predictability. The sections across the study stretch were divided into two groups, namely low travel time and high travel time sections. A section was considered as belonging to a high travel time group if the majority of the trip travel times for that section were in the high travel time clusters (cluster 3 and cluster 4). A section was labeled low travel time section if the majority of the trip travel times belonged to the low travel time clusters (cluster 1 and cluster 2). It is seen that all the high travel time sections had either a bus stop or an intersection. These high travel time sections were similar with respect to the magnitude of travel times and ease of prediction. For example, section 26  was similar to section 47 (TIDEL park) because both belong to the high travel time group, compared to a section labeled as low travel time section.To check for the temporal variations of the clusters formed, the cluster memberships were plotted for every hour of the day. Sample plots, one for a high travel time section and one for a low travel time section, are shown in The next analysis concentrated on the proportion of clusters for each day of the week. For a sample week, the proportion of memberships of each cluster was calculated separately for each day of the week and plotted as shown in K ANNs were used for testing. Predictions were obtained using both selection and fusion criterion, as explained earlier. Once the training was over, the The prediction errors were comparatively higher for sections belonging to the highest travel time cluster in most cases. To reduce the prediction errors for these sections, the standard selection-based criterion was revised using the revised selection-based criterion, as shown in In the next step, trip level, section level, and day level errors were studied. k-means clustering, and the data set was divided into five clusters.The effects of using both travel time and travel time prediction as feature vectors for clustering on predictions were examined by comparing the results obtained when only travel time is used for clustering. The same training procedure was repeated. Here, the optimum number of clusters was found to be five for A comparison of predictions for a sample section with higher variance in travel times is shown in The performance of the developed joint clustering and prediction approach was then compared with the three base methods. Overall, the results showed the superiority of the proposed joint clustering and prediction framework. The MAPE decreased, and cluster memberships stabilized over iterations. Performance improvement compared to the base methodologies indicated that the proposed iterative clustering and prediction approach can considerably improve prediction accuracy.In the present work, a joint clustering and prediction approach was developed for accurate prediction of bus travel times. It used an iterative process and considered the spatiotemporal patterns in traffic. The effects of integrating both clustering and prediction modules into an iterative joint clustering were analyzed. The impact of this integration on prediction accuracy was studied. The main findings and contributions of this study are summarized below.An iterative joint clustering and prediction approach was developed to improve spatiotemporal pattern characterization and provide accurate bus travel time predictions. The sharp decrease in MAPE from iteration 0 to iteration 1 demonstrated the advantage of dividing the data set into clusters and building separate models on them, rather than building a single model on the entire dataset. It was observed that once the MAPE value stabilized, the cluster memberships also remained unchanged, indicating the formation of stable clusters. The clusters formed were analyzed to check if they constituted meaningful clusters. It was seen that sections with bus stops and/or intersections belonged to the higher average travel time clusters during most hours of the day.A protocol to identify the correct cluster and prediction model for a test point was also developed. Two criteria—standard selection, and fusion-based criterion were incorporated. The predictions based on the selection strategy worked better than the latter. The predictions were further improved on using a revised selection-based criterion for high variance sections.The idea of using both travel time and travel time predictions as feature vectors for clustering helped in grouping points that were similar in magnitude and predictability. The improvement in prediction accuracy justifies the selection of both feature vectors for clustering.The developed joint clustering and prediction approach was compared with three base methods: a) on base data where no patterns or groups in the data are considered, b) data with fixed clusters based on chronological factors, and c) data-derived clusters. A significant decrease in prediction error was observed when the joint clustering and prediction approach was used, indicating its superiority over the other methods.The present study proposed an umbrella framework that can be used for automated clustering and prediction of travel time data, which can also be used for prediction exercises regardless of the domain and the prediction model. The framework can be applied to predict variables that vary with both space and time. The joint prediction and clustering framework was able to provide accurate forecasts of bus travel times across the study stretch with highly varying travel times. Improvements in prediction accuracy can help provide accurate bus arrival information to passengers, thereby encouraging the use of public transportation among people.The present study was based on GPS data from buses. Integrating the GPS data with other data sources such as weather data, area characteristics, the occurrence of accidents, social media alerts, etc., could improve prediction accuracy. In this study, equal-length sections were considered for analysis. However, most sections had similar travel times, as seen from the heat maps. Future studies could consider variable section lengths of uniform traffic characteristics and predict the travel times of similar sections with the same prediction model. The sections without bus stops and intersections would have similar ranges of travel times and can be considered a single section rather than multiple smaller sections. The differences or spikes may be evident only in the case of sections with bus stops and intersections, and such sections may have to be modeled separately. This may lead to more computationally efficient predictions and may be considered for future research.


TTR) gene, the Val122Ile (V122I) mutation can be found in 3–4% of African Americans. Up to 47% of patients with the V122I hATTR cardiomyopathy had a history of carpal tunnel syndrome (CTS). This raises the question should we screen for this mutation in African Americans with bilateral CTS for the purpose of preventing advanced disease associated with hATTR. This is a prospective pilot study to determine the likelihood of African Americans with bilateral CTS having the V122I mutation and whether various clinical factors contribute to that probability.Hereditary transthyretin amyloidosis (hATTR) can cause multisystem organ disorders including polyneuropathy and cardiomyopathy. Amongst the many known pathologic mutations of the transthyretin  in this cohort were found to have the V122I mutation. The absence of polyneuropathy and cardiomyopathy symptoms, presence of other CTS risk factors, and absence of family history of CTS and cardiomyopathy did not decrease the likelihood of V122I mutation in this cohort.TTR mutation in this population.The frequency of V122I transthyretin mutation in African Americans with bilateral CTS may be higher than 3–4%. The presence of bilateral CTS alone may be a justification to screen for  TTR) proteins form tetramers that serve as carrier proteins for thyroid hormone and retinol. Mutant TTR proteins form unstable tetramers that tend to dissociate into monomers, which can form pathologic amyloid fibrils in various organ systems. The disease manifestations of hATTR include cardiomyopathy, polyneuropathy, autonomic insufficiency, carpal tunnel syndrome (CTS), and more. Many different TTR mutations have been described worldwide (Hereditary transthyretin amyloidosis (hATTR) is an inheritable autosomal dominant disorder. Normal transthyretin  study, the most prevalent American . The THAAmerican .TTR mutation with only CTS is not an indication for treatment if there is no evidence of hATTR polyneuropathy or cardiomyopathy. Still, bilateral CTS is one of the so-called Red Flag symptoms that justifies a diagnostic investigation for hATTR, in the appropriate clinical context  African American seen in the neuromuscular clinic or EMG lab of University of Florida in Jacksonville, diagnosed with bilateral CTS, were at least 18 years of age, did not have an existing diagnosis of amyloidosis, and could give informed consent were recruited for the study. The study protocol was approved by the University of Florida Institutional Review Board.Patients were given a clinical diagnosis of CTS if they reported intermittent or persistent numbness/tingling in digits 1, 2, or 3 for at least 1 month , and hadTTR gene. Genetic testing was performed through Invitae , a College of American Pathologists-accredited, Clinical Laboratory Improvement Amendments-certified laboratory. Patients who were found to have a TTR mutation were given genetic counseling, referred to appropriate providers, and managed according to current practice standards.Patients were de-identified prior to their blood or saliva specimen being sent for genetic testing for mutation of the Each patient's age, gender, Red Flag symptoms, any risk factors of CTS, and family history of CTS and cardiomyopathy were collected through a set of questionnaires.Data was summarized using counts and frequencies (percentages). Associations were assessed using the Fisher's Exact test. The level of significance was set at 5%. All analyses were done in SAS® for Windows Version 9.4.Two men and 14 women participated in the study. The average age was 55.75 years, ranging from 38 to 73 years. The results of genetic testing, presence of co-existing Red Flag symptoms, risk factors for CTS, and relevant family history for each patient are presented in TTR mutation. Both were women and in the sixth decade of life. One was heterozygous, and the other was homozygous, for the mutation. The other 14 patients did not have a TTR mutation. The percentages of patients with and without TTR mutation, with Red Flag symptoms, other risk factors of CTS, family history of CTS, and cardiomyopathy, are summarized in Two of the 16 patients (12.5%) had the V122I Table 2TTR mutation vs. no mutation.Association of red flag symptoms, CTS risk factors, and family history of CTS and cardiomyopathy with V122I TTR mutation. Of the two patients with the V122I mutation, the one with homozygous mutation reported symptoms of cardiomyopathy but had no specific diagnosis.None of the patients had an existing diagnosis of cardiomyopathy. Symptoms of cardiomyopathy were reported in nine of the patients without the TTR mutation and one of the two patients with V122I mutation reported a prior diagnosis of neuropathy, although they denied the typical sensory symptoms of polyneuropathy.Three patients without a TTR mutation, two endorsed orthostatic symptoms, and six endorsed GI symptoms. The two patients with the V122I mutation denied orthostatic and GI symptoms.In those without a TTR mutation and one with the V122I mutation had an existing diagnosis of diabetes. Thirteen of those without a TTR mutation and both with the V122I mutation had other risk factors for CTS (mainly frequent repetitive use of the hands). One of the patients with V122I mutation had a diagnosis of rheumatoid arthritis, and the other had a diagnosis of hypothyroidism. Both patients with the V122I mutation endorsed performed jobs or activities that required frequent repetitive use the hands.Two of the patients without a TTR mutation, and a family history of CTS in one or more first degree relatives was reported in eight patients without a TTR mutation. None of the two subjects with the V122I mutation knew of any first-degree relatives with cardiomyopathy or CTS.A family history of cardiomyopathy in one or more first degree relatives was reported in four patients without a TTR amyloidosis (including wild-type and hereditary), the probability of having CTS was the highest during the 5–9 years prior to the diagnosis of cardiac amyloidosis, and that CTS was an independent mortality risk factor in transthyretin amyloidosis  who participated in the study. It is interesting to note that both patients with V122I mutation in this cohort were in their 6th decade of life. A previous study showed that for African American patients with V122I hATTR cardiomyopathy, the average age at diagnosis was 70, although the first cardiac symptoms may have preceded the diagnosis by more than a decade  are subject to recall error, since they were not verified. All patients in this cohort had self-identified as (Black) African American, and from an ethical standpoint, their self-reported racial identity is indisputable. However, from a Mendelian inheritance standpoint, when studying the prevalence of a gene mutation in a racial cohort, individuals of mixed racial origin could affect the carrier frequency of that mutation. The possibility of multi-racial origin in any of the individuals of this cohort was not explored.TTR mutation is unknown. We explored the predictive value of some of the major Red Flag symptom for a TTR mutation, such as symptoms of cardiomyopathy, orthostatic hypotension, or GI complaints, and they did not seem to increase the likelihood of a TTR mutation in our African American cohort with bilateral CTS. However, the predictive value of other Red Flag symptoms, such as renal dysfunction, vitreous opacities, or unexplained weight loss were not explored.The so-called Red Flag symptoms are often found in patients diagnosed with hATTR, and these symptoms (and signs) can justify diagnostic investigations in the clinical setting. However, many of these symptoms are non-specific, and their predictive value for hATTR or TTR mutation than those with idiopathic CTS. In that study, increased median nerve cross-sectional area correlated with increased severity of idiopathic CTS, but this correlation was not apparent in those with TTR mutation (TTR mutation in patients with CTS remains an interesting area of exploration.We did not routinely perform ultrasound studies on patients with CTS. However, a recent study using peripheral nerve ultrasound showed the average median nerve cross-sectional area was smaller in those with mutation . WhetherTTR mutation. If this probability is reproducible in a larger study, it could be clinically impactful. Biopsy confirmation of ATTR deposition in patients with bilateral carpal tunnel syndrome with V122I TTR mutation may be possible in a future study with long term follow up as well.It must be emphasized that those with the V122I mutation in this study were not confirmed to have amyloidosis. Confirmation of hATTR causing CTS would require tenosynovial biopsy during CTS surgery, which was not a part of this study. It is also possible to have a false negative biopsy in an individual with amyloidosis simply due to sampling error. Not every case of CTS requires surgery and carpal tunnel release surgery is often performed for more severe cases or those refractory to non-surgical management. A nationwide Danish registry study that included 56,032 patients showed CTS surgery was associated with higher risk of amyloidosis and heart failure compared to control subjects, although this study did not distinguish the type of amyloidosis . In a prUltimately, whether identification of the V122I mutation based on CTS prior to the onset of cardiomyopathy, polyneuropathy, or dysautonomia will ultimately impact mortality and morbidity associated with hATTR, remains to be determined.TTR mutations with the aim of preventing advanced disease associated with hATTR. Despite the limitations of this study, the findings here could suggest that the presence of bilateral CTS in African American individuals, especially in their 5th or 6th decade of life, may be an adequate justification to screen for a TTR mutation, regardless of Red Flag symptoms, other risk factors for CTS, or family history of CTS or cardiomyopathy. Of course, a larger study would help to verify these findings. Ideally, a future study would address the limitations of this study. Furthermore, in individuals found to have a TTR mutation on the basis of bilateral CTS, it would be valuable to determine what proportion of them may already have cardiomyopathy. Ultimately, if screening for a TTR mutation based on a diagnosis of bilateral CTS leads to identification of otherwise overlooked hATTR cardiomyopathy or prevention of advanced hATTR-associated disease in a significant number of African American individuals, it may be justified to incorporate this screening approach into a practice guideline.This was a prospective evaluation of the predictability of bilateral CTS for the V122I mutation in an African American population, and we found that 12.5% of our cohort had the mutation. We focused on the African American population, because carrier rate of the V122I mutation in this population was already established to be 3–4%, which serves as a benchmark, in that any screening approach that identifies a higher percentage of the mutation can be clinically impactful. The greater purpose of this effort is to determine efficient ways to identify The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by University of Florida, Jacksonville, Florida, Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.JS designed and carried out the study, wrote the abstract, introduction, much of the methodology, results and discussion of the manuscript. MB contributed to the design of a database for the study, carried out the study, and contributed to the methodology section of the manuscript. CS contributed to the design of the database, performed statistical analysis, and contributed to the methodology section of the manuscript. All authors contributed to the article and approved the submitted version.University of Florida internal funding.JS has participated on the Alnylam Pharmaceuticals advisory board in 2020, given a disease awareness talk in 2021 for Alnylam, and received financial compensations for those activities. The remaining 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.