The complexity and non-linear dynamics of socio-motor phenomena underlying social interactions are often missed by observation methods that attempt to capture, describe, and rate the exchange in real time. Unknowingly to the rater, socio-motor behaviors of a dyad exert mutual influence over each other through subliminal mirroring and shared cohesiveness that escape the naked eye. Implicit in these ratings nonetheless is the assumption that the other participant of the social dyad has an identical nervous system as that of the interlocutor, and that sensory-motor information is processed similarly by both agents’ brains. What happens when this is not the case? We here use the Autism Diagnostic Observation Schedule (ADOS) to formally study social dyadic interactions, at the macro- and micro-level of behaviors, by combining observation with digital data from wearables. We find that integrating subjective and objective data reveals fundamentally new ways to improve standard clinical tools, even to differentiate females from males using the digital version of the test. More generally, this work offers a way to turn a traditional, gold-standard clinical instrument into an objective outcome measure of human social behaviors and treatment effectiveness. The wearable sensors revolution has brought behavioral science to a new era of precision. Across many research areas in basic and translational sciences, it is now possible to monitor natural motions continuously, as they unfold between two people in a social dyad, or even as part of a social group. Indeed, the advent of new advances in digital technology opens many new avenues of inquiry in the social, clinical, and psychological sciences. It is now possible to track multi-layered activities generated by our nervous systems while our brain controls our bodies in motion. Such tracking affords various levels of discourse, including a macro- and a micro-level of description.At a macro-level A, we canThere is a form of autonomous mirroring that tends to occur in social interactions from birth, when within a few weeks human babies can entrain their bodily biorhythms to the rhythmic speech of their mother ,7 and peThe body of work on human development and the capacity of human babies for social readiness has relied on high grade instruments, microfilm, wearables, and other means beyond human observation. This is so because several of these pre-cognitive socio-motor behaviors are much too complex, variable and subtle to be captured by the naked eye ,20. TheyWe know that people automatically sway together when they converse and when they joke ,23, thatOne possible way to probe the social dyad in a systematic manner is by using as the backdrop of our experiment well-established and broadly adopted tests of social interaction that have already been standardized in some form C. One suSocial interactions naturally occur in a very different manner  Natural interactions are extremely complex, dynamic, and flow organically in (at times) unpredictable manners. One of the advantages of using the ADOS as a backdrop of our study is precisely that it is conceived to allow for such fluidity using several tasks that can be administered in the order in which the situation affords, rather than in a fixed order. Yet, despite this fluidity, because of the standard ways in which each task is conceived, the overall test preserves a systematic manner of administration across different ages and different verbal capacities, ranging from minimally to fluidly verbal cases. The ADOS test has not officially included neurotypical controls to build a normative scale . It is aIntegrating macro-and micro-levels of analysis will augment in unprecedented ways our knowledge about action execution and action observation in this closed loop of highly variable, transient, and sustained dyadic cohesiveness e.g., C–E. We mIn the social sciences in general, this approach could advance more than one line of inquiry into the non-linear, dynamic, and stochastic complexity of micro-level social exchange, making these important aspects of our social being no longer hidden to the naked eye.This study was approved by the Rutgers University Institutional Review Board. The study is compliant with the Helsinki Act.This study used the tasks from the research grade ADOS-2 , a standThe experiment consisted of four visits. In the first visit, the neurotypical control participants were administered the tasks from the ADOS-2 module that were most appropriate in terms of age and verbal capacity. The first visit also examined autistic subjects under similar ADOS-2 module criteria, i.e., using the most appropriate module according to the child’s age, verbal status, and cognitive capabilities (as determined by the rater clinician.) The autistic participants were familiar with one of the two raters but not the other. Controls only participated in visit one.The second visit employed an ADOS-2 module that was compatible with the child’s verbal ability, even if it was easier than the most appropriate module used in visit one. The idea was to vary the module while keeping the rater familiar to the children in both visits. The third visit switched to a new, unfamiliar rater but kept the most appropriate module. The fourth visit kept that rater but changed the module to an easier one, feasible but not the most appropriate (if one were to use the ADOS-2 to detect autism.) In our case, we used this test as an experimental assay to evoke dyadic social interactions. https://njace.us/), funded by the New Jersey Governor’s Council for the Medical Research and Treatments of Autism.We tested a total of 29 participants, 10 females and 19 males see . There wBecause of the data type and methods that we introduce for personalized behavioral analyses, this cohort was sufficient in size. We test the proposition that combining pencil-and-paper methods with digital means would reveal information about dyadic behaviors that we would miss using observation alone. We built indexes that combined the rater’s scores derived from observation with digital data collected using light wearable sensors. The sensors  synchronously co-registered motions continuously at 128 Hz, thus providing big data for personalized analyses. We study here linear acceleration  and of the shared spatio-temporal parameters of the dyad acting in concert A. We co-An index of Dyadic Strength is built as a ratio whereby the numerator is derived from the Dyadic Coherence, using analyses in the frequency domain A,B. The We analyze data in the time and frequency domains and construct various socio-motor indexes. In the time domain, we examine the variability in MMS using in-home developed analyses of time series data. These include the characterization of the MMS as deviations from an empirically estimated mean, determined using maximum likelihood estimation (MLE) of the best continuous family of probability distributions fitting the data. Previous studies involving natural behaviors had revealed the continuous Gamma family as a good characterization of human digital data registered with these wearables ,32,33. TWe derived several adjacency matrices to represent these activities using dynamically evolving weighted directed graphs. Furthermore, we adapted various network connectivity analyses from brain research and used them here to characterize a grid of sensors registering the continuous naturalistic social interactions of a dyad. We focus on the cohesiveness of the dyadic interactions from the spatio-temporal spaces shared. We also examine the kinematic synergies of self-interactions in each dyad participant.Among the connectivity metrics that we used, we specifically assessed possible differences between males and females across the cohort. We used the clustering coefficient metric, a measure of the degree to which nodes in a graph tend to cluster together. We used the Betweenness Centrality metric, measuring the extent to which a vertex lies on paths between other vertices. Vertices with high betweenness may have considerable influence within a network by virtue of their control over information passing between other vertices. Related to this, we examined the characteristic path length, the average shortest distance path (geodesic), denoting he number of edges in the shortest paths between all vertex pairs. In all cases we gathered the data generated by the dyad across the tasks and used the same number of data points in males and in females, to ask if, given a scatter of similar size, the values distributed significantly differ. Since we had fewer females (10) than males (16), we relied on the minimum number of values in the females and cycled through all the values of the males (bootstrapping from the data) to ascertain the degree to which they differed when the number of elements were identical for each parameter and for each cohort. To compare the groups, we used the rank-sum test and visualized the histograms and the scatters across all connectivity parameters scaled to range between 0 and 1. This normalization allowed us to visually compare males and females across network connectivity metrics and stochastic parameters.We used Euclidean norm (Equation (1)) to obtain the scalar value of acceleration from the tri-axial acceleration time series, sampled The resultant time series of peaks and valleys for an experiment’s participant (EP01), during the ADOS “Construction task”, and the rater are shown in These time series of linear acceleration and angular speed have peaks and valleys that fluctuate in amplitude and inter-peak interval times. We focused in this paper on the fluctuations in signal amplitude, taken as relative deviations from the empirically estimated Gamma mean. To estimate the mean, we fit the continuous Gamma family of probability distributions to the frequency histogram of the raw data peaks. The Gamma family fits the data in an MLE sense with 95% confidence intervals for the shape and the scale parameters, respectively . Using tThe peak amplitude data mean, shifted and centered at the empirically estimated mean, was then scaled to the real valued interval  using Equation (2)These unitless waveforms are called micro-movement spikes (MMS) see C. The MMWe chose 12 s time windows as our unit for the Gamma parameter estimation because this was the minimal task segment across the entire set and it provided tight confidence intervals at 128 Hz sampling rate.Several metrics per unit time (12 s windows independently sampled without overlap) are derived to quantify socio-motor phenomena, inclusive of leading patterns within the dyad agents, cohesiveness and phase delays. Below we enumerate these metrics in the temporal and frequency domains. Furthermore, we explain our adaptation of network connectivity analyses commonly used in brain science ,31 to thDyad Variability : To quantify the differences in frequency histograms derived from the MMS, we use the Earth Mover’s Distance metric [1,2 quantity between the right wrist and the left wrist of the child, whereas entry in row 5 and column 2 represent the EMD5,2 between the left wrist of the clinician and the left wrist of the child. EMD1,2 captures variability in bodily nodes’ self-interaction because these are from the child’s own body. In contrast, EMD5,2 captures variability in dyadic interactions because they are from a shared dyadic spatio-temporal pattern derived from pairwise activities between the clinician and the child. e metric  commonlye metric . The avee metric ,2 in rowCoherence-Phase-Frequency Parameterization (frequency domain): Power spectrum analyses  of the child and the torso (T) of the child. This is the maximal level of synchronicity between these self-body parts. As with the EMD matrix before, here we focus on the self-interaction entries and on the dyadic entries, separately. Under this convention, entry MaxCoherence2,3 represents a self-interaction entry. The corresponding entry in the MaxPhase matrix has 0 value, thus indicating that these two self-body parts are synchronized with 0 lag and this occurs at 30Hz, the corresponding entry in the MaxFrequency matrix.The first matrix comprises the maximal cross-coherence value at each entry. For example, entry MaxCoherencei leads node j in the  entry. Lastly, the frequency matrix provides information about the frequency range at which the cross-coherence is maximal at a phase lag. We can examine the activities for known physiological ranges up to 30 Hz, and/or beyond those ranges up to 64 Hz in this case, focusing on different frequency bands to examine different patterns of entrainment for different dyads, etc.  and links between nodes. The links represent the level of pairwise maximal coherence. We use network connectivity analyses and obtain OutDegree, InDegree, total degree, strength, modularity, clustering coefficient, etc., to capture different states of network connectivity across tasks representing states of the dyad whose biorhythmic activity dynamically evolves over time. For the corresponding MaxPhase matrix, we adopt the convention that node examples ,37.) In Dyad Coherence Metric: The total dyad coherence is obtained by summing over the entries of the dyadic portions of the matrix (circled in Dyad Strength Index: An index measuring the strength of the dyad (Equation (3)) combines the value from the Dyad Coherence metric in the numerator and the value from the Dyad Variability metric in the denominator. Higher value of the ratio indicates lower variability and higher cross-coherence during the interaction. This quantity was normalized between  using the maximal value across all tasks.Delay in Cohesiveness: For maximal coherence values, we sum the lag values over the dyadic entries of the phase matrix to determine, under our  order convention which person lags behind the other person when the shared dyadic body parts are maximally coherent.Social Readiness Metric: Using the combination of macro-level data (ADOS scores) and micro-level Dyad Strength quantity, we build a parameter space where we localize all controls and autistic participants to learn where in that parameter space the controls lie. The assumption here is that the control with the highest value of Dyad Strength and the lowest value of ADOS score has high social readiness potential. Then we build a relative metric of Social Readiness by taking the difference between this representative participant and every other participant in the cohort. This is a positive quantity spanning from 0 to the maximal value across the cohort. We normalize both the ADOS scores and the Social Readiness quantity using the corresponding maximal values, and we can then profile the full cohort simultaneously at the macro- and micro-level of inquiry. This can inform us about the potential of each child in the cohort for appropriate social interactions that the clinical test expects and that the body performs. Leading Profile: To assess who leads, the child and clinician, during the dyadic interaction for each task, we use the OutDegree metric , 3 (RW), 5 (Torso))Child and (1 (LW), 0 (RW), 3 (Torso))Clinician. As an example of lead-lag calculation for EP01, he spent 17 time units in the Construction Task (CT) with a 12 s time unit (128 Hz × 12 s gives 1536 frames and this is the minimum time length of a task across the entire cohort.) This number of frames provided enough information to empirically estimate statistical parameters with 95% confidence intervals. At time Child (OutDegree = 3), is compared to LWClinician (OutDegree = 1). The Child leads this interaction as it has a higher value of OutDegree. Similarly, the Child leads seven to nine interactions, none are led by the Clinician and two are balanced . Consequently, at time t = 1, the Child leads. Each of the entries in the Child vector are compared to the entries in the Clinician vector, giving a total of nine possible dyadic interactions. For example, the first interaction, being LWt. We can see that at t = 1, the child leads as explained above. The calculation for the other time units follows and a profile across tasks is shown in The lead-lag patterns can be visualized as in The combination of macro- and micro-level of inquiries can be appreciated in Notice that several of the autistic participants have social readiness potential in the range of controls, despite high ADOS scores.Another metric that we can derive from the network connectivity analysis is the extent to which each node leads other nodes in the grid of six sensors, conceptualized as an interconnected network. To that end, we use the OutDegree metric e.g., E which sWhen the interlocutor is neurotypical, the rater’s patterns mirror the range of neurotypical values, but when the interlocutor is autistic, this range shrinks. Since these are self-interactions (inter-node cross-coherence phase for each agent) and the dyad also shares the intra-node cross-coherence, we then obtained graphs in We see that, as with the self-interaction nodes, the dyadic interaction nodes reveal a mirroring bias whereby, for the same clinician, same child and same module, the range of values in the leading parameter is on average much higher when the children are neurotypical , the module is the less language-appropriate one. In visit three, the children perform the appropriate module, as in visit one. Despite the familiarity with that module, the patterns of leadership ranges shrink with the new, unfamiliar rater. Here we see that the new rater’s range becomes much broader when the children are familiar with her in visit four, and the module is already familiar to the child, from visit one. For both raters, there is an implicit mirroring effect with the autistic children that is inevitably bound to bias their scoring. The raters are interacting in a closed loop with the child and influencing the interaction that they evoke, respond to and rate. The cross-coherence network connectivity metrics capture the inherent biases in the leading patterns across the ADOS tasks. In all cases the rater dominates the interaction albeit with marked differences between controls and autistics in the full range of values across the cohort, susceptibility to familiarity with the rater and easiness of module.The network connectivity analyses invariably reveal for controls and autistics that the rater leads the interaction most of the time. This can be appreciated in Two raters participated in the study, one in visits one and two, the other in visits three and four. As mentioned, the appropriate ADOS module was administered in visits one and three. Less appropriate modules were administered in visits two and four. This experimental assay allowed us to probe the responses of the dyad to the switch in raters  For the autistic children, the leading profile derived from the self-interaction entries of the matrix changes with the change in clinician, despite maintaining the same ADOS module, whether appropriate or not E,F. ThisAmong the experimental participants, several had similar ADOS scores. This is not surprising, given the narrow numerical range of discrete values of these scores and the large heterogeneous population sample. Upon taking a random draw of participants from the population, it is not possible to cover all different subtypes using these discrete scores’ range from macro-level criteria. To instantiate this point, we present the socio-motor data derived from the biosensors for two experiment participants with identical ADOS scores but fundamentally different socio-motor phenotype. We examined their ADOS activities using the same module and rater. Likewise, following up the sensitivity of the children’s nervous system to changes in clinician, we here asked if the same autistic child interacting with the two clinicians in different visits would be differentially perceived by the clinicians. We tested this question using the micro-level socio-motor patterns from the clinicians and comparing them across the tasks that were common to the child. Given the sensitivity of micro-level socio-motor patterns to changes in clinician, modules and the passage of time from visit to visit, we then ascertain the extent to which we could use the digital data derived using the ADOS test as an outcome measure and possibly turn this test into an intervention tool, beyond the static notion of a macro-level detection instrument. Adding the socio-motor micro-dynamics is amenable to further investigating this question, task by task. To that end, we probe the delay in attaining cohesiveness as a metric of natural social interactions. Delay in Cohesiveness (see methods) is obtained by summing over phase-lag values of the entries of the phase matrix for which maximal cross-coherence was attained between the child’s and the clinician’s biorhythmic activities. This is the socio-motor space cohesively shared by the two agents of the dyad when their bodily biorhythms synchronize with different phase lags. At 0 lag they are perfectly in sync, but that state is often transient. Lag patterns add up to out-of-phase synchronous patterns across child and clinician. We measure that Delay in Cohesiveness and build a parameter space to learn about this as a function of Dyadic Strength (previously defined.) We find that controls span the full range of Delay in Cohesiveness while most lie on the higher values of Dyadic Strength A. In conThis result motivated us to examine the tasks individually and propose a task training regime whereby, in a personalized manner, one could rank which tasks have highest Dyad strength, with variable delay in cohesiveness that converges toward the right lower quadrant of the graph. Then we can use those tasks to start gradually training the person while incorporating other tasks, as social learning improves in the precise sense that Dyad Strength increases, Delay in Coherence is variable and, at the macro-level, the rater begins to unambiguously perceive the positive changes. p << 0.01 according to the non-parametric rank-sum test.The network connectivity analyses revealed fundamental differences between males (16) and females (10) in the cohort. The network connectivity parameters revealed better connectivity patterns in females than males. Since these patterns are derived from the dynamic dyad, they imply better social rapport with the clinician in females than males. The characteristic pathlength was significantly shorter in females than males, suggesting faster information transmission throughout the network, a feature that was accompanied by significantly lower NSR in females, lower clustering coefficient values denoting more distributed network in females, with more efficient (sparser) dyadic node information accompanied by higher betweenness centrality in the dyad nodes. These patterns turned out to be highly different when comparing males’ and females’ micro-movement data, as generated by the dyadic network from the digital ADOS. However, better connectivity patterns in females may make it harder for the clinician to visually recognize social difficulties in the female phenotype. All comparisons of these parameters yielded highly significant differences for the time series data from the accelerometer A,B and fThis study leveraged the digital data output by wearable sensors during the performance of a standard clinical test to significantly augment the information that we could gain during the assessment of dyadic social interactions. Turning the standard tasks of the research ADOS test into experimental assays and manipulating several parameters of the experiment, we were able to improve the characterization of socio-motor behaviors across the population, inclusive of neurotypical controls and autistic participants.We digitized this test while neurotypical children interacted with the rater and uncovered new aspects of the test that helped reveal the potential for social readiness in autistic children. We also learned that the rater dominates the interaction, leading most of the time in both neurotypicals and autistics, with a mirroring effect that inevitably biases the shared cohesiveness of the interaction, channeling a broader range of variability in leadership patterns for neurotypicals and a much narrower range in autistics. The mirroring effects occur at the personal level of activity in what we coin self-interactions of the nodes  It also occurs at the shared spatio-temporal patterns of cross-coherence between several body parts of the child and the rater. This shared cohesiveness that self-emerges and evolves across the tasks in a session contributes to the strength in dyadic interactions present in autistic children and is therefore revealing of their potential for social readiness. We would not have discovered this socio-motor parameter had we not included neurotypicals in our research-ADOS assessment. As social interactions depend on developmental socio-motor milestones, and these in turn depend on the maturation of the nervous system, our results underscore the need to include normative data from neurotypical participants in any study or assessment of autistic social behaviors. Furthermore, objectively quantifying the level of bias from the rater during the interactions enables us to curtail it or enhance it as needed, thus providing new means to causally induce a child’s reaction in a much more controlled manner than has been traditionally done.The use of the research ADOS standardized modules in our study allowed us to test the same child with the same rater under different social demands. When the module was appropriate, we saw a consistent reduction in the range of variability in the leading patterns across raters, in relation to their patterns for a less appropriate module under a context of more familiarity with the rater. This is important because, at the micro-level of socio-motor behaviors, the same child may demonstrate more social competence, given that s/he is more familiar with the person and/or the tasks. This is not something apparent to the naked eye of an observer and much less so when the observer may be also distracted when trying to rate the interaction. There is a bottleneck in information processing that inevitably prevents the rater from seeing this aspect of the interaction. Adding the micro-level of analysis thus presents us with the opportunity to harness this potential for social readiness and offer the child (autistic or otherwise) better social support. We can then utilize this standardized test as an avenue to train the child to be social without having to instruct how to do so, but rather by leveraging this micro-layer of information that we can extract from the shared spatio-temporal cohesiveness of the dyad under more relaxed conditions  Socio-motor phenomena are adaptable. We can use these biometrics to track the progression of adaptation at the micro-level of inquiry, underscoring once again how much more we gain by integrating them into the current behavioral assessments tools at the research and at the clinical levels.Dyadic social interactions are typically a dialogue with balanced contributions from both parties involved. They succeed at communicating when there is appropriate turn taking, when joint attention is not sustained for too long or when it is not too brief, and when the entrainment between the bodily biorhythms lead to implicit agreement supporting non-verbal communication. There is a delicate balance at the micro-level activity that scaffolds social rapport of the interacting dyad at the macro-level. The results from our analyses reveal a prevalence of the rater leading the interaction with both neurotypicals and autistics. This rater dominance turned the test into a quasi-monologue style of interaction, perhaps an unintended consequence of having the same person evoke the social overture of the child, while responding to it, and rating the outcome. Inevitably, the leadership role of the rater skews the interaction. Although this is not discussed in the social behavioral sciences, here we reveal it using micro-level analyses of the shared spatio-temporal and frequency parameters, characterizing the fluctuations of the biorhythmic activity generated by the two bodies in motion during the dyadic exchange.This strong skewing influence of the rater on the dyadic social behaviors changes the outcomes of the child’s socio-motor patterns for the exact same task and module when different clinicians administer the research ADOS to that child. Consequently, not only at the micro-level of social responses, but also at the macro-level of observable responses, a given child could be perceived very differently by different clinicians. There are both positive and negative consequences here. The positive side is that we can precisely characterize the child–rater’s reactions to each other and, in the context of therapy, use this digitized instrument to determine which therapist has by default more rapport with the child. This would be especially relevant in the early stages of the therapy. Likewise, we could use this test and biometrics in the context of a teacher-child relationship, to select the teacher that will most likely (by default) have the best rapport with the child. This is important for emotional social learning in general.The negative aspect is that, for a test that aims at detecting something with high precision, there is no chance that it will do so. The detection problem becomes ill-posed: given a score, what is the most likely socio-motor phenotype? The map from score to socio-motor phenotype is many-to-one. This result bears implications for our (in)ability to define the autistic phenotype(s) and reliably uncover autistic subtypes in a random draw of the population. We could not use this test to stratify the broad spectrum of autism.Since this test informs and largely steers the science of autism, and since given the ADOS score it is not possible to infer the most likely socio-motor phenotype, for detection purposes it may be beneficial to combine different levels of inquiry and produce a more reliable objective metric impervious to rating styles, personality or cultural nuances. This should be possible by providing a digital characterization of social interactions in general, as we have done here, with a clinical example that uses standard pre-specified tasks amenable to illustrate these various points.We emphasize that there are many more possible biometrics that we can derive from these tasks and interactions ,38,39,40One important aspect of the study was that some of the autistic children returned to the lab for a total of four visits. This passage of time was important to assess the extent to which the socio-motor phenomena assessed at different levels of inquiry would reflect the rate of change in neurodevelopment that the children underwent. We found that while the macro-level of description from observation (using in this case the research ADOS scoring criteria) remained static, the micro-level of description and statistical inference fluctuated over time, describing a stochastic trajectory that could reveal individual trends for each child and for the cohort.Having the ability to assess developmental trajectories in tandem with changes in somatic-sensory-motor physiology is important to build the notion of a dynamic diagnosis chart that could reflect such changes in maturation and function. Underlying all these socio-motor biorhythmic phenomena is a growing, adapting and developing (coping) nervous system. Thus, relying exclusively on coarse observational metrics that fail to capture change will prevent the ability to provide proper support to nurture the growth of these systems and the social axes that they scaffold. Introducing these digital biometrics of socio-motor behaviors can help us bridge the gap between neurodevelopmental rates of change and coarse clinical behavioral criteria.Another aspect of the study that is worthwhile underscoring is the fundamental differences in network connectivity patterns that we found between males and females. These differences in connectivity patterns relate to socio-motor parameters derived from the dynamically interacting dyad. Thus, unlike the paper-and-pencil version of the ADOS, which has failed to detect social differences in females (by observation), here the digital ADOS does so across all parameters under consideration. Furthermore, we also examined the Gamma NSR empirically derived using MLE and found fundamental differences between the MMS signatures of males and females across the cohort. This result is congruent with prior work involving person-centered analyses of involuntary head motions ,42,43, dAdopting standardized digital technology and integrating it with these gold-standard psychological tests may help us develop new outcome measures of treatments and provide parameter spaces where we can track the trajectories of interventions. A testable hypothesis is that, as participants repeat the ADOS performance, it may be possible to ascertain which tasks give higher dyad strength. If we were to focus on those tasks first to improve social interaction, then it would be possible to shift to the other tasks, thus aiming at broadening the repertoire of tasks that lead to appropriate social exchange, tailoring this to the child’s inherent strengths in an individualized manner. Indeed, digitizing social behaviors could provide a guide to assess the changes in socio-motor parameters introduced here such as Dyad Strength and Delay in Cohesiveness, computed as relative metrics, obtained first in neurotypicals, and as such revealing of the expected course of socio-motor development, constructed along the path of least resistance. Our work offers more than one way to do this while leveraging the wearable sensors revolution and preserving the clinical gains already attained with observational means.Although the digital characterization of the ADOS test may hold the promise of revealing new aspects of the ADOS interactions that may otherwise remain hidden to the naked eye, there are several caveats regarding the adoption and use of the present methods. The major limitation is the current lack of mechanisms that can scale up the results from this reduced cohort in the laboratory to thousands of participants in clinical settings. Future use of the analytics presented here can be extended to biorhythms registered with off-the-shelf wearables such as smart watches and web cameras outputting shareable digital data, even across remote settings. To that end, our laboratory has developed a new concept “The Lab in a Box”. This remote kit for behavioral data acquisition and analyses offers continuity to the administration of behavioral tests such as the ADOS in times of social  distancing. However, deploying such methods on a large scale would require a concerted effort across multiple disciplines, business models and entrepreneurship beyond academic settings. This exceeds the scope of this paper, but it is perhaps something to keep in mind in order to translate the present results to clinical and home settings, offering the possibility to scale up the use of this technology to tens of thousands of users.Another limitation of the present analysis is that other pipelines could have been used to analyze the data. This begs the question of whether the general results would have dramatically changed in that case. In earlier preliminary analyses of these data sets using different analytical pipelines, larger number of sensors in the interconnected grid, different bodily locations for the additional sensors, different kinematic parameters, and different children, we observed similar trends . As suchWe have shown that by integrating macro-level rubrics used to assess appropriateness of social exchange with micro-level biorhythmic activities co-registered synchronously in both agents of the social dyad, we can uncover much more than we would when using one level of inquiry alone. Our work underscores the need to combine pencil and paper methods with objective instruments that add a finer layer of granularity to the study of the complex dynamics of social phenomena. Without a doubt, this is a case where the overall sum amounts to much more than its individual parts.EBT holds the US Patent “Methods and Systems for the Diagnoses and Treatments of Nervous Systems Disorders” combined in the paper as micro-movement spikes, MMS data type and Gamma process.


Remotely piloted unmanned combat aerial vehicle (UCAV) will be a prospective mode of air fight in the future, which can remove the physical restraint of the pilot, maximize the performance of the fighter and effectively reduce casualties. However, it has two difficulties in this mode: (1) There is greater time delay in the network of pilot-wireless sensor-UCAV, which can degrade the piloting performance. (2) Designing of a universal predictive method is very important to pilot different UCAVs remotely, even if the model of the control augmentation system of the UCAV is totally unknown. Considering these two issues, this paper proposes a novel universal modeling method, and establishes a universal nonlinear uncertain model which uses the pilot’s remotely piloted command as input and the states of the UCAV with a control augmentation system as output. To deal with the nonlinear uncertainty of the model, a neural network observer is proposed to identify the nonlinear dynamics model online. Meanwhile, to guarantee the stability of the overall observer system, an adaptive law is designed to adjust the neural network weights. To solve the greater transmission time delay existing in the pilot-wireless sensor-UCAV closed-loop system, a time-varying delay state predictor is designed based on the identified nonlinear dynamics model to predict the time delay states. Moreover, the overall observer-predictor system is proved to be uniformly ultimately bounded (UUB). Finally, two simulations verify the effectiveness and universality of the proposed method. The results indicate that the proposed method has desirable performance of accurately compensating the time delay and has universality of remotely piloting two different UCAVs. At present manned/unmanned formation is the developing trend of future war, the unmanned combat aerial vehicle (UCAV) can remove the physical restraint of the pilot, maximize the performance of the air fighter and effectively reduce casualties. However, restricted by the development of current intelligence technology, the UCAV still cannot complete the tasks independently. Therefore, a remotely piloted UCAV will be a prospective mode of air fight in the future, and remotely piloted technology has become an important way to win unmanned aerial combat ,2,3.The remotely piloted system consists of UCAVs, the wireless sensor network (WSN) and the remotely piloted station seen in . The proFor the problem of time delay, many researchers have studied and proposed different methods. The predictive approach is very efficient for calculating the time delay ,8. To prDue to the need of strong maneuverability, the general aerodynamics of the UCAV is unstable; the UCAV requires its own control augmentation system to guarantee self-stability ,27. ConsFor this problem, many scholars have focused on the model uncertainty and nonlinear unmodeled dynamics. The intelligent algorithm using a fuzzy logic system and a neural network as an approximate estimator is widely studied ,31,32. F(1)A novel universal input–output nonlinear dynamics model of a UCAV with a control augmentation system is established. Considering that the pilot often pays attention to the position information when piloting a UCAV, and the position is just twice the integral of acceleration, which is universal for any UCAV. Consequently, we establish a universal nonlinear uncertain model which uses the pilot’s remotely piloted command as input and the states of the UCAV with a control augmentation system as output. In addition, the nonlinear characteristics of the UCAV’s actuator are also considered.(2)To deal with the nonlinear unmodeled dynamics, a radial-basis-function (RBF) neural network method is applied to identify the nonlinear dynamics model online. Meanwhile, to guarantee the stability of the overall observer system, an adaptive law is designed to tune the neural network weights.(3)A time-varying state predictor is designed based on the identified nonlinear dynamics model to achieve accurate predictions of the time delay states.(4)The overall adaptive neural network observer-predictor scheme is shown to be uniformly ultimately bounded (UUB) via the Lyapunov approach. The predicted errors are proved to converge by analyzing the trajectory. Two simulation results show that the design predictor can identify the nonlinear dynamics model precisely and can predict the flight states effectively.Compared with previous studies on remotely piloted UCAVs, this paper is an extension of the previous method proposed in . A prediThe remainder of this paper is organized as follows. In this paper, we use the nonlinear longitudinal dynamics model of a UCAV built in ; the detIn the previous section, the longitudinal dynamics model of UCAV is given. However, the strong maneuverability of the UCAV is usually unstable, and it has its own control augmentation system. Therefore, the object piloted is not the UCAV dynamics itself, but the whole UCAV after the control augmentation. Different from the remote piloted low-speed UAV, the remote piloted command sent by the pilot is no longer the elevator deflection, but the longitudinal acceleration command.Therefore, in this paper, the dynamics model, from the pilot’s acceleration command to the acceleration response of the UCAV, is modeled as a nonlinear uncertain model, and it will be approximated in Remark 1.In Equation (2),denotes the dynamics model from pilot’s longitudinal acceleration commandto the response of the UCAV’s longitudinal accelerationvia the control augmentation system. The dynamic process is not only related to the aerodynamic and motion characteristics of the UCAV itself, but also to the response performance of the control augmentation system and the nonlinear characteristics of the actuator. In addition, due to the strong maneuverability of UCAV, its aerodynamic characteristics are very complex, and the couplings between aerodynamic parameters and flight dynamics are strong, thusis an unmodeled dynamics in this paper, and it will be approximated later.The latency in the pilot-wireless sensor-UCAV closed-loop system is defined as the time elapsed from pilot’s command until an expected state feedback is displayed in the pilot/vehicle interface . The timRemark 2.According to , the totcan be combined asto make it easier for analysis. Then, the time delay model can be simplified as follows:Assumption 1.For the time-varying delay To achieve a convenient expression in the following section, the dynamics model of a UCAV with time-varying delay can be expressed asIn this paper, the unknown functions will be approximated by an RBF neural network. It has been proven that for an arbitrary real continuous nonlinear function Then the unknown function Remark 3.In this paper, we denoteas the Euclidean norm, andDefinition 1.We say that the solution of a dynamic system is UUB if for a compact setofand for allthere exists aand a numbersuch thatfor allThe greater transmission time delay existing in the pilot-wireless sensor-UCAV closed-loop system causes pilot-induced oscillation and degrades the pilot/vehicle system stability and tracking performance. Therefore, a time-varying state predictor is designed in this section to predict the time delay states. However, because the dynamics model of the UCAV’s control augmentation system is unknown, an adaptive RBF neural network observer is proposed to approximate the unknown nonlinear function. Moreover, a corresponding lemma and the convergence proof of predicted errors are presented, respectively.The proposed predictor performs according to the following structure:For the three-order systems Equation (4), the predictor is specifically expressed as:Remark 4.The objective of the predictor is that: when,,andRemark 5.To achieve the predictor Equation (8), we need to estimate the unknown nonlinear function.In this section, we use an adaptive RBF neural network method to approximate the unknown nonlinear function Then, for Equation (11), an observer is designed as:Defining the state and output estimated errors as Then the error dynamics may be written as:According to the approximation property of an RBF neural network, the continuous nonlinear functions in the observer Equation (12) can be represented by a neural network with constant ideal weights Assumption 2.It is assumed that the ideal weights Let the neural network functional estimations for The neural network output errors of the hidden layer are defined asDefine the weights’ estimated errors asAdding and subtracting Defining the disturbance term Then the proposed observer Equation (12) becomesThe neural network observer produces a generalized RBF neural network system. Since an RBF neural network is composed of an arbitrarily linear transfer function and a nonlinear mapping operator, the nonlinear plant predefined in Equation (11) can be represented in terms of an RBF neural network.The output estimated error Then the state-space realization of Equation (27) can be expressed asLemma 1.If a strictly proper rational function with Lemma 2.Consider the linear time-invariant system in state-space representation:where ollowing , every swhere where where Theorem 1.Assuming that the control inputis bounded, that is. Consider the nonlinear system Equation (11) and the present adaptive RBF neural network observer system Equation (24), Equation (22) and Equation (34), then the state estimated errorand the neural network weight estimated errorsandare UUB. See the Therefore, the unknown nonlinear function Based on the approximated nonlinear function, then the proposed predictor Equation (8) can be rewritten in the following forms:In this section, simulations of two UCAV models with significantly different parameters are taken to verify the effectiveness and universality of the proposed predictor. The main parameters of two UCAVs are listed in The actuators of the two UCAVs are chosen as the same nonlinear model: the backlash is In order to identify the nonlinear models of two UCAVs with control augmentation systems, the RBF neural network adopts the structure of 3-7-1, the input vector has estimated value Simulation initial states are set as From The predicted states and predicted errors of UCAV-A are shown in (1)Building a novel universal dynamics model for remotely piloted UCAVs with a control augmentation system. The dynamic process from a pilot longitudinal acceleration command to the UCAV response is modeled as a nonlinear uncertain function, and the longitudinal velocity and altitude are taken as states, which are the first and second integrals of the longitudinal acceleration respectively. This generalized model is suitable for different UCAVs, and does not need to know the model of the UCAV in advance.(2)An adaptive neural network observer based on Lyapunov is proposed to estimate the nonlinear uncertain model online, and a time-varying state predictor is designed based on the identified nonlinear dynamics model to predict the time delay states. The system stability conditions of the closed-loop system are proven using Lyapunov. The effectiveness and universality is verified by simulation.(3)The proposed method is widely suited to the application of a remotely piloted vehicle with a control augmentation system in the WSN. Therefore, this method can efficiently resolve the problem of state prediction for the remotely piloted system with time delay.This study investigates an adaptive neural network observer-based universal state predictive method for remotely piloted UCAVs, with control augmentation systems in the WSN. The main contributions consist of the following three aspects:


Hemophilic ankle arthropathy is manifested by degenerative functional alterations and chronic pain. Myofascial release techniques are used to treat soft tissue adhesions, relieve pain, and reduce tissue sensitivity.This study aims to evaluate the safety and efficacy of a protocol using self-myofascial release with a foam roller to be applied in patients with hemophilic ankle arthropathy.Patients with ankle arthropathy (N=70) will be recruited, enrolled, and assigned to one of two groups—experimental or control—in a 1:1 allocation ratio. Patients will be recruited from 5 centers in different regions of Spain. Patient data will be collected at baseline, posttreatment, and follow-up. The primary outcome will be frequency of ankle joint bleeding (self-reported). The secondary outcomes will be ankle range of motion ; joint pain ; joint status ; muscle strength (measured with a dynamometer); functionality of lower limbs ; activity (self-reported); and muscle flexibility (measured using the fingertip-to-floor test). The treatment program includes 11 exercises that must be administered bilaterally. A mobile app will be developed where each patient will be able to observe the exercises to be carried out. Each session will last 15 minutes with 5 physiotherapy sessions per week for a period of 3 months. It is expected that patients with hemophilia who receive the foam roller intervention will show improvement in mobility, pain, and status of the ankle joint; muscle strength; and function in the lower extremities.The study has been approved by the institutional review board of the University of Murcia. Patient recruitment will begin in September 2020, and the intervention period will last until June 2021. Data collection will take place between September 2020 and October 2021.This protocol describes a randomized clinical trial to examine the safety and efficacy of a self-myofascial release intervention using a foam roller in patients with hemophilic ankle arthropathy.ClinicalTrials.gov NCT03914287; http://clinicaltrials.gov/ct2/show/NCT03914287.PRR1-10.2196/15612 Hemophilia is a congenital coagulopathy characterized by a deficiency of a clotting factor (factor VIII in hemophilia A and factor IX in hemophilia B). Most clinical manifestations are musculoskeletal such as bruising and hemarthrosis. The recurrence of joint bleeding causes degenerative, progressive, and chronic joint deterioration (hemophiliac arthropathy); chronic pain; and a deteriorated perception of the patient's quality of life. Symptoms of hemophilic arthropathy include limited range of motion, decreased periarticular muscle strength, decreased proprioception, and chronic pain ,2.The ankle joint, a crucial component of locomotion, is one of the most affected joints (as are the knee and elbow joints) , imposinThe treatment of hemophilic ankle arthropathy includes pharmacologic and orthopedic interventions with the aim of improving symptoms in the patient. The administration of anti-inflammatory and analgesic drugs , conductPhysiotherapy can play an extremely important role in the treatment of hemophilic ankle arthropathy. Manual therapy techniques , therapeThe degenerative process, itself, is one of the intrinsic mechanisms affecting the fascial system, since it favors loss of elasticity and flexibility, and triggers a process of pathological cross-linking of collagen fibers. Fascial therapy aims to remove fascial tissue restriction through mechanical stimuli applied for 3 to 5 minutes in order to promote the piezoelectric effect in the crystalline matrix of the fascia . The mecFascia is the soft tissue component of the connective tissue matrix that extends through the human body forming a continuous three-dimensional composite of structural support throughout the body . MyofascSelf-myofascial release with a foam roller is used to treat fascial adhesions and to restore the normal extensibility of soft tissues . Self-myThe use of foam rollers for myofascial release is based on findings of postintervention changes to joint range of motion and pressure pain thresholds which may be due to a mechanical and neurophysiological responses ,25. The The objective of this paper is to describe our approach to the design and implementation of a protocol for self-myofascial release using a foam roller for patients with hemophilic ankle arthropathy with the aim of reducing the frequency of joint bleeding; improving range of motion; reducing joint pain; and restoring functionality, structural integrity, muscle flexibility, and muscle strength.This study is designed as a randomized controlled multicenter clinical trial  to establish the safety and efficacy of a physiotherapy intervention consisting of self-myofascial release using a foam roller. Once eligibility is determined, participants will be randomized to either the intervention  group or the control group.This study has been approved by the research ethics committee of the University of Murcia (2428/2019). Patients will be included if they have been diagnosed with hemophilia A or B, are 18 years of age or older, have been diagnosed with bilateral hemophilic arthropathy of the ankle , and are on prophylactic or on-demand treatment with factor VIII or factor IX concentrates.Patients will be excluded from the study if they are not able to ambulate; have been found to have inhibitors (antibodies to factor VIII or factor IX), have neurological or cognitive alterations that prevent them from understanding the questionnaires and physical tests, or choose not to give informed consent (have not signed the statement of informed consent).The target sample size for inclusion in the study is 70 patients. The sample size is justified with respect to the prevalence of patients with congenital coagulopathies; there are 2039 patients with either hemophilia A and B or von Willebrand disease in Spain, of which 612 meet the selection criteria for the study (Spanish Federation of Hemophilia). Based on these data, the sample size at national level would be 236 individuals, with a confidence level of 95% and an expected dropout ratio of 15%. Thus, a sample size of a total of 70 patients from the 5 centers will be used.Participants will be randomly assignment using opaque envelopes to one of two groups—experimental and control. Random assignment of patients will be carried out after cluster recruitment (based on hemophilia type and patient age) to ensure homogeneity of the study groups. This assignment will be carried out by a person who is not involved in the study objectives and who is unaware of the identity of the participants.Baseline assessments will be carried out at Hemophilia Association centers. Measurements will be performed by a physiotherapist who is unaware of patient group assignments.After the treatment period and 3 months after completion, the patients included in both groups  will be re-evaluated by the same rater under the same conditions as their initial evaluation.Dependent variables  will be measured at each study assessment . A 10-point visual analog scale will be used to evaluate patient perception of joint pain, ranging from 0 (no pain) to 10 (maximum perceived pain). An algometer  will be used for the assessment of pressure-induced pain (the amount of pressure at which the person perceives pain), both at the joint and at other body sites . PressurThe 6-minute walking test  measuresPatients will continue their factor VIII or factor IX concentrate treatment as prescribed by their referring hematologists. Throughout the study, the prescribed pharmacologic treatment, dosage, and periods of substitute treatment of the participants will not be altered. Participants in the control group will receive no physical therapy using self-myofascial release and will continue with their usual routine of physical activity and exercise. Outcomes will be assessed under the same conditions as those of the experimental group.At the beginning of the study, the main investigator will explain the characteristics of the intervention to be carried out to the experimental group. Each session will last approximately 15 minutes, with 5 physiotherapy sessions over a period of 3 months. Each patient will perform the interventions at home. Participants will have free access to the mobile app. Access to the platform will be approved after the patient signs the informed consent form. Once the study is complete, the contents of the app  will be The protocol for self-myofascial release of the lower limbs using a foam roller and solid ball massage, adapted to patients with hemophilic ankle arthropathy, will include self-myofascial release of the plantar, back of the leg, and hamstring regions, as well as adductor, abductor, and pelvitrochanteric muscles. A mobile app (designed by the research group) will be used to demonstrate all the exercises in the self-myofascial release protocol. Each time the patient exercises, he or she will be able to watch a video explaining the characteristics of each exercise . This free app will also collect adherence data recorded as days of exercise by the participant.Patient will need to have a suitable floor mat. A massage ball will be used for pressure point massage , typically 40 mm to 50 mm in diameter, made of a hard polyurethane, but slightly padded. Two smooth low-deformability foam rollers (90 cm in length and 15 cm in diameter) will also be used.The distribution of the sample, the changes after the intervention and follow-up period in each group, and the intra and interindividual effect will be analyzed. We will use the intent-to-treat method to include all individuals who were randomized in the final data analysis.The statistical analysis will be carried out using SPSS statistical software . The Kolmogorov-Smirnov test will be used to test for normality, and the Levene test will be used to test for homoscedasticity. If the conditions of normality and homoscedasticity are violated, nonparametric tests will be used.F test will depend on the significance of Mauchly sphericity. If significant, the Greenhouse-Geisser correction will be used. To assess clinical relevance, we will calculate the standard error of measurement and minimum detectable change for each dependent variable.Descriptive statistics (mean and standard deviation) will be calculated for all dependent variables. A one-way repeated measures analysis of variance will be used to compare the groups  at 3 assessment times . If the interaction is found to be significant, pairwise comparisons will be performed. The significance level will be set at α=.05. To control the error rate, Bonferroni correction will be applied. The results of the The study has been approved by the ethics committee of the University of Murcia (ID: 2428/2019). Patient recruitment will begin in September 2020, and an intervention period will continue until June 2021. Data collection will take place between September 2020 and October 2021.This project is the most ambitious physiotherapy study, in terms of methodology, recorded to date in Spain. The inclusion of 70 patients with hemophilia from 5 different regions for participation in a physiotherapy program will confer on this project a high statistical power, which is unusual in a rare pathology such as hemophilia. Patients with hemophilic ankle arthropathy will undergo treatment with self-myofascial release using a foam roller. The research team is made up of multidisciplinary hemophilia specialists, renowned physiotherapists with extensive clinical experience, and researchers in the field of hemophilia, as well as experts in methodology and statistics. Coordination between different regions of Spain, with the participation of universities, hospitals and associations of patients, is an uncommon effort in the field of hemophilia-related physiotherapy research.Another potential strength is that this protocol can help to establish a rapid, safe, and effective intervention for patients with hemophilia. In addition to clinical improvements, it could facilitate greater adherence to physiotherapy treatments and improve the quality of life of individuals with hemophilia.Self-myofascial release requires no economic investment in the case of manual therapy. Validating its safety and efficacy could promote the development of a quick, inexpensive, and simple physiotherapy intervention that can easily be used widely.


Ecosystem services depend on the interrelation between people and the environment, and people are increasingly recognizing the social value of ecosystem services. Based on humans needs related to the values of ecosystem services, riparian greenways, properly planned and managed for resiliency, could provide great opportunities for social ecological change and transformation toward sustainability. We focus on the ecosystem service values of such greenways based on resilience in urban communities. The purpose of this study is to assess the social value of ecosystem services for resilient riparian greenway planning and management based on a survey of residents living near the Yangjaecheon riparian greenway in Gwacheon, South Korea. First, cluster analysis was performed with data from 485 completed surveys to identify different groups of respondents. Importance-performance analysis (IPA) was then applied to develop planning and management guidance for the riparian greenway based on group characteristics. Two distinct groups were identified: the Strong Social Value of Ecosystem Services group and the Neutral Social Value of Ecosystem Services group. Different distributions were found between the two groups based on gender and residency period, and significant differences were also found for age and familiarity with the riparian greenway. The results show what each group perceived to be important and how well the riparian greenway met their expectations regarding ecosystem services. These results indicate the perceived value of ecosystem services on the basis of the group characteristics, helping establish the direction for resilient riparian greenway planning and management approaches. Riparian greenways are vegetated linear corridors formed by the connection of two or more vegetation buffer strips that are established along a river . Such grTo manage riparian greenways sustainably in urban communities, the beneficiaries or the anticipated value of ecosystem services need to be understood. Urban communities are complicated social-ecological systems with multiple strong or weak interactions between components at various spatial and temporal levels and scales ,20,21. TThe valuation of ecosystem services can be a particularly useful indicator of human welfare and sustainability at the macro level . Many stIn the process of spatial planning for resilient systems, the social value of ecosystem services is an essential consideration for environmental sustainability and economic growth in social-ecological systems in human society ,42. BecaThe purpose of this study is to assess the social value of ecosystem services for resilient riparian greenway planning and management in urban communities. This study thus examines residents’ perception of the importance and performance of ecosystem services to assess the social value of ecosystem services provided by riparian greenways. The implications of the findings will be discussed to provide spatial planning and management guidance for the development of resilient riparian greenways according to the perceived social value of ecosystem services. This study can help planners and managers of riparian greenways understand the attitudes of users and thus identify directions for potential planning strategies based on the target users.2, and has a basin area of 37.21 km2. The Makgyecheon River flows from the southeast of Gwacheon to the northwest until it joins the Yangjaecheon River. The Makgyecheon basin area is 10.48 km2. Riparian trails were developed along both sides of the river, and hiking and biking are the most popular recreational activities in the area. The Yangjaecheon and Makgyecheon greenways have excellent usability because these rivers are easily accessible from downtown and residential areas.For the purpose of this study, Gwacheon, a small- to medium-sized urban area near Seoul that is located in the midwestern region of Gyeonggi-do, Korea, with an approximate population of 71,000, was selected . Gwacheo(1)Classification of users into different groups based on their perceptions of the importance of ecosystem services;(2)Examination of demographic information on and familiarity with riparian greenways to compare the group characteristics;(3)Assessment of the differences between the perceived importance and the performance of the ecosystem services by using an importance-performance analysis (IPA); and(4)Discussion of planning and management guidance for the development of resilient riparian greenways by focusing on each group.Here, we assess the social value of the ecosystem services provided by riparian greenways to generate discussion about how planning and management may be improved to allow riparian greenways to serve as a more resilient social-ecological system. This study thus examines residents’ perception of the importance and performance of the social value of ecosystem services provided by riparian greenways. Specifically, this study involved four steps:This study can help planners and managers develop resilient riparian greenways through the understanding of the attitudes of users and thus identify directions for potential planning based on the target users.The study sample was the residents who live near the study site: the Yangjaecheon and Makgyecheon riparian greenways. The survey was delivered to each resident’s mailbox in a residential area in Gwacheon adjacent to the riparian greenways. The researchers contacted the representative of the residential area and were granted permission to deliver the survey sheets. The mail-back survey sheets were delivered to 2500 households in this residential area. This mailing included a cover letter that explained the purpose of the study and how to mail back the survey sheets in one week. A total of 512 individuals responded; thus, the response rate was 20.48%.The questionnaire used for this study included three main sections. The first section consisted of questions related to the social value of ecosystem services attributes. These attributes were identified from Reed and Brown  based onThe second part of the questionnaire was designed to investigate the visitation patterns and familiarity with the study site. To measure familiarity with the riparian greenway of Yangjaecheon, the scale items were developed based on our literature review. According to several studies, familiarity is influenced by the level of exposure to information, the degree of intimacy, and the frequency of interaction ,49,50. TThe third part of the questionnaire included questions related to sociodemographic data, including the residency period. The residents’ responses to the questions in the last two parts were used to identify the segments.A preliminary survey was conducted as a pilot test to verify the reliability of all variables and the questionnaires. After the instrument development process, a series of on-site surveys was performed near the study site using a random sampling method. To investigate the reliability of the survey instrument, the collected data were analyzed using descriptive statistics and a reliability test. All data were analyzed using IBM SPSS Statistics 12.0 . A total of 85 (90.4%) respondents provided useful data after the removal of 9 invalid questionnaires. The respondents’ average age was 41.93, and 71.8% of the respondents lived in Gwacheon. The collected data were analyzed using descriptive statistics. Reliability was also assessed for the importance of social values (Cronbach’s α = 0.782), performance of social value (Cronbach’s α = 0.874), and familiarity (Cronbach’s α = 0.861).The data were analyzed using descriptive statistics, cluster analysis, IPA, and t-tests with IBM SPSS Statistics 12.0 . The demographic information was evaluated using descriptive statistics. Descriptive statistics were also used to assess the perceived importance and performance of riparian greenways in terms of the social value of ecosystem services. After the descriptive data were presented, a reliability test was performed for each variable. The reliability test indicated that all variables were highly reliable for further analysis .Subsequently, cluster analysis was used to classify the respondents into different groups based on the perceived importance of ecosystem services. A hierarchical clustering procedure was adopted to group the residents, with the Euclidean distance between the cases used as a similarity measure. The clustering procedure included the K-means clustering method to determine the best number of clusters based on the importance attributes of the social value of ecosystem services.IPA was performed to compare the perceived importance and performance of the riparian greenways to understand the social value of ecosystem services based on the clusters. These clusters of residents were compared based on the different constructs related to the familiarity and visitation pattern data and that of the demographic categories. In addition, t-tests were used to identify the mean differences among the cluster groups. Chi-square tests were also performed with the cluster and classification data. The next step applied IPA grids to each cluster of residents. Finally, a t-test in support of the IPA was used to determine whether a significant difference existed between the perceived importance and performance relative to the list of variables related to the social value of ecosystem services.IPA is a technique that can be used with certain attributes to analyze customer satisfaction based on the expectations of a product’s or service’s performance . The IPAThe analysis used data from the 488 completed surveys of the 512 collected surveys. p < 0.001). These clusters were labeled as the Strong Social Value of Ecosystem Services group (S-SVES group)  and the Neutral Social Value of Ecosystem Services group (N-SVES group) , as shown in After evaluating the overall importance of the social value of ecosystem services, we determined how the residents could be meaningfully divided into different groups. We also assessed how they differed in their perceptions of the degree of importance of the different variables that measure the social value of the ecosystem services provided by riparian greenways. The cluster analysis showed that two groups (clusters) were appropriate for the data based on the residents’ perceptions of the importance of the social value of the ecosystem services variables. The t-test results also indicated that the 12 attributes contributed to differentiating the two clusters  between the S-SVES group  and the N-SVES group . An independent t-test was used to investigate the differences in familiarity with the riparian greenways between the S-SVES group and the N-SVES group  and neutral ecosystem services values (N-SVES group) based on the reported social values of ecosystem services. This study attempted to identify both the importance and performance of the social value of the ecosystem services in the riparian greenway using an IPA. According to the IPA, the “Aesthetic”, “Biological”, “Future”, “Intrinsic”, and “Life-sustaining” values were all found to be important and performing well. For the S-SVES group, however, the “Learning” value was not as important but was performing as well as the other value categories. This result suggests that less effort can be exerted toward educational activities and promotional materials for the S-SVES group. Other areas, such as the “Cultural”, “Economic”, “Historic”, and “Spiritual” values, were reported to be less important and performing at a lower level. If these low IPA perceptions are not consistent with the goals of the greenway’s management, then additional resources may be needed to boost the perception of the importance and performance of these values among the area’s residents. The “Recreational” and “Therapeutic” values both tended toward the intersection of the IPA quadrants for both the S-SVES and N-SVES groups. These values are neither the highest- nor lowest-ranked variables in terms of importance or performance. Recreation is clearly an important goal for greenways. This finding suggests that the residents are generally satisfied with the Yangjaecheon greenway as a place for recreation. The same is true for the therapeutic qualities of the greenway. Although many approaches are available to measure the environmental and biological performance of greenways, fewer methods are available to measure their social performance. IPA offers an effective and flexible tool to evaluate local residents’ perceptions about the functioning of greenways along a number of important social dimensions.This study also examined the differences between the two groups based on their demographic information and their familiarity with the study site. The S-SVES group placed higher importance on the social value of the ecosystem services variables. This group was composed of a higher percentage of older female residents reporting significantly higher familiarity with the Yangjaecheon greenway than the N-SVES group. The N-SVES group placed lower importance on the social value of the ecosystem services variables. Greenway managers can use the information obtained through cluster analysis to target certain residents for educational and promotional information, such as the N-SVES group, which reported lower importance and performance scores in general than the S-SVES group. Greenway managers can also use this information to recruit willing volunteers or provide special services and activities to residents who highly value riparian greenways, such as the S-SVES group.The results of this study show that recognizing the value of ecosystem services according to group characteristics can help set the direction for riverside greenway planning and management, which is the basis for maintaining a resilient riparian greenway.


Heat stress triggers behavioural and physiological response and thus negatively affects productivity in livestock. Among farm species, pigs are especially susceptible to exposure to high air temperatures. The evaporative pad cooling system, high pressure fogging, sprinkling as well as elevating of air velocity and floor cooling are the methods most often used in pig facilities to alleviate the effects of heat stress. This article mainly discusses issues linked with the effectiveness of the various cooling methods on improving the indices of animal welfare.An increase in the frequency of hot periods, which has been observed over the past decades, determines the novel approach to livestock facilities improvement. The effects of heat stress are revealed in disorders in physiological processes, impaired immunity, changes in behaviour and decreases in animal production, thus implementation of cooling technologies is a key factor for alleviating these negative consequences. In pig facilities, various cooling methods have been implemented. Air temperature may be decreased by using adiabatic cooling technology such as a high-pressure fogging system or evaporative pads. In modern-type buildings large-surface evaporative pads may support a tunnel ventilation system. Currently a lot of attention has also been paid to developing energy- and water-saving cooling methods, using for example an earth-air or earth-to-water heat exchanger. The pigs’ skin surface may be cooled by using sprinkling nozzles, high-velocity air stream or conductive cooling pads. The effectiveness of these technologies is discussed in this article, taking into consideration the indicators of animal welfare such as respiratory rate, skin surface and body core temperature, performance parameters and behavioural changes. Bearing in mind the important issues of animal welfare it must be stated that the optimal microclimatic conditions for livestock is a main factor which provides for the animal’s comfort and health. Thus, the proper environmental conditions may also lead to maintain a suitable level of animal production. The main elements creating the microclimate in a facility for farm animals are: air temperature, relative humidity and air speed, as well as the concentration of harmful gases and other pollutants. The lighting and solar exposure of the building are also significant ,2,3. TakThere are various environmental modifications which may enhance heat exchange in pigs. The systems may cause a decrease of air temperature in a building or cause direct cooling of an animal’s skin. Some of these applications use the effect of water evaporation . Heat loss in pigs during hot weather may also be improved by implementation of methods enhancing convection or conduction heat exchange. In pig housing, technologies based on increasing air velocity such as zone cooling and tunnel ventilation have often been used ,9. EspecChanges in parameters of animal physiology, behaviour and productivity have been widely considered as indicators of animal welfare ,12,13,14The objective of this paper is to present the actual state of knowledge of the most widely used methods of cooling pigs and to show the effectiveness of these technologies on improvement of animal welfare indicators. According to the knowledge of the authors of this article, the more comprehensive approach to the impact on the animal’s body of the functioning of various cooling technologies is not very common and not often found in the world literature on this species.In homoeothermic animals, heat production resulting from metabolic processes must be exchanged within a body (across cellular and vascular membranes), and between a body and its environment . The abiIn thermoneutral environmental conditions the processes of heat production and its removal from the body are kept in balance, however it is always a dynamic equilibrium. It involves continuous and variable metabolic heat production (cellular metabolism and cell work) and convective and conductive heat transport through tissues . EventuaThe provision of proper housing conditions may cause a possibility of demonstration of whole forms of behavioural thermoregulation and thus provide enhancing of animal comfort. Under high air temperatures pigs present a decrease in their activity, lying in cold and humid areas and increased wallowing behaviour. When kept outside they may also exhibit shade-seeking. Moreover, the heat-stressed animals increase water intake and reduce feed intake. Limited contact with the pen mates is also observed ,20,21,22When discussing the effect of high ambient temperatures, it should be stated that there are two types of challenging situations. Exposition to ambient heat for a short period and for a longer time. It has been shown that there is a biphasic profile of response to the heat load . Within Due to a lack of functional sweat glands, increased evaporation through the respiratory track is the only effective way to dissipate heat load in pigs ,28. HuynThe reduction of voluntary feed intake in heat-stressed animals is the one of the most important adaptation processes ,23,30. TIt is widely known that a reduction of food intake has negative implications on animal production ,34. HoweWhen discussing molecular/cellular response to the heat-load exposure, it may be generally concluded that it is divided into different phases. Primarily, the response is based on heat-shock protein expression, next interferon-inducible genes and then activation of small nonspecific stress responses of specific cell lines .Heat-shock proteins (HSPs) are considered as one of the most important heat-stress markers . The incThe development of biomarkers linked with molecular and cellular response and the generally expanding knowledge on topics related to biological processes induced by heat stress with use of advanced genomic approaches may certainly be used as a novel means of striving for better strategies to alleviate the negative environmental impact in livestock species. However, in studies presented in this review, respiratory rate, measurements of temperature, assessment of morphological or biochemical markers as well as behavioural changes were the basic indicators of evaluating the effectiveness of cooling technologies.Various environmental modifications may be implemented to improve convection, conduction, radiation and evaporative heat loss in pigs during hot ambient temperatures. Moreover, to enhance the effect of animal comfort during hot weather, a combination of different cooling methods is often used. It concerns especially technologies combining the cooling effect of forced-air velocity together with water evaporation.Fogging, misting or showers as well as evaporative pads have been used in pig housing ,11,53. TIn turn using high-pressure fogging systems, >5 MPa, or a fan and pad system (evaporating pads) cause the effect of adiabatic air cooling. In brief, this is a process in which energy exchange occurs as a result of contact of air molecules with water molecules. The sensible heat transferred from air to water covers only the demand for energy necessary for the evaporation process . The migTaking into consideration all the cooling methods based on water evaporation, it is worth mentioning that the drawback of these technologies may be an increase of air relative humidity. As researchers have shown, increased humidity causes serious difficulties in terms of excess heat from the animal’s body ,18. MoreSome of the aforementioned studies were conducted in pig facilities when only microenvironmental conditions have been taken into consideration ,62. HoweHaeussermann et al.  and GodyDirect cooling has also been found to have a positive impact on feed intake . In thisIn the study of Huynh et al. , growingThe positive effect of directed cooling of pigs’ skin was also found in pigs transported to a slaughterhouse ,68. In tForced convection is one of the most effective ways of improving an animal’s heat loss. In pig facilities the systems may be installed in a way to cool animals in a special zone  or high air speed over the animal may be achieved in the whole living area  ,69.Modern buildings may be equipped with a tunnel ventilation system where the operation of a bank of fans mounted at one end of the building causes an increased inflow of air from the other end of the room. Design tunnel barns at about 2 m/s of air speed is a popular solution used in pig maintenance . An optiThe comparison of the performance parameters in pigs maintained in modern and older types of facilities has been studied . There nIn the other study  the authA lower level of neutrophil to lymphocyte N/L ratio in peripheral blood (considered as a better marker of exposure to stress in pigs compared to cortisol and cortisone levels in urine) was found in pregnant sows kept in tunnelled, ventilated rooms supported by large evaporative pads. In turn, the higher level of this marker was noticed in sows maintained in a facility when only sprinklers were provided .Zone cooling is another method enhancing animal convective and evaporative heat loss. The cooling of the air stream is especially applicable in individually housed group of pigs. In the study of Dong et al. , the opeHigher air velocity was used in the other studies ,69. In tIn this experiment the sows were kept individually; in turn Barbari and Conti  observedAn evaporative-cooling pads system is often used to decrease the air-stream temperature in zone-cooling technology ,10,64,65In the other experiment , compariZone-cooling technology associated with evaporative pads was tested also in terms of improving the performance indicators of sows ,64. For When discussing the methods of cooling pigs through a decrease of air temperature inside the building, it is worth mentioning that currently energy-saving systems of air treatment based on earth-air heat exchange have been developed . AnotherTaking into consideration the large amount of time pigs spend lying, especially individually kept sows, contact with a cool surface may lead to improved comfort of an animal during hot periods. The developing of a floor cooling system using underground water was used both in open-type and closed pig facilities ,75. In tBased on a preferential test, it was found that gilts most often chose the conductive cool-pads to rid themselves of heat load compared to the drip-cooling or snout-cooling methods . In the In the above-mentioned study , air temIn the studies of Cabezón et al.  and ParoThe aim of the other study  was to eIt may be generally concluded that in terms of modern sows at the farrowing and lactating stage, there are opinions that direct cooling with the use of conductive pads is a better solution than lowering the air temperature in the whole building. This way of providing individual cooling for females of different litter sizes and different lactation stages seems to have more advantages for animal welfare and production .It is also worth adding that not only the application of technologically advanced conductive cooling technologies may bring about benefits. As it was showed in finishing pigs that cooling of a partly solid floor was effective in reducing respiratory rate and increasing the time the animals spent lying in a comfortable position .An increase in the frequency of hot periods which has been observed over the past decades is a growing challenge in providing livestock with adequate living conditions. The choosing of a proper cooling technology depends mainly on the type of pig-farming system as well as the model of facilities. This review has shown that even the older types of building may be equipped with a cooling technology such as sprinkling, fogging system, zone cooling or conductive-cooling pads. The decrease of air temperature before its entry into the building, via the use of smaller surface evaporative pads, is also a universal solution. It seems that the evaporative-cooling pads system combined with high forced-air movement is one of the most effective methods positively affecting the indicators of pig welfare, regardless of the technological group. Moreover, as the results have indicated, this technology may lead to an improvement of psychological and performance parameters in pigs even in countries with climate of high air humidity . Respira


Biatrial flutter is a rare form of macro-reentrant atrial tachycardia that involves both the right and left atria. Single-loop biatrial flutter is typically associated with scarring of the septum from prior ablation or surgery and is generally made up of two interatrial connections—that is, the coronary sinus and Bachmann’s bundle. Entrainment and high-density mapping allow for rapid diagnosis and development of a treatment strategy. Ablation planning should also take into consideration the preservation of interatrial conduction. We herein discuss a case of single-loop biatrial flutter presenting as a typical atrial flutter and review the differential diagnosis and physiology of the arrhythmia. Typical cavotricuspid isthmus (CTI)-dependent atrial flutter has a distinct, easily recognized pattern on the electrocardiogram (ECG) and has become a readily ablated single-loop reentrant arrhythmia in the right atrium (RA). Occasionally, during electrophysiology (EP) study, other patterns of arrhythmia are found that mimic typical atrial flutter, especially in patients with preexisting scar tissue from prior surgery, ablation, or inflammatory disease. Biatrial loop tachycardia, a rare form of reentrant arrhythmia associated with scars on the septum, can be more challenging to treat. As such, a thorough understanding of its possible mechanisms is necessary before successful ablation can be performed. We present the case of a patient with typical-appearing atrial flutter in whom a single-loop tachycardia with activation around the tricuspid and mitral valve was found and discuss the differential diagnosis as well as the substrate requirements of the tachycardia and considerations for ablation.. Thereafter, mitral valve replacement was performed through this larger incision involving the RA, septum, and LA. Postoperatively, the patient developed atrial fibrillation and was placed on amiodarone for several weeks and then taken off the medication. Several months later, he developed an atrial flutter as shown in Figure 2. The ECG showed a slow atrial flutter with morphology consistent with that of a typical atrial flutter.A 56-year-old man with diabetes, hypertension, and coronary disease presented with severe mitral regurgitation and underwent mitral valve replacement with coronary artery bypass grafting (CABG) in April 2019. The surgeon initially performed a vertical incision in the left atrium (LA) between the right pulmonary veins and the interatrial septum in the interatrial groove (Waterston’s groove). However, because of poor visualization, another horizontal incision was made in the posterior RA and included the atrial septum The patient was placed on anticoagulation and, after discussion, wished to proceed with a cardiac EP study. The patient was brought to the EP laboratory and catheters were placed in the coronary sinus (CS) and anterolateral RA , along with a His-bundle catheter (HBE)., low lateral RA (Deca 1–2) , and distal CS (DCS) . The postpacing interval (PPI) for each of the sites was within 20 ms of the tachycardia cycle length (TCL), suggesting a biatrial tachycardia as depicted in Figure 3D. The ablation catheter (Abl) was then placed on the CTI . Given that both adjacent sides  of the CTI appeared to be within the circuit, ablation was conducted along the CTI, prolonging the CL from 340 ms to between 370 and 380 ms, but did not terminate the tachycardia.Entrainment mapping was performed from the proximal CS (PCS) As a result, repeat entrainment mapping was performed from the low lateral RA (Deca 1–2), PCS, and DCS with the longer CL atrial flutter and the PPIs were found to be within 30 ms of the TCL, again suggesting the involvement of both atria in the tachycardia.4B show activation occurring from the anterior RA down the lateral wall of the RA, then moving to the posterior RA above the inferior vena cava (IVC). Subsequent activation of the septum then occurred, followed by proximal to distal CS activation. High-density voltage mapping  was also used to delineate scar from prior surgery. When combined with high-density activation mapping, the electroanatomic map showed activation occurring through a channel on the posterior wall that was bordered by scar. It also revealed that a portion of the circuit was still missing (light blue color) between the DCS and anterior RA, consistent with activation over Bachmann’s bundle (BB). Mapping of this remaining portion of the circuit would have required access to the LA and was not deemed necessary and was not performed to avoid unnecessary procedural risk to the patient.A multielectrode catheter  was used to perform high-density activation mapping in the RA and in the CS. , with a PPI of 370 ms that was identical to the TCL. Pacing from the ablation catheter at a high output of 15 mA was also performed to exclude the possibility of ablation of the phrenic nerve. Ablation in this area slowed and terminated the tachycardia, which could not be induced at the end of the procedure.Entrainment was performed adjacent to the posterior RA channel  and 6B, occurring over BB with DCS activation occurring prior to PCS as compared to while in tachycardia.In addition, importantly, while attempting to check the line of block at the CTI by pacing the lateral portion of the CTI, activation of the LA was noted to change postablation 1The ablation of typical RA flutter as recognized by the 12-lead ECG has become an effective treatment for symptomatic patients. However, not all atrial flutters that appear typical can be successfully treated by ablation at the CTI. In this case, entrainment mapping demonstrated findings consistent with atrial flutter involving the RA and LA, suggesting the role of both chambers in the condition.2 The differential diagnosis included (1) single-loop macro-reentry involving the RA and LA, (2) double-loop reentry in a figure-of-eight pattern around the tricuspid and mitral valves, and (3) RA flutter with LA participating as a passive bystander during entrainment. In this case, double-loop reentry around the tricuspid and mitral valves as first reported by Shah et al.3 was excluded by the direction of CS activation with the RA activated in a counterclockwise pattern. Here, activation occurred from the PCS to DCS, while figure-of-eight dual-loop reentry would be expected to occur from the DCS to PCS.Ip et al. elegantly outlined the differential diagnosis of such a patient with entrainment from low lateral RA, PCS, and DCS with a PPI − TCL value within 30 ms.2 While this might suggest that the LA is a bystander to the RA, this phenomenon might also be explained by local His A conduction during PCS entrainment with slow conduction or block distal to the conducted His A.The possibility of RA flutter with the LA participating as bystander for the initial atrial flutter CL of 340 ms was not easy to exclude and, during PCS entrainment, we did not observe the His-atrial electrogram (His A) to follow (concept of linking between the LA and RA) the DCS activation  as mentioned in the paper by Ip et al.After CTI ablation, which was associated with slowing of the tachycardia, the conduction time increased from the low lateral RA to the PCS. Repeat entrainment mapping following CTI isthmus ablation was consistent with continued involvement of both the RA and LA. High-density electroanatomic mapping was conducted after the CTI line and showed activation of the RA occurring posteriorly across a small channel of tissue formed by scarring from a previous surgery, which was used to create a line of block and terminate the arrhythmia.High-density electroanatomic activation mapping played an important and complementary role in this case by helping to explain the response to entrainment mapping seen with the second atrial flutter. High-density mapping allowed for visualization of low-voltage areas from the patient’s prior surgery acting as anatomic barriers along with the activation pattern, which involved both the RA and LA.6 Kitamura et al. used ultra-high-resolution mapping to describe three different types of biatrial tachycardia found in their series.6 Among 422 atrial tachycardias in their series, nine biatrial tachycardias (2.1%) were identified, of which three (33%) were classified as involving single-loop reentry around the mitral and tricuspid valves with two interatrial connections. The other two types of biatrial tachycardia categories described included a reentrant circuit encompassing most of the mitral annulus and RA septum with two interatrial connections and a reentrant circuit involving the LA septum and RA septum with two interatrial connections, respectively. These authors also noted that septal scar was an important requisite for biatrial tachycardia together with the presence of two interatrial connections  to allow for circus movement tachycardia. In the present case, the surgical scar along the septum (second incision) with enlarged atria likely predisposed the patient to biatrial tachycardia.Biatrial tachycardias, while a rare form of macro-reentrant tachycardia, are increasingly being recognized and are usually the result of either previous ablation, surgery, or intrinsic disease/scarring along the septum.Ablation at the CTI of the single-loop biatrial flutter around the tricuspid and mitral valves  would normally be expected to terminate the arrhythmia. However, in our case, the atrial flutter changed and slowed, ultimately finding another way to reach the PCS via a posterior RA channel. Ultimately, by mapping and ablating the second RA posterior channel, the tachycardia was terminated to the sinus. This, however, also limited sinus activation to the LA via BB as evidenced by the activation of the DCS being earlier than that of the PCS.6; however, for other types of biatrial tachycardia, care should be taken to avoid complete disconnection of the interatrial bridging at the level of BB or the CS.Targeting the site of ablation in biatrial tachycardia usually involves the identification of a critical isthmus requisite for the tachycardia to continue. For those circuits involving the valves, ablation ideally should be performed at the RA or LA isthmusSingle-loop biatrial tachycardia around the mitral and tricuspid valves is a rare form of macro-reentrant tachycardia involving both the RA and LA that can be diagnosed by entrainment as well as activation mapping. A septal scar with the presence of two interatrial connections is required for the tachycardia to occur and ablation at the RA isthmus usually is successful in eliminating this tachycardia. In this case, termination did not occur with CTI ablation but, instead, changed to a second atrial flutter requiring a second ablation line for termination, which also eliminated RA to CS activation of the LA.