The need for a more focused preventive nutrition approach, as opposed to a curative one, will then be presented on the basis of the ‘healthy core metabolism’ concept. This will lead us to propose a new classification of food products based on processing for future epidemiological studies. As a result of applying the holistic approach, health food potential will be redefined based on both food structure and nutrient density. These new paradigms should help define a more ethical preventive nutrition for humans to improve public recommendations while preserving the environment.This concept paper intends to define four new paradigms for improving nutrition research. First, the consequences of applying a reductionist  Furthermore, widespread standardized diets do not always respect cultural habits or tradition (such as fast food), and rates of chronic diseases related to poor nutrition  continue to increase dramatically worldwide . In. In16]. Adopting a healthy state approach would lead to new human intervention studies in “real life” conditions that follow healthy individuals in their natural environment and characterize their behaviors, physiology and food consumption in more realistic ways . The adv“Finally, we hypothesized that true primary preventive nutrition should focus on the growth phase to reach the maximum capital of a given physiological function so that—Whatever the further decline—Healthy Life Years may approach or coincide with theoretical Life Expectancy” .A holistic approach views whole, natural and minimally processed foods as more beneficial to a person’s health than recombined and refined ultra-processed foods ,22,23,24i.e., fruits, vegetables, grains, dairy, or red and white meat. The problem is that the most conclusive, solid and relevant scientific evidence has been obtained by considering foods according to their degree of processing [Therefore, the third paradigm we propose is to consider the extent of food processing in food ranking for epidemiological studies. In food frequency questionnaires and food pyramids, foods are generally clustered according to their botanical original or animal species, ocessing . Indeed,ocessing ,31,32,33Within each typical food group, the degree of processing may vary considerably, from minimally processed to ultra-processed: for example, an apple may be eaten whole, canned with syrup, as a purée or as refined juice, and each degree of apple processing corresponds to a different health potential. We can provide such examples for each food group.This is not to say that ultra-processed foods are useless, but rather that they should be used with parsimony as niche products, e.g., when practicing intense physical exercise, rapidly satisfying a little hunger, or not having time to eat fresh and/or natural complex foods, or even for soldiers or astronauts. Today, ultra-processed products tend to become predominant, such as in very large cities or in the poorest populations, leading to dramatic increases in the prevalence of chronic disease and subsequent expensive health care costs.In addition, this new classification of food should be taught from primary school and may encourage the agro-food industry to deliver more healthy foods. Education is therefore essential in helping citizens make better food choices and in obliging food companies to adapt to these new demands.As we have previously discussed, reductionism has led to the fractionation and refining of natural whole foods to isolate ingredients for further recombination, with an important loss of micro- and phyto-nutrients and thus a lower health potential. Reductionism (or “nutritionism”) has also led us to consider foods as only a sum of its nutrients. This quantitative view of food is only a part of the whole picture. Recent data clearly emphasizes the important role of food structure in its health potential, what is called “the matrix effect” ,34,35.durum wheat [It is very clear that food health potential depends on both nutrient composition and food structure properties , such asum wheat . In thisum wheat .i.e., a holistic approach, studying the healthy state, new food classifications and considering food structure, will allow us to completely reconsider health food potential and nutritional recommendations. For example, the new Brazilian dietary guidelines released at the end of 2014 are the first to propose holistic nutritional recommendations based on food pyramids that are built according to the degree of food processing [We think that the application of these four new paradigms in nutritional sciences, ocessing .Although this paper focused on nutrition, to be even more holistic, it is worth remembering from the standpoint of health that not only is it a person’s diet but also his or her lifestyle in general that contributes to overall health, including social environment, smoking and physical exercise.In addition to reductionism, holism is now indispensable if we want to reconcile mankind with its environment , health and diets. This will involve an important shift in our way of thinking and to completely reconsider our way of leading studies in nutritional sciences. This is a very motivating challenge in the effort to develop sustainable diets by 2050.


The Distribution of the Human Blood Groups (1954) was an “indispensable” reference book on the “anthropology of blood groups” containing a vast collection of human genetic data. It was based on the results of blood-grouping tests carried out on half-a-million people and drew together studies on diverse populations around the world: from rural communities, to religious exiles, to volunteer transfusion donors. This paper pieces together sequential stages in the production of a small fraction of the blood-group data in Mourant's book, to examine how he and his colleagues made genetic data from people. Using sources from several collecting projects, I follow how blood was encountered, how it was inscribed, and how it was turned into a laboratory resource. I trace Mourant's analytical and representational strategies to make blood groups both credibly ‘genetic’ and understood as relevant to human ancestry, race and history. In this story, ‘populations’ were not simply given, but were produced through public health, colonial and post-colonial institutions, and by the labour and expertise of subjects, assistants and mediators. Genetic data were not self-evidently ‘biological’, but were shaped by existing historical and geographical identities, by political relationships, and by notions of kinship and belonging.Arthur Mourant's  •The Distribution of the Human Blood Groups (1954) was a vast collection of population genetic data.Arthur Mourant's •It presented blood-group frequencies as a ‘scientific’ methodology for studying human diversity.•The paper follows how Mourant and his colleagues made population genetic data.•Data were structured by the ways in which populations were defined and accessed by researchers.•Populations were shaped by institutions, governments, and historical, racial and national identities. Studies in History and Philosophy of Biological and Biomedical SciencesWhen citing this paper, please use the full journal title 1The Distribution of the Human Blood Groups. Mourant, a physician, serologist and geneticist, was director of the Blood Group Reference Laboratory in London, an institution internationally recognized as a centre for expertise on blood grouping techniques. During the previous few years, Mourant had carved out a successful research programme collecting data on the blood-group frequencies of people around the world. Blood groups were almost the only human traits with clear-cut Mendelian inheritance, and for Mourant and many others, blood-group genetics offered a promising set of methods for the study of racial diversity. Published by Blackwell Scientific Publications in Oxford, The Distribution of the Human Blood Groups was 400 pages long and contained the results of tests done on half-a-million people represented in nine maps, 40 tables and a vast bibliography. The American Journal of Physical Anthropology described Mourant's book as “indispensible”, the American Anthropologist called it “brilliant”, and the Royal Anthropological Institute journal Man considered it to be “the most important” contribution to “the anthropology of blood groups” to date  in the serum of one sample reacting with ‘antigens’  on the red cells of the other. Blood groups were simultaneously antigens and categories accounting for agglutination patterns. Their rising significance in transfusion medicine after the First World War led to a vast proliferation of studies on the blood-group frequencies of different racial and national populations, which were mobilized to serve post-First World War discourses on nationalism, colonialism, race and ancestry.Mourant's success was closely associated with his institutional positions . After tThe Distribution of the Human Blood Groups, and reflects on how its analysis and representation made it both credibly ‘genetic’ and understood as relevant to human ancestry, race and history.Building on existing accounts of how blood groups were mobilized to articulate broader political agendas,2How did researchers decide which populations to sample? Mourant's first research project on blood-group distributions began with a puzzle that geneticists had raised in the early 1940s. Soon after the Rhesus blood groups had been discovered, they were found to cause an incompatibility between Rhesus-negative women and their Rhesus-positive foetuses, which could result in life-threatening anaemia in newborns. Population geneticist J. B. S. Haldane and serologist Alexander Wiener had independently pointed out that the lethal consequences of this condition should have caused the rarer of the Rhesus alleles  to be selected out of populations . HaldaneWhy was this population so compelling? The Basques had served a multiplicity of historical narratives about human history. One researcher sarcastically pointed out that the Basques, at one time or another, had been supposed akin to the “ancient Egyptians, Guanches, Berbers, Etruscans, Phoenicians, Lapps, Finns, Bulgarians, or to Asiatic races”, even “the sole survivors of Atlantis!”.11Journal of the Royal Anthropological Institute (JRAI) promoting scientific research on this “special race without analogy with any other known group”. de Barandiarán belonged to a community of Basque exiles living in London and Paris owing to persecution from Franco's regime. In his article de Barandiarán suggested that through their research, anthropologists might help persuade governments to “respect and protect the ethnic elements of the Basque people, not only for [their] antiquity, but [also] for [their] scientific interest”  ‘venepuncture’ technique. Applying a tourniquet to the arm, the doctor would use a fresh Bayer's ‘venule’—an automatic combined syringe and sample tube—to withdraw 2–5 cc of blood directly into a tube, which was then sealed. Doctors in Britain used this method in routine blood collection, and Mourant recommended that only those medically qualified should use it in field conditions. He strongly encouraged serologists to invest in expensive Bayer venules because they were particularly good at keeping specimens fresh, and because it was “even more expensive to pay the cost of airfreight on specimens which are unfit for testing”.23The assistants belonged to the tribes concerned, spoke the local languages and were respected for the excellent work they had done to promote health. For example, the assistants vaccinated children, took blood for lab tests and provided antibacterial or antimalarial treatment if required.24Published reports disclose few instances of resistance by would-be research subjects, but it is clear that collectors could not always take participation for granted. Allison himself noted in his published work when populations were “un-cooperative” , p. 158,Other blood collectors were explicitly coercive. For example, one of Mourant's Brazilian contacts described how the people of one population “objected that they were not sick and thus they did not need any blood examination”. This researcher reported that “a rough clinical examination followed by prescription and even the distribution of some medicine settled the question”.25On the whole however, and beyond Allison's own recollections, details of how blood ownership was negotiated are missing from both published work and private correspondence, giving the impression that blood collections were straightforward. Certainly the extraction of a small quantity of blood did not require the kind of protracted, complex exchanges Warwick Anderson describes in his account of Carlton Gajdusek's acquisition of brains in Papua New Guinea . But recThe acquisition of body parts, fluids and tissues is never neutral: we know that strategies for persuading people to donate blood in the British setting depended on propaganda that relied on the fashioning of concepts of altruism and gift giving . WithoutIn summary, collections of blood samples representing ‘populations’ were configured by sampling decisions in the field, the expertise of local assistants, and obligations among kin and community. Further embedded in that data were the, sometimes tacit, assumptions by collectors about who qualified as ‘pure’ members of a particular category. Fieldwork encounters linked the construction of genetic identity to other notions of kinship and belonging.4I now want to turn to another kind of collection; not of blood itself, but of the donor cards generated by the transfusion services in Britain. During the Second World War, a new British transfusion service had registered hundreds of thousands of volunteer donors whose records—inscribed with information about blood group—were kept in depots around the country. After the war the new National Blood Transfusion Service (NBTS) expanded its scope, as blood transfusion ceased to be simply an emergency therapy but also began to be used routinely during hospital operations. Mourant became a prominent figure in the NBTS and attended regular meetings with the Regional Transfusion Directors at the Ministry of Health. Using his authority in this setting Mourant brokered the acquisition of donor cards from depots and turned them into data suitable for the geographical mapping of genetic diversity.In March 1948, British geneticists John Fraser Roberts and Cyril Darlington wrote to the Nuffield Foundation asking for money to support a new research project that would make use of the rich wealth of potential data accumulating in transfusion centres.In the late 1940s and early 1950s Britain was struggling to come to terms with changed relationships within its empire, a demographic crisis, and a severe labour shortage . These wBut although Fraser Roberts and Darlington felt that the donor ‘panels’—local lists of volunteers registered with the transfusion service—were potentially ideal resources for mapping the country's genetic diversity, they were careful about what could count as credible genetic data. They worried that people with blood types less useful to the NBTS were resigning disproportionately from panels, and that the records of retired donors were being thrown away owing to lack of space. The panels in many areas were “in danger of being rendered useless for anthropological research by selective removal of cards”.Fraser Roberts' detailed account of his protocols gives us a rare glimpse of the paper work done to produce genetic data from the records. Because the Newcastle donor records had not been duplicated, Fraser Roberts persuaded the workers there to send their records in batches to the LSHTM and allow the staff in London to copy the “relevant particulars” onto punched cards.before collection, while for the latter populations were derived from the donor records. Starting with the Ordnance Survey map showing the locations of the donors, the researchers aggregated these into groups of 20–70 individuals, keeping separate “individual towns, parts of towns and villages” and adding together “rural areas … where it was practicable.” Crucially, Fraser Roberts also took into account natural and man-made features of landscape, so that “attention was paid to … [the] valleys, roads and railways, that might be expected to facilitate communication”.A striking difference between the kind of population data produced from collections overseas and those derived from the British donor cards was that for the former the populations under study were generally delimited Fraser Roberts complained that relying on the postal address was “the most difficult and time consuming part” of the study, and he later persuaded the blood transfusion services to “incorporate certain additional points of anthropological interest into the next reprinting of their record cards”.35The pilot study was a great success, resulting in a detailed map of blood-group frequencies distributed across the middle part of Britain . Buildin37The British Blood Group Survey ran for more than a decade, and the researchers involved took careful steps to keep their NBTS colleagues interested in the project, giving lectures and presenting maps at meetings and conferences. Nevertheless, it was not self-evident to those working for the transfusion services why the ‘anthropological’ work was important, and Mourant often had to remind transfusion officers to send in their records. Even by 1953, only six of the twelve regional centres were regularly sending in records from new donors, perhaps testifying to the perceived risk to the cards. Mourant reprimanded transfusion directors who were “not yet sending in cards”, and complained to others that “a proportion of the cards submitted by all regions bore incomplete information”.In short, there were notable differences between the kinds of data collected in Britain and those collected overseas, including whether populations were defined before or after the collections had taken place. Thus the world maps presented in Mourant's book  brought 5Nature to explain that new research on blood group distributions offered “a valuable basis for a genetical interpretation of human diversities”, but he outlined an urgent challenge:One of the problems is how to collect, assess and make available to anthropologists the vast and rapidly growing mass of data existing in the form of unpublished records and of publications in a very large range of journals.39In 1951, Mourant wrote to Nature letter announced the establishment of a new institution, on the premises of the Royal Anthropological Institute, devoted to the collection, management and analysis of paper records: the Nuffield Blood Group Centre.Mourant's The establishment of a blood group clearing house at the Royal Anthropological Institute points to a new agenda for the discipline. After the war, its members had begun discussing how the wartime atrocities of National Socialism had challenged what it meant to study race. In 1946 Herbert Fleure, the new President of the Institute, had used his inaugural speech to announce that it had been “a mistake to divide mankind into groups termed ‘races’”, and to recommend that anthropologists focus their efforts on how “drifts of people in different directions carried ancient characters far and wide”.In 1951, Fleure chaired the committee's first public event: a “special meeting” for “anthropologists, serologists and geneticists to survey the functions and need of blood group studies in anthropology”. Held in the Eugenics Theatre at University College London, the meeting began with research papers from “practically all the leading workers” on blood group genetics—including Fisher, Mourant, Darlington and Fraser Roberts—and was followed by a discussion devoted to garnering wider opinion on the establishment of a new “Reference Centre for Results”. This new centre, it was decided, would “correlate, tabulate and report on all blood group research having a bearing on anthropology”, and would formalize some of the work that Mourant was doing to foster the “interchange of information” between researchers.42The centre was established in 1952 with Mourant overseeing its work, a role he took on alongside his continued responsibilities at the Blood Group Reference Laboratory. The Nuffield Foundation provided £14,000 for the centre's first five years. Working in a small cottage at the back of the Royal Anthropological Institute building in Bedford Square, clerical assistant Kasimiera Domaniewska-Sobczak and librarian J. W. Wasung classified offprints on blood group distributions in a card index, and organized and catalogued incoming data “in preparation for computation”. Statistician Ada Kopeć used a “Monroe calculating machine” to carry out this “computation”.44The Distribution of the Human Blood Groups.Together, Kopeć, Domaniewska-Sobczak, and Wasung classified the data on blood-group distributions, assessed it “statistically” and made “the results available to anthropologists and other research workers”, leading to the publication of alleles in that population .O allele.The tables also give some indication of the statistical analysis carried out by Kopeć. The rows on the furthest right quote blood-group results not in terms of the percentage of individuals with a given blood group, but rather the percentage frequency of sic], a very much higher frequency than would be expected on the basis of genetical equilibrium” , he presented not a single reference to any paper that dealt with the production of historical, linguistic or anthropological knowledge. By leaving out the sources for his information about the populations under study, Mourant presented their identities as taken-for-granted. Moreover, Mourant rarely mentioned how individuals were recruited as research subjects, and where he did, it was almost always with reference to a ‘local’ expert, e.g. de Barandiarán's ‘expert guidance’ on ‘pure Basques’, and Yturri's skill at identifying Basques with ‘intact lineages’. Later in the 1950s, standards for sampling shifted, and blood collectors began recruiting linguists and social anthropologists to give advice on whose blood should be collected.calibrate blood-group genetic data in relation to existing knowledge.Mourant's presentation of blood-group data—and the fact that he and other researchers rarely concluded anything dramatically new about the populations they studied—suggests that blood groups were not living up to the lofty ambitions made for them. However, we might see the strategies that Mourant used to present blood-group results as serving to [I]n the present stage of genetical anthropology the main task is the most complete possible genetical analysis of the parent populations, for only with the help of this knowledge can the history of their descendants be deduced. , p. 148Continuing the metaphor of calibration, Mourant even referred to his book as an “instrument for research”, a characterization that was echoed by Joseph Birdsell who called it an “important and finely polished research tool” . “GenetiApparently, when enough data had been collected on the “parent” populations of the world, blood-group frequencies would be a fit instrument for probing more subtly mixed populations.7Mourant's work offers glimpses of the kinds of practices used to produce blood-group genetic data, from the bodies that yielded blood to the presentation of population data on the printed page. ‘Populations’ were not simply given, but were produced during the sequence of practices for their collection, collections that varied according to the institutions and people recruited to them. The map shown in yet to probe the origins of ancient peoples, but to calibrate a new tool: blood-group genetic data. More broadly, Mourant's project offered a cogent way of rendering genetics ‘human’: aligning blood-group frequencies with human populations gave the data the potential to reveal new knowledge about human difference, ancestry and history, even if Mourant's conclusions were deferred. On the one hand this is a story of the way in which human difference was made genetic; on the other it is about how genetic data were made human.The construction of blood groups as devices for probing human biological difference relied on notions of kinship, racial and national identity, multiple historical traditions, and questions and practices imported from diverse disciplines. In other words, the varied work that went into making populations into biologically relevant entities was not simply or self-evidently ‘biological’. Side-stepping the question of whether this recourse to ‘cultural’ knowledge was disingenuous or naïve, this work made blood groups look like they could yield convincing knowledge about human life and its history. Notwithstanding Mourant's claims about blood groups being “objective criteria” for studying race, we might view his book's purpose as not


The integration of new information and communication technologies (ICTs) is becoming increasingly important in reorganizing health care. Adapting ICTs as supportive tools to users' needs and daily practices is vital for adoption and use.In order to develop a Web-based personal electronic health record (PEPA), we explored user requirements and needs with regard to desired information and functions.A qualitative study across health care sectors and health professions was conducted in a regional health care setting in Germany. Overall, 10 semistructured focus groups were performed, collecting views of 3 prospective user groups: patients with colorectal cancer (n=12) and representatives from patient support groups (n=2), physicians (n=17), and non-medical HCPs (n=16). Data were audio- and videotaped, transcribed verbatim, and thematically analyzed using qualitative content analysis.For both patients and HCPs, it was central to have a tool representing the chronology of illness and its care processes, for example, patients wanted to track their long-term laboratory findings . Designing health information in a patient accessible way was highlighted as important. Users wanted to have general and tumor-specific health information available in a PEPA. Functions such as filtering information and adding information by patients  were discussed.In order to develop a patient/user centered tool that is tailored to user needs, it is essential to address their perspectives. A challenge for implementation will be how to design PEPA’s health data in a patient accessible way. Adequate patient support and technical advice for users have to be addressed. The integration of new information and communication technologies (ICTs) is becoming increasingly important in reshaping the way health care is understood and delivered . SignifiHowever, design and implementation of innovative patient-centered PHRs has not proven to be easy. Experiences from nationwide approaches such as the National Health Service implemented personal electronic health record HealthSpace (England) show that it failed due to a lack of usefulness and user friendliness, as well as poor alignment to users’ expectations and self-management practices . AccordiMoreover, current literature shows that patients and health care professionals may have complementary perspectives regarding PHRs. In general, patients do have a positive attitude towards the use of a PHR -13 and aIn our research project, we are developing a patient-controlled personal electronic health record (PEPA) in chronic care of patients with colorectal cancer. As a subset of PHRs, the Web-based PEPA would enable patients to access, maintain, and manage (including access management) a secure copy of their personal health information integrated from various HCP primary systems . Within the PEPA concept, patients are understood to be active partners who manage their personal health information across health care settings.For an innovative ICT like PEPA to create added benefit and function as a supportive tool in managing complex chronic illness and care, it is essential that it fit into the real world, daily practices, and health care structures of patients with cancer and their HCPs. Therefore, it is important to better understand the needs and requirements of prospective users. The aim of this study was to explore needs and requirements of potential users with regard to the content and function of a PEPA.A pilot project called “Information technology for patient-centered health care” (INFOPAT), funded by the German Federal Ministry of Education and Research (2012-16), has been initiated in the Rhine-Neckar region (population: 2.3 million) in Germany aiming to improve cross-sectoral health care especially for patients with colorectal cancer. Within this project, a PEPA is being developed and implemented regionally.In the first phase of this INFOPAT-project, a qualitative, exploratory study design using focus groups was chosen, to allow intensive exploration of requirements and needs of selected user groups. The following general research questions were explored within this analysis: (1) What requirements do potential users have regarding the PEPA content?, (2) What information do potential users perceive as relevant to have available in the PEPA?, and (3) Which PEPA functions do potential users perceive as useful?Ethical approval was given by the Ethics Committee of the University Hospital Heidelberg (S-497-2012). All participants gave their written informed consent. The participants’ anonymity and confidentiality was ensured throughout the study.In a regional , cross-sectoral health care setting, prospective user groups of a PEPA were identified. The first user group comprised patients with colorectal cancer (ECOG Performance Status 0-1 ) as wellPatients were recruited through the National Center for Tumor Diseases (NCT) in Heidelberg, Germany, where they received their cancer treatment. Additionally, patients were recruited via an umbrella organization, Heidelberger Selbsthilfebüro, for patient support groups in Heidelberg. Clinicians  and other non-medical HCPs  were also recruited at the NCT. General practitioners (GPs), registered medical specialists , and health care assistants from GP practices were recruited by the Department of General Practice and Health Services Research .The decision to collect data through focus groups was based on the explorative character of the research topic. A focus group is a kind of group interview with participants who are involved in the research field of interest. The group processes that are evoked by focus groups can help participants explore and clarify their views, attitudes, and opinions, which would be less accessible in a one-to-one interview .From March until October 2013, 10 focus groups with a total of 47 participants were conducted. For all user groups, separate focus groups were performed  . On averAn experienced researcher used a semistructured, pilot-tested interview guide based on a literature review and expert discussions for conducting the focus groups. At the beginning of the focus group, a small amount of information was given on the PEPA concept to all participants. At all focus groups, the moderator was supported by a co-moderator. A third researcher wrote a protocol that was integrated into the data analysis phase of this study. The focus group discussions lasted until the saturation of theoretical arguments was reached.The approach for the descriptive qualitative analysis used in this study ,23 dealtTherefore, the performed qualitative content analysis included inductive development of categories and a deductive application of categories. In a first step, three transcripts were reviewed independently by the first author (IB), a coauthor (MK), and the last author (DO) using the preliminary category system and additional key issues were identified. After summarizing and labeling key issues as codes, the codes were sorted into main and subcategories . The codIn order to facilitate better readability, the key findings are presented in categories, subcategories, and aspects. Tables that present the categories enable differentiation between the user groups’ perspectives with respective aspects mentioned. The quotations cited in this article were cross-checked by a native speaker in the Department of General Practice and Health Services Research after translation from German into English.Overall, the key results presented here show that focus group participants discussed user requirements like the presentation of information, tumor specific information that is needed, and possible useful functions .During the focus group discussions, issues on PEPA information and how it should be presented in a PEPA were central in all groups. The following user requirements on these issues were identified .The volume of information that should be provided in a PEPA was discussed in all three user groups. Different needs regarding this issue emerged. In particular, participants from the physicians’ focus groups expressed their need for complete data in a PEPA. They wished to have information available in the PEPA as much as possible: “I always expect all information from such a record” (GP1-F10).On the other hand, other participants within the physicians’ group and patients saw a challenge in manageability of large amounts of data: “It’s just such an enormous thing…can you still manage it, do you want to manage it—everyone will have this huge thing to maintain” (Patient4-F01).In all three user groups, the need for time and content-related limits in information volume was mentioned. Issues on limiting the volume with a timeline were addressed especially by patients, for example, only data from the last 10 years, although they were unsure about when to draw the line. Some patients mentioned that they did not want to have every detailed laboratory result in their PEPA. Similarly, participants from both professional user groups  thought it would be useful to limit the amount of medical results for practical reasons: “Yes, but not everything…I don’t need all 20 of those little blood exams” (Patient4-F01) and “It would perhaps be quite good if only a certain number of the results were in it” (HCP-F06).A central issue was how to present information in a PEPA for patients. Designing health information in a patient accessible way was discussed by all three user groups. Several patients emphasized their need for having comprehensible information in their PEPA. They highlighted the fact that patients are mostly laypersons who typically have problems understanding medical jargon. One patient suggested a copy of the record that is reworded in patient assessable language while realizing that the associated effort was significant: “I’ve often wished I had a, what shall I call it—a patient copy…to me that’s something that summarizes the most important events of my own life in terms of illness, translated into a language that I can understand” (Patient2-F03).Similarly, the HCPs user group saw the need for changing the way of presenting medical information in this patient-owned tool, and participants from the physicians’ focus groups also required adapting the presentation of medical results to the patients’ needs: “How the results are displayed needs to be changed completely so that it can be used for the patients” (Physician 3-F04).Moreover, options were discussed for supporting the comprehensibility of medical terms in a PEPA for patients by the patient and non-medical HCPs focus groups. The usefulness of a glossary, especially in handling medical abbreviations was stressed:But with the speed…at which the information is given in a one-off appointment, I at least am not able to take it all in. And then I sit at home and really don’t know what this RT, all these abbreviations, what that means. Such a kind of glossary would be extremely helpful here.Patient2-F03During the focus group discussions, in all three user groups, themes related to chronological information recurrently cropped up. For patients as well as their HCPs, it was important that a PEPA structure would facilitate tracking the course of illness and treatment over time: “First of all, I want to see my medical history shown completely for myself” (Patient1-F02) and “I also think that it would be important to have the data in a way that you can track the progress/ process quite quickly” (GP1-F09).Some physicians explicitly highlighted the need for presenting the PEPA information in chronological order for their daily practice in treating patients with colorectal cancer but concurrently stressed the big challenge in technological practicability:The challenge certainly lies in putting individual results into a useful chronology.Physician3-F04I think it’s sensible to categorize it (the information) and assign it to the different areas so that you really end up with this chronology…he had the last chemotherapy on day xy and this was the medication and a week ago he took a break because his blood values were bad.Physician3-F04A further issue pointed out in the physician focus groups was that physicians dealt with patients’ health information in electronic patient records within their daily work where, currently a lot of necessary health information is provided in an unstructured way, for example, in medical reports or physician’s letters (as PDF files). From their perspective, a PEPA would have a real benefit for their daily work if it could identify and utilize unstructured information from various information systems and present it in a structured form in the PEPA:because if it can’t do that, I end up with what feels like ten PDF files from the patient and one is the doctor’s letter from the University Hospital and one is the doctor’s letter from the oncologist and the third PDF is maybe a copy of a prescription…The question is, how do we make the new system more than just the scanned-in doctor’s letters.Physician3-F04Patients focused more on the possibility of observing how their condition developed over time . They would benefit from using a PEPA, for example, if tracking their long-term laboratory findings would be possible: “My tumor marker values, for instance, it would be really interesting to see how they progress” (Patient4-F01).In general, issues with PEPAs related to design and layout were not central to discussions. In particular, patients did not have a detailed idea on how the PEPA layout and its user interface should appear: “The design isn’t that important to me” (Patient4-F01). However, participants from both professional user groups  had several overall requirements regarding this issue. Both wished that a PEPA would have an ergonomic layout that is clearly structured: “The whole thing…really needs to be completely clear” (GP1-F05). Furthermore, the importance of the PEPA’s ease of use for a broad range of users was emphasized: “It needs to be very simple” (GP4-F05) and “understandable to everyone” (HCP1-F07).Regarding the design of the PEPA’s front page, participants from all three user groups, especially physicians mentioned that the information presented at the frontpage should be restricted to key information like administrative data, contact persons, diagnoses, or the current medication plan. Further information of interest they would like to open on sub-levels: “Really the most important...I mean name, address, relatives, telephone number, allergies, diagnoses, maybe the last medication plan—that’s it. And you can open the rest if you want to” (GP2-F05).Some participants from the patient and the physician user groups pointed out a priority for current issues. They wished to view current information first on the front page. Some participants from both professional user groups  suggested even highlighting important or new information, for example, in terms of color to highlight relevance.If new entries are added, they need to be specially marked, not integrated into the mails, so that I don’t have to search and read through everything again to find out what’s new. It should be introduced somehow and indicated that it’s new.Patient6-F03that some things are highlighted in a different colour, important things.HCP6-F06Tumor-specific information was identified as relevant to have available in the PEPA for care delivery in patients with colorectal cancer. Particularly, participants in the physicians focus groups focused on tumor-specific information related to tumor diagnostics and tumor treatment .Moreover, general information was identified from the users’ perspective as relevant to have available in the PEPA see . The focIdentifying user requirements on PEPA functions revealed several topics that the focus group participants in the three user groups addressed. In addition to storage of and access to desired personal health information including clinical data, some identified central functions of a PEPA were selected and are presented in One central issue discussed in all three user groups was the opportunity for patients to add information to a PEPA in addition to the HCPs. The usefulness of information on subjective well-being that patients could add to a PEPA was emphasized. Some patients expressed the wish to share information on their well-being with their HCPs. Participants from both professional user groups  gave examples on information they perceived as clinically relevant that they would want to know from the patient : “Well, yes, it’s data that the patient might generate themselves…It would be important to know that in terms of pain treatment, for instance” (GP2-F10).A participant from a physician focus group suggested providing this function as a patient journal that would be kept by the patient in the PEPA: “Of course, that would be especially important, yes, if he could write a kind of journal…while he’s undergoing chemotherapy about how it’s going” (GP1-F09).Furthermore, participants from both professional user groups mentioned the possibility for patients to add commentaries on medical results. For instance: “add something to it, a note/comment/commentary, if he wants, so that someone else who accesses it can either take it into account or not” (GP1-F05).Critical comments were also made regarding patients’ adding information. From the physician group, requirements for a separate section for patient entries were identified to ensure that data entered by patients are not mixed with those uploaded from professionals and further to ensure that patient-added information would be marked as such:Is that really necessary?...Then we’d need to enter certain codes for the patient to show where in his record… such as Patient History, where he can only enter something himself there and not add in other things.GP1-F10Given the fact that several physicians from different health care settings would have PEPA access, participants from physician focus groups expressed concerns and uncertainty regarding negative consequences on professionals’ liability for reacting to patient-added information or commentaries: “In theory you could go even further with the liability thing, if three or four doctors check the record and all saw that he was feeling worse and no one reacted, whose fault is it?” (GP1-F09).Having the possibility to filter information in the PEPA was important to focus group participants from all three user groups: “But then there should be a filter function so you can filter out things fairly quickly, that would be important” (GP1-F09). Especially in terms of handling large amounts of data that a PEPA could provide, physicians perceived a filter function as essential: “The data volume soon won’t be a problem…but you need to be able to filter really well.” (GP4-F09).Related to this topic, physicians perceived a filter function for currentness as useful, for example, listing medical results from the latest to the oldest: “Yeah, yeah, yeah. Well, I think the detailed filter function is very important too, eg to search for the latest results.” (GP2-F09).Also, having the opportunity to filter the PEPA information for a diagnosis, for example, colorectal carcinoma or a topic of interest was highlighted as useful:and so I can say, only colorectal carcinoma, then I only see everything connected with this diagnosis. If he comes to me because of high blood pressure, then I click at the top on just this episode and only see these things, that would be the benefit of it.GP1-F10Electronic communication could be a PEPA feature provided to its users. Among both HCP user groups, especially among physicians, ambivalence towards messaging with patients was revealed during the discussions. Some participants perceived this function as useful whereas others did not: “A kind of messaging function, being able to send messages to the patient would be useful: ‘Attention: please do not eat anything before attending your CT appointment tomorrow’” (Physician1-F04) and “That doesn’t make any sense” (GP5-F05).Some physicians saw the positive potential of this feature for enhancing communication among HCPs involved in the patients’ treatment: “And perhaps sometimes a better coordination or a note to the GP as the most important second contact, leaving short messages via both channels without having to hold long phone calls and so on. This would certainly be beneficial” (Physician3-F04).Concerns regarding electronic communication with patients that were expressed by physicians during the discussions referred to a perceived pressure by permanent availability of HCPs: “And if I then need to look up who just wrote to me and who I need to write to now because something urgent has happened, then I don’t need an emergency service any more, then I’m permanently on call” (GP1-F10).It was argued that patients would develop high expectations concerning the HCPs’ availability in terms of dealing promptly with patient concerns, if such communication features would be available. They feared that their limited time resources could be overstrained by providing this feature to patients:They can order prescriptions from us by e-mail and pick them up the next day. It’s actually a great function, but the problem is that patients send prescriptions at midnight and want to have them ready at 7 a.m. They think we sit here all day just for that.HCP3-F07The aim of this study was to explore requirements and needs of potential users with regard to the content and function of a PEPA. In our study, key requirements and needs were identified from users’ perspective. Overall, our participants were very much focused on themes according to their daily routines. They wished for a PEPA that allows and facilitates tracking the course of illness and treatment over time. Professionals expressed the need for presenting PEPA information in chronological order for their daily practice in treating patients with colorectal cancer. In this context, one central desired function to our participants was the opportunity to filter information and thus to categorize information for several purposes like time or content.Physicians specifically highlighted the potential of a PEPA if it would enable them to view all information as history related to one single episode, for example, colorectal cancer. Closely linked with this requirement was the need to identify and utilize unstructured information and present it in structured form. Currently, a problem in daily practice described by professionals is that a lot of necessary health information is provided in an unstructured way, for example, in medical reports or physician’s letters (as PDF file). A real benefit for their daily work would be if a PEPA could identify and utilize unstructured information from various IT systems and present it in a structured form in a PEPA. However, there is a lack of literature addressing this issue .A significant issue for patients and their HCPs was that PEPA information including medical information will be accessible to patients in their patient-controlled tool. Consequently, if patients managed their PEPA, they required that the presentation of data has to be adapted to the patient’s needs as a layperson, in particular, comprehensibility. Problems in understanding clinical documentation have often been an issue reported by patients ,25-27. OIn addition to storage and access to personal health information including clinical information ,29, seveDespite the fact that electronic communication with HCPs is an often required and provided function ,10,28-31In line with other studies, our findings referred to treatment-related information  enabling a broad perspective during design and analysis stages. Some limitations in recruitment of participants have to be acknowledged. Most patients willing to participate in the study were men, and the level of education was relatively high. It can be assumed that the innovative and technical character of this approach attracted early adopters of ICT ,8,43, thFrom the user perspective, a PEPA was seen as a potentially useful tool for patients with colorectal cancer and their HCPs in cross-sectoral cancer care. A PEPA has potential to support patients in managing their chronic illness and is conceptualized to facilitate information exchange between patients and their HCPs as well as among HCPs or institutions across health care sectors. However, chronic diseases do have a long-term and episodic character. In order to create an added benefit to its users, a PEPA has to be oriented to these phases and episodes of care. A challenge for implementation will be how to design a PEPA’s health data in a patient accessible way. In order to create a real patient/user-centered tool that is tailored to user needs, patients and their HCPs have to be involved early in development, implementation, and evaluation processes. User preferences according to their daily routines in managing chronic illness have to be addressed. Furthermore, adequate patient support and technical advice for users have to be provided.


Social status, defined as the relative rank or position that an individual holds in a social hierarchy, is known to be among the most important motivating forces in social behaviors. In this paper, we consider the notion of status from the perspective of a position or title held by a person in an enterprise. We study the intersection of social status and social networks in an enterprise. We study whether enterprise communication logs can help reveal how social interactions and individual status manifest themselves in social networks. To that end, we use two enterprise datasets with three communication channels — voice call, short message, and email — to demonstrate the social-behavioral differences among individuals with different status. We have several interesting findings and based on these findings we also develop a model to predict social status. On the individual level, high-status individuals are more likely to be spanned as structural holes by linking to people in parts of the enterprise networks that are otherwise not well connected to one another. On the community level, the principle of homophily, social balance and clique theory generally indicate a “rich club” maintained by high-status individuals, in the sense that this community is much more connected, balanced and dense. Our model can predict social status of individuals with 93% accuracy. Social status refers to the relative rank (or position) that an individual holds in a society , 2. For However, the relationship between social network structure and social status has not been widely recognized or studied, especially from the perspective of communication channels, such as voice call, short message, and email. Researchers have studied the interplay of social status and language signals , 7, cognThe dynamics of social status can actively influence the strategies to make friends and maintain connections, which could re-structure the social circles of individuals. The social relationships of individuals can also rearrange the promotion or demotion of their social status and further reform the social hierarchy (or circles) in the organization. Furthermore, social status might also impact how information diffuses or cascades in a network via different communication channels. We discover that there are, indeed, different communications and social networking underpinnings as a consequence of individuals with different status in a social network. This can be especially compelling in a corporate organization that by design has individuals with different positions (or status)—managers and their direct reports (or subordinates).To that end, we collected three communication networks from two different enterprises. Two mobile communication networks, i.e., voice call (CALL) and short message (SMS) networks, are extracted from two-month communication logs of an Asian telecommunication company with 50 managers and 182 subordinates. And an email communication (EMAIL) network is from Enron Inc. with 155 managers and 22,322 subordinates spanning over one year  is the expectation of feature function fk given the data distribution and 𝔼Pθk[fk] is the expectation of feature function fk under the distribution Pθk given by the estimated model.For model learning, the task is to find a parameter configuration {function , 39. SpePθk. To solve this challenge, we use Loopy Belief Propagation, due to its ease of implementation and effectiveness, to approximate the marginal distribution Pθk. Then we are able to obtain the gradient by summing up all the factor graph nodes. Finally, we update each parameter with a learning rate η with the gradient. Related algorithms can be found in [The graphical structure in the above model can be arbitrary and may contain circles, which makes it intractable to directly calculate the marginal distribution found in , 41.θ, we can now assign the value of unknown labels Y by looking for a label configuration that will maximize the objective function, i.e.With the estimated parameter S1 Text(PDF)Click here for additional data file.


Modern psychology is apparently in crisis and the prevailing view is that this partly reflects an inability to replicate past findings. If a crisis does exists, then it is some kind of ‘chronic’ crisis, as psychologists have been censuring themselves over replicability for decades. While the debate in psychology is not new, the lack of progress across the decades is disappointing. Recently though, we have seen a veritable surfeit of debate alongside multiple orchestrated and well-publicised replication initiatives. The spotlight is being shone on certain areas and although not everyone agrees on how we should interpret the outcomes, the debate is happening and impassioned. The issue of reproducibility occupies a central place in our whig history of psychology. It often carries the misleading implication that hypotheses can be readily discarded in the face of something called a ‘failed’ replication. Popper ). ). SocialOSC Reproducibility project involved 270 collaborators attempting to replicate 100 findings from 3 major psychology journals Psychological Science (PSCI), Journal of Personality and Social Psychology (JPSP), and Journal of Experimental Psychology: Learning, Memory, and Cognition (JEP: LMC). While 97 of 100 studies originally reported statistically significant results, only 36 % of the replications did so with a mean effect size of around half of that reported in the original studies.In the largest crowdsourced effort to date, the P < 0.05 criterion, whereas 21 of 42 (50 %) of cognitive psychology effects did so.” The reasons for such a difference are debatable, but provide no licence to either congratulate cognitive psychologists or berate social psychologists. Indeed, the authors paint a considered and faithful picture of what their findings mean when they conclude “…how many of the effects have we established are true? Zero. And how many of the effects have we established are false? Zero. Is this a limitation of the project design? No. It is the reality of doing science”. (Open Science Collaboration p.4716-7) All of the journals exhibited a large reduction of around 50 % in effect sizes, with replications from JPSP particularly affected - shrinking by 75 % from 0.29 to 0.07. The replicability in one domain of psychology (good or poor) in no way guarantees what will happen in another domain. One thing we know from this project, is that “…reproducibility was stronger in studies and journals representing cognitive psychology than social psychology topics. For example, combining across journals, 14 of 55 (25 %) of social psychology effects replicated by the The studies that were not selected for replication are informative – they were described as “…deemed infeasible to replicate because of time, resources, instrumentation, dependence on historical events, or hard-to-access samples… [and some] required specialized samples (such as macaques or people with autism), resources , or knowledge making them difficult to match with teams”. Thus, the main drivers of replication are often economic in terms of time, money and human investment. High cost studies are likely to remain castles in the air, leaving us with little insight about replicability rates in some areas such as functional imaging (e.g. ), clinicPipeline project’ by Schweinsberg et al.  this rule is wrong not only in a few exceptional instances but as it is routinely applied to the majority of experimental reports in the psychological literature” p.152. Often such claims give rise to a version of Feynman’s maxim that “Extraordinary claims require extraordinary evidence”. The remarkableness of a claim, however, is not necessarily relevant to either the type or the scale of evidence required. Instead of setting different criteria for the ordinary and extraordinary, we need to continue to close the wriggle room.While some might view the disjunction between belief and evidence as ‘healthy skepticism’, others might also describe it as resistance to evidence or even anti-science. A pertinent example comes from Lykken  who desc“Scientists should not be in the business of simply ignoring literature that they do not like because it contests their view.” single influential articles rather than insisting on a replication across independent labs and multiple contexts” .Taking this to the opposite extreme, some researchers may choose to ignore the findings of meta-analyses at the expense of selected individual studies that accord more with their view. Giner-Sorolla  maintainStoebe & Strack rightly point-out, “Even multiple failures to replicate an established finding would not result in a rejection of the original hypothesis, if there are also multiple studies that supported that hypothesis.” [and] ‘believers’ “…will keep on believing, pointing at the successful replications and derogating the unsuccessful ones, whereas the nonbelievers will maintain their belief system drawing on the failed replications for support of their rejection of the original hypothesis.” (p.64). Psychology rarely – if ever- proceeds with an unequivocal knock-out blow delivered by a negative finding or even a meta-analysis. Indeed, psychology often has more of the feel of trench warfare, where models and hypotheses are ultimately abandoned largely because researchers lose interest .Jussim et al.  provide In a classic study, Darley & Gross  found peold, lonely, bingo, wrinkle) makes them subsequently walk more slowly. However, Doyen et al. [This is not an unusual case, as Jussim et al. report several examples of failed replications not being cited, while original studies continue to be readily cited. The infamous and seminal study by Bargh and colleagues  showed tn et al.  failed tn et al.  showing n et al. . Since 2In science the way to answer questions about replicability of effects is through statistical techniques such as meta-analysis”. Others are more skeptical: “Meta-analysis is a reasonable way to search for patterns in previously published research. It has serious limitations, however, as a method for confirming hypotheses and for establishing the replicability of experiments” . Meta-analysis is not a magic dust that we can sprinkle over primary literatures to elucidate necessary truths. Likewise totemically accumulating replicated findings, in itself, does not necessarily prove anything (pace Popper). Does it matter if we replicate a finding once, twice, or 20 times, what ratio of positive to negative outcomes do we find acceptable? Answers or rules of thumb do not exist – it often comes down to our beliefs in psychology.Some view meta-analysis as the closest thing we have to a definitive approach for establishing the veracity and reliability of an effect. In the context of discussing social priming experiments, John Bargh  declaredBMC Psychology contains 4 articles  and in or wrongly enables some ideas to persist despite a lack of support at the level of individual study or trial. This has certainly been argued in the use of meta-analyses to establish a case for psychic abilities, where Storm, Tressoldi & Di Risio [Judging the weight of evidence is never straightforward and whether a finding sustains in psychology often reflect our beliefs almost as much as the evidence. Indeed, meta-analysis rightly Di Risio  identifymeta-analysis is analogous to statistical alchemy for the 21st century…the main appeal is that it can convert existing things into something better. “Significance” can be attained statistically when small group sizes are pooled into big ones” (p. 71). Undoubtedly, the conclusions of meta-analyses may prove unreliable where small numbers of nonsignificant trials are pooled to produce significant effects [This is a kind of free-lunch’ notion of meta-analysis. Feinstein  even sta effects . Nonethe effects ).http://www.cbtinschizophrenia.com/), which has been used by others to test new hypotheses  offer extremely good suggestions relating to some of these conflicts in meta-analytic findings. Lakens and colleagues offer 6 recommendations, including permitting others to “re-analyze the data to examine how sensitive the results are to subjective choices such as inclusion criteria” and enabling this by providing links to data files that permit such analysis. Currently, we also need to address data sharing in regular papers. Sampling papers published in one year in the top 50 high-impact journals, Alsheikh-Ali et al.  reportedes (e.g. ).triangulation of evidence and in this particular instance, supplementing traditional meta-analysis and P-curve analysis [adversarial collaboration could dovetail with Lakens et als’ proposal regarding hosting relevant data on web platforms. In such a scenario, opposing views could test their hypotheses in a public arena using a shared database.Taylor & Munafo (this issue) advise greater analysis . In passanalysis  urged scanalysis ). Coyne openness is unusual in psychology journals, but does offer readers a glimpse into the process behind a replication (or any paper), allows the person being replicated to contribute and comment on the replication, to reply and be published in the same journal at the same time.In the context of adversarial collaboration, some uncertainty and difference of opinion exists about how we might accommodate the views of those being replicated. One possibility again requires openness and that is for those who are replicated to be asked to submit a review; and crucially, the review and replicator’s responses are then published alongside the paper. Indeed, this happened with the paper of Coppens et al. (this issue). They replicated the ‘testing effect’ reported by Carpenter (2009) – that information which has been retrieved from memory is better recalled than that which has simply been studied. Their replications and meta-analysis partially replicate the original findings, and Carpenter was one of the reviewers whose review is available alongside the paper . Indeed, from its initiation, BMC Psychology has published all reviews and responses to reviewers alongside published papers. This degree of substance of our spotlight is people, cognition and brains, we sometimes care too much about the ‘truths’ we choose to declare. They have implications. Similarly, we should not ignore the incentive structures and conflicts between the personal goals of psychologists and the goals of science. They have implications. Finally, the attitudes of psychologists to the transparency of our science needs to change. They have implications.Ultimately, the issues that psychologists face over replication are as much about our beliefs, biases and openness as anything else. We are not dispassionate about the outcomes that we measure. Maybe because the


In English vocabulary learning, continuation is an important factor; however, many learners are not good at continuing learning because they tend to prefer amusement or rest. Our proposed system is targeting learners who are eager to learn but are not able to continue learning for various reasons. We especially focused on English vocabulary learning, and described an approach for learners who have difficulty with continuing learning. Our developed application aggressively supports the learners’ sustainable motivation by gamification techniques and an efficient difficulty setting method. The term “electronic learning,” that is, “e-learning,” has become popular since the mid-1990s, and its goal is to create a community of inquiry independent of time and location through information and communication technologies E-learning has an advantage that a learner can learn alone anytime and anywhere; however, it also has a disadvantage that it is difficult for the learner to maintain his/her motivation. In this section, we clarify a position and a characteristic of our study, through considerations of related works which enhance the learners’ motivation in the e-learning environment.a succeeded to enhance the users’ motivation to check in their location to the service through gamification techniques that each user can get some points and badges when checking in. In addition, Preira et al.  it increases wasteful time for learning; (2) learners will get tired of learning if the learners get tired of the video game; (3) the pain of learning in itself is not decreased; therefore, in our application, we selected simple English vocabulary learning in a repetition style with some gamification factors.The first factor is a growth character system. The character shown in Figure This is one of the interactive activities in our system for identifying the level of learners’ efforts. The objective of this system is to stimulate learners’ motivation by setting the other objectives such as games.The second factor is the time trial question and ranking system. In the time trial system, learners can attempt to answer as many questions as possible correctly in a minute. After their attempt, our system shows the clear points depending on the accuracy rate, the number of answered questions, and the difficulty of answered words as illustrated in Figure The last factor is SNS connectivity. In this application, learners can submit their clear points to SNS services easily. The learners can satisfy their desire for recognition from others, and this creates a rivalry with others.Implementing of gamification is expected to maintain learners’ short-term motivation; however, for keeping their long-term motivation, it is desirable that the learner discovers a pleasure or a purpose of learning in itself. Many learners have difficulty with memorization learning such as English vocabulary learning. In our application, we visualize each learner’s efforts to make the learner’s growth and the increase of knowledge much more recognizable.This application shows a learner’s efforts such as the number of answered questions, the number of correct answers, and the difficulty of learned questions. The graph upper left in Figure The learner can confirm the degree of his/her efforts using numeric values and graphs which prevents the decrease of motivation.In desk learning, to date, it has been a problem that learners have difficulty in understanding their improvements: how many words the learner can answer correctly, in this case.However, utilizing e-learning, which can record and analyze all answers of each learner, our application can visualize the degree of the learners’ mastered knowledge. Our application shows the rate of mastered words and the average rate of correct answers as illustrated in the blackboard at Figure An advantage of e-learning is that it is easy to collect and analyze learners’ learning histories. Our application collects all learners’ learning histories on a cloud as illustrated in Figure u∈{u1,u2,u3,...,un} knew each English word w∈{w1,w2,w3,...,wm} as true (T: the learner knew it) or false (F: the learner did not know it) as shown in Table un knew the word wm, we can estimate that un knew wm because un is similar to u4 and u6.In this study, based on the assumption of the similarity between each learner’s mastered or unmastered words, we propose a new method that estimates whether the learner knows unlearned words by the degree of similarity between each learner. Applying the matrix in collaborative filtering technique Value based on a weighting average of similarity values by 10 learners’ nearest neighbors. Value means the estimated value which indicates whether the learner u can answer the word w correctly. Rounding Value to the nearest whole number, when the rounded value is 1, it means that the learner u has already mastered the word w. Similarity means the degree of similarity between the learner u and v. These are calculated as follows,Our method calculates u is a learner about whom we estimate whether a word w has already been mastered, V′ is a group of 10 learners’ who have the highest degree of similarity of all learners, rvw is the latest answer for the word w by the learner v , and |W′| is the number of words which the learner u has already learned. Distance means the distance between the learner u and v, and it is calculated by Euclidean Distance according to the following formula.where All words in our application can be classified as one of the following four kinds: mastered word, unmastered word, estimated mastered word, and estimated unmastered word. Using answer history data, our application can assess whether a learner has already mastered a word when the learner has challenged the word in our application. When the learner could answer the word correctly on the most recent attempt, the word is classified as a mastered word. When the learner could not answer the word correctly at the last time, the word is classified as an unmastered word. Using the above-mentioned method estimates whether the learner can answer the word correctly. When our method estimates true, the word is classified as an estimated mastered word. When our method estimates false, the word is classified as an estimated unmastered word. It is generally said that a rate of over 80 % known words in long sentences is good for sustainable motivation when reading long English books. Our application sets questions with the same ratio of the above-mentioned four kinds of words because our goal is to support English vocabulary learning with sustainable motivations; therefore, the ratio of mastered words is 25%, the ratio of unmastered words is 25%, the ratio of estimated mastered words is 25%, and the ratio of estimated unmastered words is 25%. Because unmastered words have already appeared one or more times despite incorrect answers at the most recent attempt, assuming that the learner knows unmastered words, the sum of the ratio of the known words is 75%. The learner can review and learn new words in this ratio with sustainable motivation.c which has 105 questions included in our application. We evaluated the estimation accuracy using a cross-validation method for each learner as illustrated in Figure To evaluate the estimation accuracy, we collected 105 questions’ answers by 53 participants using a developed web application Table Focusing on the accuracy of each, this result indicates that our proposed method could estimate, from 10 extracted words, whether or not about 90 words have already been mastered with 82.7% accuracy. However, because of the bias, if we estimate all results as true, the accuracy was 80.6%. Although the accuracy of our method is a little higher than the acuracy of all true, in terms of F-measure, our proposal both F-measure (T) and (F) was better than them.Although we should compare the tendency of the learner’s learning continuation between our proposed system and other e-learning systems, it is difficult to compare the tendency under the same conditions. We performed a questionnaire to consider our application’s evaluation and its effects through actual uses by twenty-seven participants. The participants are composed of undergraduates and graduate students whose age is between 19 and 24. Participants answered the questionnaire for each function on a scale of one to five: five means “Strongly agree”, four means “Agree”, three means “Neither agree nor disagree”, two means “Disagree”, and one means “Strongly disagree.” We show the contents of the questionnaire and its results in Table According to these results, many participants answered “Agree” for much of the content; however, we focus on some distinguishing points. First, between content no.2 and no.6, time trial challenge receive more “Agree” responses than weak point learning; however, it also receive more “Disagree” responses. We considered that the learners felt that time trial challenge was more characteristic than weak point learning because the number of answers of “Neither agree nor disagree” in the time trial challenge was significantly fewer than that in the weak point learning. Therefore, time trial challenge has a good influence on learners’ sustainable motivation for some learners. Second, about content no.11, the ratio of “Agree” was 73.1% which was the highest ratio of all; therefore, most learners are especially interested in the clear points and ranking function. Finally, about content no.13 and no.14, both these contents have a lower ratio of “Agree”; further, the ratio of “Disagree” in no.14 was 61.5% which was the highest ratio of all; therefore, most learners were not interested in submitting their score to SNS services, and they thought that the SNS function did not affect their motivation in this case.Because our application got many “Agree” answers, we considered that the gamification techniques had a good influence in some functions. In this paper, we found out that learners were especially interested in the clear points and ranking function, and were not interested in SNS submitting. We do not believe that the SNS function is not good for sustainable motivation, but we believe that a suitable utilization of SNS supports learners’ motivation; therefore, we should consider how to utilize SNS services to maintain learners’ motivation in future efforts.In this study, focusing on motivated learners who cannot continue learning, we developed an English vocabulary learning support system for sustainable motivation. This application is equipped with the necessary functions for English vocabulary learning. In addition, we utilized information technology, such as gamification techniques, cooperation with SNS, and an unlearned words estimation based on the degree of similarity between each learner. Therefore, we believe that we have succeeded in making an application that supports the growth of self-sufficient learners in the following steps: (1) learner who cannot continue learning; (2) learner who enjoys our application in terms of gamification; (3) learner who is interested in self-growth; (4) self-sufficient learner.This application is currently available on Android platforms 2.2 and above; further it is published in Google Play. As future efforts, we will evaluate the degree of continuation using our application. Moreover, to improve our proposed estimation accuracy, after gathering more usage data, we will consider parameters and estimation algorithms.a Foursquare https://foursquare.com/b Ke-Tan for TOEIC basic vocablary: https://play.google.com/store/apps/details?id=com.has.seelearningc TOEIC vocabulary level check Vol.1 http://t-hase.rhcloud.com/


We welcome the comments from Emanuel et al. .In a systematic review, Pfirrmann’s method  was endop ≤ 0.009).In our work , we valiIn our study, we also demonstrated that disc height was smaller in people with high pain and/or disability, substantiating the clinical utility of the measure. While Emanuel et al. argue that factors such as high inter-subject and intra-subject variation limit the use of disc height as a clinical or epidemiological measure , this can be mitigated by standardising assessments to a particular time of the day (e.g. morning). While quantitative mapping shows promise, such techniques are highly sophisticated, expensive and not widely available.We contend that our data validate disc height as a readily available, simple and effective means of assessing intervertebral disc degeneration, but do acknowledge that disc height may not be the best singular measure for disc degeneration. We welcome further efforts to identify continuous measures that sensitively assess disc degeneration.