Approximately 6.5 million adults have chronic heart failure (HF), the number one cause of 30-day hospital readmission. Managing HF and its symptoms is critical for patients. Hospitalization may impact patients’ perceptions of illness control, which can affect illness management. However, how hospital readmissions are perceived as related to one’s ability to control their HF and its symptoms has not been examined.The purpose was to explore the experiences of people with HF in managing their illness , understand their perceptions of illness control after recent hospital readmission, and clarify the concept of illness control in people with chronic HF.A qualitative approach, applied thematic analysis was employed. Purposive sampling was used to identify participants. Semi-structured interviews were conducted in 10 participants’ homes. Ongoing, concurrent, and comparative data analysis was used with ATLASti© data management software.Two themes were identified, strategies to control HF and barriers to controlling HF. Strategies to control HF included four subthemes: managing dietary intake and medications; self- advocacy; monitoring symptoms; and support. Barriers to control also had four subthemes: healthcare systems issues; health care professional relationships and interactions; personal characteristics; and knowledge deficits.People use many different strategies to control HF. Control comes from both within and outside of the individual. The desire to control HF and its symptoms was evident, but implementing strategies is challenging and takes time, experience, and trial and error. Individuals did not view readmission negatively but as necessary to help them control their symptoms. Heart failure (HF) is a progressive condition that has become a significant public health problem, and the prevalence increases with age . AccordiControlling HF requires that individuals adhere to a complex treatment plan of dietary changes, take medications as prescribed, and monitor signs and symptoms, including daily weight, edema, dyspnea, and activity tolerance . In an iwere controlling their illness but were still being hospitalized  and that’ll make his blood pressure drop. So we have to be careful how we do it” (Logan).All participants recognized medications as necessary for HF control. However, views on who was responsible for the medications varied. For example, some individuals felt that taking medications was something they controlled themselves. Others saw family members or significant others who managed the medications as responsible. In contrast, others suggested it was solely up to the HCP who made prescribing decisions as being in total control of this aspect of care. Participants focused on medications and their role in controlling HF, particularly when compared to behavioral and lifestyle modifications. “I said I’m not taking it. And I missed a day and a half and felt better. Then I thought. I said, nah, I’ve got to take it because I don’t want the fluid back on me, so I went back to taking it” (John).Self-advocacy Many participants expressed the importance of self-advocacy or having a family member advocate on their behalf when they were too ill. They wanted to be viewed and respected as experts on their bodies and symptoms. “No. I know my body. I know how it felt… I know the difference” (Amos).This theme persisted across time living with HF, from those who had only been diagnosed for a month to those with longstanding HF. However, those with longstanding HF appeared to have more proficiency and confidence in determining the cause of their symptoms and were more vocal about it with their HCPs.“Like I said, be proactive. Learn all about your disease you can. Educate yourself. Ask the tough questions. If you don’t think the doctor is doing like he wanted to or wassupposed to or think he should do, ask him why. I used to be scared to ask the doctor anything, but now I’m not because if you don’t, I mean, how you gonna find out?“ (Karl).Monitoring symptoms All participants discussed the “constant monitoring,“ “vigilance,“ and “constant checking” of their symptoms. Common symptoms that they tracked included their breathing ability, insomnia, restlessness, anxiety, and fatigue or, as described in their words, “sluggishness” (Amos), “washed out, I felt like I’d been through a washing machine, a wringer” (Reilly) and “not just tired, exhausted” (Bernice). The seriousness or severity of symptoms guided actions and care-seeking. For example, one individual said, “when you can’t breathe, it is critical” while another knew that the symptoms were severe enough to warrant a call to 911 rather than a call to the physician’s office. One participant noted that he utilized the symptoms to decide whether to seek care, and if so, where, either at the doctor’s office or the hospital, stating that all of the services that he would need would be centrally located at the hospital and that this may be the better option. Some individuals expressed having warning signs that their HF was worsening, “…I can tell when it’s fixing to start, I can tell” (Karl), while another said, “Since he’s had it so many times, we know when the symptoms are coming” (Logan). In contrast, others described a more sudden and rapid onset “It came back fast, it built up on him real fast” (Joy), and another individual also said, “just all of a sudden, just out of nowhere, it started again” (Jim). Multiple comorbid conditions also played a role in monitoring and interpreting symptoms. Individuals that had other health problems, particularly lung problems such as asthma and chronic obstructive pulmonary disease had greater difficulty discerning the cause and the appropriate response. For example, one interviewee said, “I thought it was my lungs that were the problem but turns out it was my heart” (Logan).Support Support was a key strategy to successfully managing and responding to HF. Support, expressed as intrinsic and extrinsic to the individual, came from many sources, including spiritual, family, significant others, HCPs, and others with HF. Individuals used this support as a source of strength, “I thank God for our family, the unit because you can pull off each other’s strength” (Logan) and was viewed as guiding HCPs in caring for people with HF. Family members encourage healthy behaviors, such as quitting smoking, avoiding sodium and taking medications, and aiding with daily living activities by moving in temporarily or offering their own homes as a place to recover. Others mentioned seeking the advice of friends who have HF to find out what worked for them, their experiences, and who they recommended for care, both individual HCPs and hospitals. One participant expressed that while he did not know anyone with HF, he thought this would have been an asset as he navigated the illness.Barriers to controlling HF. Barriers were things individuals identified that they had to overcome or prevented them from controlling or managing their HF and were rooted in the health system, relationships with HCPs, knowledge deficits, and personal characteristics.Healthcare systems issues The healthcare system presented many challenges, including sharing of information or coordination of care among facilities, such as the veteran’s administration and the local hospital, as well as problems within each facility. One participant said, “… just before it was time to go, to leave, there were all these different medicines. No one had a grip on what medicines that I was on. I mean, it was a mess” (Jim). Another individual felt that they were not getting what they needed from the hospital they were going to,I believe in going to the doctor, trying to find out what was wrong. And I felt like, okay, after two times in the hospital, and I’m still feeling the same way, I’m still sick, I’m still tired, and, I’m like, you know, this is crazy. What do I do? I’m not getting better. I felt like the system failed me” (Amos).“Frustration with the system and thinking they were following directions and doing what they were told but still not feeling better were commonly expressed. Additionally, individuals said that they understood that the goal of hospitals, insurers, and HCPs providers is for patients to stay out of the hospital. They also did not want to be hospitalized. However, their experiences and the reality of HF are that it is progressive, with periods of exacerbations and remissions requiring hospitalization.Challenges in provider relationships and interactions Healthcare professionals inadvertently communicating that a person can always control their HF and stay out of the hospital is not entirely true. These messages may cause a delay in care-seeking and a more severe presentation once individuals reach care. Every participant described some delay in seeking care. Understanding each individual’s rationale for delays is essential in care management. The other message people reported receiving is to go to the emergency room (ER) if they do not feel well. “You could call your doctor. You can’t get to talk to them, you know, —so you have to wait a day or two. You’re gonna have to wait to get in. They tell you, “If it’s important, go to the ER,“ so I went to the ER.“ Another commonly discussed problem was the uncertainty or lack of awareness that HF was the problem at the initial hospitalization, but once they were readmitted, all the stops came out. On index admission, Jim said, “They didn’t, they didn’t mention anything to us about heart failure, did they? … The readmission is when they actually began to run these tests, and they found out for sure what it was,“ while another, Reilly said “The first time, when I came home, I didn’t have any nurse. Now they’ve got me with the visiting nurse. She comes twice a week …”. Many participants discussed how the readmission was a “relief.“ They knew they needed to be hospitalized to feel better and get the help they needed for symptom control. John said, “he (the cardiologist) said, ‘Well, I’d rather you be in the hospital,‘ and I said, ‘I’d rather be there. This is one time that I need help really’.“All participants described challenges in their relationships with their HCPs. Mistrust of HCPs, poor communication between HCPs and patients and among HCPs, lack of advocacy by nurses, and missed opportunities were the negative experiences mentioned by participants about their interactions and relationships with doctors, nurses, therapists, and other providers such as emergency medical services. One participant felt that if the HCPs who are experts could not identify worsening HF, how could he? “And I was getting bigger and bigger and bigger. And I kept asking I said, ‘What are we gonna do about this?’” (Karl). Another individual spoke about the severity of his scrotal swelling and difficulty walking, yet, his concerns were not addressed. However, despite these factors, positive relationships enabled them to overcome barriers. For example, one participant described the HCPs practice as “the factory” and was cynical about the cookie-cutter feeling he got at the office. Still, he continued going there because he liked and trusted his HCP.Personal characteristics and beliefs Some personal characteristics and beliefs impacted the interactions with the healthcare system, and in turn an individuals’ illness control. One participant stated that she felt that the hospital administrators and staff just “do not care about patients” and will “just get you well and then go on and send you home” (Bernice), and others felt that there was hesitancy to get “specialists” (Logan) or “cardiologists” (Jim) involved. Individuals recognized that they were a barrier to managing their HF, alluding that their habits and ways are ingrained and difficult to change, such as smoking or dietary habits. One participant said, “Let me tell you something, I’m 72 years old. I don’t intend to change anything at my age now, and I don’t” (Joy), while another advised that those with HF should “Do as I say, not as I do” (John).Knowledge deficits Finally, knowledge deficits and misunderstandings were also barriers to managing HF. Some examples included a knowledge deficit on the correct time to weigh, misunderstanding the proper dietary restrictions, and misinterpretation of symptoms, mainly when there were multiple comorbidities, which contributed to the increase in illness management complexity. One individual said about daily weights, “I used to, wasn’t doing it.… but now I weigh two or three times a day” (John), while another said that after the readmission, “I do that now once I get out the bed morning time…” . When asked about a HF diet, one individual stated, “I have cut back on eating … more to lower calories” (Joy), confusing the diet for her diabetes with the diet for HF. Another participant said, “… well, the second time I was in ‘cuz they, uh, said I had, uh, what is it, COPD? And that’s part of the problem, my breathing and whatnot” (Logan) while others failed to understand the chronic nature of HF, “… my heart is good, uh I still got eight more years to go” (Reilly), while another said, “I’ll be glad when I get away from— (the water pills) and those big ole horse pills (potassium supplement)” (Logan).In addition to the strategies for managing HF and barriers to HF control, information about whom people with HF felt was responsible for control after experiencing hospitalization was discovered. The concept of control, who was in control, and how the HF was controlled, seemed to vary across participants. This finding follows the CSM theory, in which factors such as patient experiences, cultural considerations, and individual beliefs about the dimensions, such as timeline and control, drive the development of illness representations and direct self-regulation and behavior. Many individuals, while they knew that HF required them to adopt behavioral changes related to diet, fluid, and symptom monitoring and medications, relied upon others, such as significant others or HCPs to help regulate them, particularly the medications. Healthcare professionals reinforced illness management and self-care, but patients felt limited in what they could do. “… the doctor has told us that it’s something that we can manage but we can’t manage it but so far” (Logan).Another individual expressed understanding that medicines control HF but felt that the HCPs ultimately direct this area of care, and it can be a point of confusion “…just before it was time to go, to leave, was all these different medicines. No one had a grip on what medicines that I was on. I mean, it was a mess” (Jim).Another participant echoed the sentiments of medicine controlling their HF and other comorbid conditions when he stated, “That’s here what keep me livin’, so I’ll take it. I might as well take it” . In addition, illness control was related to individuals’ clinical characteristics, that is, time from diagnosis of HF or how long they had lived with HF. As might be expected, those who participated in this study and had HF for a longer period were more expert on their symptoms, what had to be done, and how to do it, compared to those who were newly diagnosed or had their HF for a shorter period.Overall, many participants worked hard to control their illness, did what their HCPs recommended, and still felt they needed more support and guidance. When they ran into trouble, they sought care, usually at the ER, because they had reached a critical point, such as being unable to breathe. Others believed they understood what they needed to do to control their illness but were not motivated to implement necessary changes and admittedly recognized this. Knowledge about the illness, personal symptoms, and what to do improved with time, meaning the longer they had HF, the better they were at controlling, managing and recognizing worsening HF symptoms.To our knowledge, this is the first study to examine the patient experience of illness control after discharge from a hospital readmission for HF. There were similarities across individual experiences and significant differences in patients’ perceptions of illness control. Two themes were identified. The first theme, strategies used to control HF consists of four subthemes. The subthemes show that after discharge, patients tried to control their illness by managing diet, medication, and symptoms and advocate for themselves with support from others. However, they faced several barriers to illness control, which was the second theme. The second theme also consisted of four subthemes. The subthemes show that barriers came from several sources, such as healthcare systems, HCPs, and their own, such as their negative perceptions and lack of knowledge. These findings present essential targets of interventions to improve illness control, such as more support from HCPs and significant others and more effective communication between patients and HCPs to enhance effective strategies for the management of diet, medication, and symptoms.Participants reported receiving information on medications, diet, daily weighing, and their importance and verbalized the necessity of these illness management strategies. However, it was clear that their understanding was incomplete and often inaccurate, and they had difficulty implementing the strategies once they were at home. In addition, even when they knew what they should be doing, some could not because they could not afford or access the equipment and tools  and the right foods . It was also evident that individuals knew to record the data, such as daily weights, but were not sure what else to do with that other than to “bring it to the doctor” or for those using telehealth or other nursing services such as home health, that the “nurses are looking at that.” In other words, they frequently did not know how to act on that data because they were not informed, empowered, or confident or did not understand the relationship between weight, fluid retention, and HF illness management. Individuals with an understanding seemed to question their decision-making and so poignantly stated that if the HCPs had difficulty identifying and managing their HF, how could they be expected to do so? They had difficulty identifying the source of symptoms, particularly when they had comorbidities. These findings align with the propositions in the Situation-Specific Theory of Heart Failure Self-care , 25 thatAdditionally, beyond self-confidence or the belief that something can be done is self-efficacy, which according to Bandura  is the bHaving a voice and being heard about symptoms and other aspects of their HF was essential to participants, and many stated that either they or their family members advocated for their needs. While this may go against the notion that they do not manage well, it reveals the tension and difficulties between being motivated to self-manage, thinking they are self-managing, and being appropriately equipped and prepared to do so. Dunbar and colleagues  suggest However, in this study, participants wanted their HCPs to appreciate their “self-expertise” or being the expert on their bodies. This is consistent with the collaborative care or partnership model, in which professionals are experts about the disease, but patients are experts about their own lives . The twoA significant theme related to the concept of illness control and self-care emerged. Over time, individuals described acquired expertise, a self-knowing, an accumulation of knowledge that they acquired both about their symptoms and how to control them as well as what works best for them. For example, individuals with longstanding HF knew what to do, were more likely to question their providers, and self-advocate for things they felt they needed. This is consistent with the findings of Clark and colleagues  who repoThe current study aimed to explore chronic HF patients’ experiences in controlling their illness , understand their perceptions of illness control after a recent HF hospital readmission and gain clarity around the concept of illness control. Qualitative research is hypothesis-generating and not intended to be generalizable; thus, this is not a limit so much as an opportunity to deeply and richly explore an individual’s experience. This sample, which allowed data saturation and a wide representation of age, time living with HF, and race was representative of the region the recruitment site serves but may not represent different experiences of those living in other regions, countries, or types of communities, such as a larger city. The sample was also skewed male, despite significant efforts to recruit female participants. Despite these limitations this study contributes essential information on illness control from those living with chronic HF. However, future research, quantitative and mixed methods, can further assess and explore differences between individuals living in rural vs. urban areas, different segments of socioeconomic status, educational level, and sex. Additionally, quantitative research may be able to identify predictors of good and poor illness control and hospital readmission.Controlling HF is attempted using many different avenues by patients. This control comes from both within and outside of the individual and includes things such as medications and self-care behaviors, but it requires supportive relationships from family, significant others and HCPs. For many individuals, the desire to control the condition and its symptoms is evident but putting the pieces into place is challenging and takes time, experience, and trial and error to determine the best course of action. Individuals did not view readmission negatively; they deemed a return to the hospital as their only option due to how they felt. This suggests that individuals require assistance, coaching, or guidance in the places and spaces they return to after hospitalization.Determining what the individual wants or how engaged and activated they are to participate in the necessary changes is critical and should shape the treatment plan and conversations on managing their HF. One way of overcoming these barriers was having a trusted HCP. Strengthening these relationships may be a key strategy for helping individuals improve their self-management skills and abilities. Finally, examining communication with individuals and families about their HF, its controllability, and how it is managed. Confusing or mixed messages and focusing on the problems rather than the strengths may impair patient engagement in self-care.


Medicine can be properly considered a “Science” only until we consider Medicine in theory, medicine as a concept.But if we consider medicine as the actions we take on the sick patient, then Medicine tends to lose some of the properties of science becoming more of a “Medical Art”.Indeed, all scientific processes share two fundamental features: measurability and reproducibility. Medicine is certainly characterized by measurability; nevertheless, it is, frequently, weak in reproducibility, owing to the tremendous interindividual variability: every human being is unique and even identical twins are different.The object of interest of Medicine, the patient, is a unique human being: unique as an organism and in terms of history, experience, and relationships ; unique as to what concerns their clinical history .It has become more and more common for modern doctors to simplistically classify, label, and treat their patients according to their specific condition. As a result, these patients will be assimilated into structured paths (protocols) and will keep following those paths. This reminds us of Procrustes.In Greek mythology, Procrustes Fig. A was a vAccording to some authors, Procruste’s torture bed was wooden; according to others, it was made of rock. The bed had standard width and length and Procrustes used to make his victims lie on it forcing them to fit the bed by cutting off the parts that hung off the ends or, on the opposite, by stretching those people who were too short.This “Procrustean sin” unfortunately afflicts several younger doctors in these days Fig. B, makingA spasmodical look for protocols , 2 on whMature doctors must of course know medicine as a science and keep themselves updated with literature, but they should never lose their curiosity  and humb


Yoga, an account of his bipolar disorder and his preoccupation with meditation, when he was ‘almost sixty’ years old. One has to be a little careful in reading this book. In his own words some of it is fictional and his ex-wife alleges that it ‘is completely false’.Distinguished author Emmanuel Carrère wrote Attending a 10-day meditation retreat, he describes at length his innermost thoughts. However, there is a sense of his not ‘being in the moment’. He plans to write his experiences up as a ‘subtle little book on yoga’ and is constantly observing and recording, defining meditation in 25 different ways.Charlie Hebdo and Carrère returns to support the man's partner. Soon his thoughts come ‘thick and fast, twist like flames, burn themselves out and ignite all over again’. Unaware that his mood swings were unusual, he had previously seen himself as ‘wafted gently by the current between the two poles’, the yin and yang of affect. Now he remains in his shapeless corduroy trousers, an old sweater full of holes and trainers without laces, oscillating between bed and smoking in a dazed stupor in the local café. Admitted to hospital for 4 months, he is uncertain whether the ECT was helpful. His memory loss concerns him, as he cannot recall the events of his stay on the secure ward.On 7 January 2015, Bernard Maris was shot dead at the headquarters of the satirical magazine Writing about one's journey into mental illness one has to steer between the Charybdis of self-absorption and the Scylla of objective rationality in order to inform and maintain the reader's attention. All too often the internal chaos, despair and horror becomes all absorbing and is only interesting to oneself, rather like telling others your dreams. Carrère introduces an outside perspective when a journalist describes how he looked ‘forlorn and abandoned’, but this book still hovers on the fringe. There is a vivid passage describing the horrors of depression but, overall, it illustrates his personality more than his illness.The Ordeal of Gilbert Pinfold, in which the author dresses up his own experience in fictional terms.Psychiatrists should be aware of the subjective experience of mental disorder, and personal accounts are essential reading. However, I have already suggested that, without editing, such stories can become tedious and self-absorbed. Maybe we should see this book as being in the tradition of Evelyn Waugh's


With decades-long experience writing papers and as department chair, we have proposals, which have not been discussed previously. Changing the tradition regarding “who writes a paper” and strengthening the senior staff’s responsibility may increase productivity.As per Saeki’s view (2) beyond who writes it.A case report is often written by trainees of patient’s own attending (referred to as “attending” (tanto-i) hereafter). Senior staff can encourage them to write and offer help; however, if attending trainees lack personal motivation to write “now”, forcing them to write is difficult. In such cases, the senior staff must decide who in the department will write, under the condition that the physician understands a patient’s course and significance, regardless of whether he/she is a trainee or an “attending”. Depending entirely on the attending may lead to valuable cases not being reported, which would thus be lost forever. Reporting a unique patient is doctor’s/department’s responsibility The senior staff should be willing and prepared to write. However, one may be concerned that physicians other than the attending writing papers may lead to a bad departmental atmosphere. In such situations, the senior staff should write the paper as first author. As per the Japanese tradition, professors do not write first-authored case reports, which is peculiar. A case report is no less important than an original article, since the significance matters more than the type of the article. If a speedy publication is required and for some reason the trainee is unable to start, immediate writing should become the responsibility of the senior staff.Productivity discussions should be divided, future versus now. Educating a trainee is the senior staff’s responsibility, which can be seen as a future investment. Junior attendings are the most suitable individuals for writing. However, making it is essential to create an atmosphere where anybody can write, regardless if they are the patient’s own attending or not. This may help increase productivity. Taking time to educate or to write immediately, senior staff must decide which strategy is the best on a case-by-case manner. Experience is not the exclusive possession of attendings but a departmental or medical society resource.NoneS. Matsubara: Identification of the significance and manuscript writing. AKL: Manuscript editing. The authors are responsible for the conceptualization and the writing of the manuscript.Not applicableNot applicableNot applicable


Study of neuroticism can provide important insights. Before the inclusion of neuroticism in the study of Alzheimer's disease (AD), clinical and scientific researchers used relatively fixed models to treat AD, such as prescribing fixed doses of drugs and fixed research strategies. However, taking neuroticism into account affects drug use, the direction of scientific research, and even the mental health of the population, which translates into more immediate economic benefits It is often said that “the brain shapes the character”, the idea that “the character influences the brain” is little discussed.We often believe that “The more you practice, the better you are.” However, this is not entirely true when we look at individuals who are described to be neurotic or prone to distress. It seems that their brains are wired differently: they often have an active mind but unstable control of their emotions, which makes them more prone to negative emotions .Exploration of the pathogenesis and treatment strategies of Alzheimer's Disease (AD) shows that there are remarkable similarities between neurotic and AD brains, such as a higher deposition of pathological markers ,The enormous burden of AD on patients and their families, the economy, and the society has long been known. Although extensive research on the mechanism of AD has been ongoing for decades, no major breakthrough has been achieved. More importantly, the origins of pathological proteins seen in AD remain unsolved. Understanding the true causes of Alzheimer's requires that at least two major challenges be addressed: (1) the complexity of the disease itself and (2) the “researcher confusion” or “ lack of specificity” caused by the sheer volume of inconclusive research. Thus, study of neuroticism may provide a huge boost towards resolving the second challenge.Some common themes in current AD research include inflammation, neuronal cell death, pathological protein aggregation, synaptic and neuronal network defects, aberrant proteostasis, cytoskeletal abnormalities, altered energy homeostasis, and DNA and RNA defects.It is a well‐known fact that chronic negative experiences cause severe damage to the brain. As a result, many neurological researchers have hypothesized that neurotic brain damage can increase the risk of developing dementia. Currently, these hypotheses have been confirmed to a certain extent through molecular biology, proteomics, genetics, radiology, psychology, and clinical studies. Antonio Terracciano et al.In our previous neurological study, we considered the brain as the root of the personality, especially neuroticism, but ignored the effects that the personality could have on the brain. While we focus on the idea that emotional characteristics, such as personality, are brain‐derived, recent research indicates that some emotions can be cardiogenic.6‐methyladenosine quantitative trait loci (m6A QTLs).6A QTLs can cause similar responses in different organs and regulate the overall reactivity of the body by controlling the transcription expression. High expression of m6A QTLs is associated with neuroticism, depression, and anxiety in the brain, asthma in the lung, and coronary artery disease in the heart. Thus, we can speculate that neuroticism will also have similar effects on the body through a certain pathway, like m6A QTLs, to improve the body's reactivity, so as to make it easier to reach the threshold for the occurrence of AD pathological lesions. (3) Personalized interventions can be designed. The intervention for neuroticism is different from a conventional lifestyle intervention, as the former is specific and the latter is general. Individuals with high levels of neuroticism have higher resting activity in the left middle temporal gyrus, left striatum, and right hippocampus and lower activity in the left superior temporal gyrus and right striatum.Currently, study of AD in terms of neuroticism has three obvious advantages: 1) it can provide a new perspective of observation: macro to micro. Since neurodegenerative disease like AD can mediate macro performance  through the “molecular‐protein‐structure/function–behavior/personality traits” pathway, the ability of macro performance to influence the micro changes of the brain through the “behavior/personality traits‐structure/function‐protein‐molecular” pathway remains to be explored. In other words, AD can induce changes in the personality, but little is known about whether personalities can affect the onset or development of AD. (2) The evaluation dimension can be reduced and this can enable specific focus on the problem. Neuroticism is a comprehensive indicator, which is related not only to pathological markers but also some hormones and submicroscopic molecules, such as glucocorticoids it can pYet, a number of obstacles remain to be overcome in the study of neuroticism Figure : (1) EvaFinally, for those with high levels of neuroticism, the following question may arise: “Are there any other ‘rescues’ in the absence of a specific effective intervention strategy for neuroticism?” Some studies have shown that neuroticism develops primarily early in life and is relatively stable in adulthood.Neurology's “At my wits' end” comment on Neuroticism and AD 20 years ago,Clinical experience has long taught us that the nervous system and mental health are inextricably linked, but how the two interact remains unknown. The main reason for this lack of clarity is that we cannot even find a suitable research topic that can act as a bridge for us to study both. Since Yifan Yu: Idea conceptualization, article collection, and curation, original draft writing. Yifan Yu and Ruitong Yan: Manuscript drafting and visualization. Xiaohe Tian: Review, editing, and supervision.Prof. Xiaohe Tian is the associated editor of Ibrain. He has fully revealed these interests, and has worked out a plan for approval to manage any potential conflicts caused by the participation. Other authors have no conflict of interest to disclose.This article does not contain any studies with human or animal subjects. Ethical approval is not applicable for this article.


Effective healthcare coordination is vital when such care is provided as a collaborative effort by many individuals and their task activities are interdependent. Coordination is necessary to ensure that care not only meets the needs of patients, but also avoids negative consequences for them due to omitted, inefficient, unnecessary, or even incorrect treatments. It also helps conserve resources. This has contributed to a rapid increase in articles on this subject.Still, while care coordination topics are gaining the attention of researchers, there are a number of issues experienced, including the delineation of limitations, inconsistent definitions, and problems with measurement. Therefore, the aim of this article is to refine the concept of homecare coordination and provide a comprehensive theoretical framework, illustrated with examples from practice.Focusing on this goal, we have reviewed the extant literature on the subject to develop a theoretical homecare coordination framework. The first intermediary goal was to integrate relevant concepts across multiple theories and frameworks into a unified synthesis. We do so in two parts: (1) analysis of extant coordination frameworks and theories; and (2) the presentation of our newly developed theoretical framework for homecare coordination.The new framework differentiates clearly between coordination as a process—i.e., what people do to coordinate and coordination as an outcome—i.e., the state of coordination. Applying this distinction to both, measurement and interpretation of results helps avoid misleading conclusions. As a research outcome, our framework builds upon the extant coordination literature, considers the complex relationships among the various coordination-related factors and, while focusing on homecare, is applicable to various healthcare settings in general.A nuanced differentiation and explanation of the elements involved enable a more consistent operationalization of the coordination concept. Additionally, as they explicitly address the healthcare system's micro, meso, and macro levels, they can be applied across diverse healthcare settings to investigate homecare coordination. •Care coordination is essential to meet the needs of patients.•The lack of clear care coordination conceptualization hinders research.•To overcome this problem, we developed a theoretical care coordination (COORA) framework.•COORA distinguishes the different elements of the coordination process and the achieved level of coordination.•Distinguishingcoordination processes, (coordinating) from coordination as outcome of the process can guide future research. As a reEffective care coordination helps care providers deliver patient-centered care that meets patients' needs, largely by avoiding scheduling conflicts and simplifying the management of task dependencies. By reducing omitted, inefficient, unnecessary, or even incorrect treatment—any of which can lead to negative patient outcomes—efficient care coordination avoids both unnecessary patient burden and resource waste . ConsequThe conceptualization and measurement of care coordination in and across healthcare settings remains a challenge; and the blending of different concepts and models under the umbrella of “coordination” is pervasive in the literature. A recent example is a scoping review by Peterson et al. , which pResearch in coordination in healthcare faces a variety of issues. The first is that, depending on the context in which it is used, coordination may be interchangeable with terms such as teamwork, collaboration, or integration. Such lexical instability can complicate efforts to assess and compare studies and their results ,8. In adThe second problem is a lack of agreement on the multiple definitions of coordination, some of which are so vague that they demand interpretation. In addition, where summaries and descriptions of coordination elements  are overly broad, they make it difficult to operationalize coordination, which is essential to make it measurable in clinical settings ,9,11. OnThe third and biggest problem involves measurement. In this case, instruments developed to measure coordination rather measure care continuity or other related concepts . In addiGiven the problems outlined above, this article aims to refine the concept of coordination aiming to provide a comprehensive theoretical framework to capture homecare coordination. As we develop the framework, we illustrate its various aspects with practical examples, which will provide the basis for the operationalization and measurement of homecare coordination.2Our central component is the development of a comprehensive theoretical homecare coordination framework, aiming to integrate relevant concepts across multiple theories ,15. As nAs a first step, we screened the studies referenced in these four literature reviews. We then identified additional studies and related article by searching Medline via Pubmed®. Next, we extended the literature search to include coordination in other research fields  by iteratively searching studies referenced in identified articles using Google Scholar. We then searched new aspects described in relation to the various models and theories—i.e., different elements/underlying concepts of coordination —via Pubmed® and Google Scholar to gain a stronger understanding of underlying or related concepts as we elaborated our framework.In parallel with the literature search, which was conducted from March 2020 until March 2021, we iteratively discussed and evaluated the models, frameworks, and concepts within the research group. In addition, to deepen our understanding and include a range of expertise in the development of our new theoretical framework, we held discussions with two authors of earlier coordination frameworks ,12.Since the healthcare field is very broad and diverse, we focused in this paper more specifically on homecare in order to connect theoretical concepts with practical examples. We view homecare in this study as formal care provided to patients at their homes, including not only medical and therapeutic care but also basic care , domestic support  and social care . To better understand the context in general and to gain familiarity about the context of the focal task, we held discussions with different homecare nurses, homecare nursing experts, and homecare patients and their relatives about their understanding of coordination and possible interrelationships with other elements and concepts. We purposely selected nursing experts because of their experience in this field and invited them for discussions and focus groups. Homecare patients, their relatives and nurses were also invited to focus groups by two homecare organizations in consultation with the first author.3(1)preconditions for the need for coordination and(2)the coordination literature, with its definitions, frameworks, and theories.Our literature review revealed that there are conditions that make coordination necessary and determine the extent to which it is needed. Therefore, we divided this section into two parts.3.1Before elucidating the different elements of coordination, it is important to consider that not all work can benefit from coordination. We identified three key preconditions to coordination.Task activities have dependencies. The most important consideration is that task activities included in the work must contain dependencies. Naturally, because task activities are carried out by individuals, task dependencies will inevitably lead to member dependencies. Without dependencies, there is really nothing to coordinate ." (p.41)Schultz and McDonald  found 57In other research fields, reviews of coordination  also cite numerous definitions of the term “coordination” ,10,17. FBased on the definitions above, coordination can be seen either as an outcome or a process. A process is a series of actions taken in order to achieve a result (definition of process by Cambridge dictionary 2021). Thus, coordination as a process are the things people need to do to coordinate. The result of these actions is a coordination state or outcome . A good 3.2.2In the following section, we briefly describe the terminology of the related frameworks and theories we referenced in our framework development, along with a discussion of their similarities and dissimilarities. We start with those from the extant organizational and coordination research literatures and continue with those that have been adapted or extended specifically for use in healthcare.modes of achieving coordination : through programming and through feedback. Programming is an “impersonal” coordination mode involving the proactive application of action plans, rules, standardized information, and systems. Feedback is a “personal” coordination mode involving formal and informal, one-to-one and group communication, in response to actions by individuals or groups and focuses more on the actors. Van de Ven et al. described feedback-based coordination as “mutual adjustments based on new information” (p. 323) through either one-to-one or group communication.Van de Ven et al.  describecoordination theory and stated that coordination is “the additional information processing performed when multiple, connected actors pursue goals that a single actor pursuing the same goals would not perform” (p. 5). He classified goal-relevant tasks as either coordination tasks or production tasks: “Coordination tasks are the information processing tasks that are performed because more than one actor is involved. Production tasks are all the other tasks that are performed in order to achieve the goals” (pp.5-6). In other words, production tasks are needed to complete the task, whereas coordination tasks are needed to work with each other.Malone  introduccoordination mechanism as “a mechanism that helps teams manage dependencies” (p. 6). They differentiated explicit from implicit coordination mechanisms. Coordination processes are the implementation and use of such mechanisms. Explicit mechanisms are purposely and consciously used by participants to handle task dependencies. Implicit mechanisms are based on “shared knowledge  enables them [participants] to explain and anticipate task states and actions of participants, thus helping them to manage task dependencies” (p. 10). They further differentiate two types of coordination outcomes: coordination as the “state of coordination”, i.e., the extent to which dependencies are effectively managed; and performance or effectiveness, which occurs when key dependencies are successfully managed. These can be regarded as coordination processes and outcomes, respectively. And while Espinosa et al. acknowledge that the verb/gerund coordinating and the noun coordination are often used interchangeably, they distinguish between the two: “the process of ‘coordinating’ can be defined as the activities undertaken by the participants in managing dependencies” .No data was used for the research described in the article.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


As Nature’s version of machine learning, evolution has solved many extraordinarily complex problems, none perhaps more remarkable than learning to harness an increase in chemical entropy (disorder) to generate directed chemical forces (order). Using muscle as a model system, here I unpack the basic mechanism by which life creates order from disorder. In short, evolution tuned the physical properties of certain proteins to contain changes in chemical entropy. As it happens these are the “sensible” properties Gibbs postulated were needed to solve his paradox. A binary mechanical system provides a unifying description of molecular mechanics and emergent thermodynamics and provides an explicit solution to the Gibbs paradox. In 1876 J.W. Gibbs identified a paradox in his chemical thermodynamic treatment of entropy that has confounded scientists from Boltzmann to Einstein and that remains an intriguing puzzle to this day, 3 proviA version of the Gibbs paradox is illustrated in  state B , left, t B and Y , right. The spontaneous change in color in Most proposed solutions to this paradox are based on arguments invoking a mutable ΔS. Maxwellvariable”.The common assumption, made here by Planck and elsewhere by others, that entropic changes must be continuously variable is the basis for the infamous arbitrary division by N! employed by Boltzmann in his analysis of the Gibbs paradox. HoweverBiological systems like muscle have evolved to contain entropic forces within cells by tuning proteins to optimize their sensible properties and According to Boltzmann, the entropy, S, of a system is According to Gibbs, the entropic contribution to the free energy that drives the mixing reaction  is thenBecause a color change has little physical impact, here I consider a version of the two-state scheme in d .d , 6. For d . FocusinIn single molecule mechanics studies, we have shown that a single chemical step from B to Y displaces a spring of stiffness e, κsysd,–8 where m lengths. We havem lengths, 10 thatA single system spring of stiffness ic) force.When the system in ext=−ΔF1 , left, t1  only when placed in a proper container. The primordial soup consisted of chemical reactions dominated by thermal energy and increasing entropy, and despite the exacting physical relationships required  and 7, ba priori foundation for the principles of biological function. The above thermodynamic relationships (Large containers nic myth , 13 thationships  transforionships  and have


Real-time quantitative PCR is a technique that can measure the content of the target nucleic acid sequence of interest in a given sample. It is mainly divided into absolute and relative quantitative methods. The relative quantification is mainly used in gene expressions for functional genomic and transcriptome studies. However, to use this technology accurately, there are some key points to master. First, specific primers need to be designed to ensure amplification of the gene of interest (GOI). Second, the appropriate reference gene or reference gene combination has to be selected. Finally, scientific gene expression level calculations and statistics are required to obtain accurate results. Therefore, this work proposes a workflow for relative quantitative PCR and introduces the relevant points so that beginners can better understand and use this technology. Real-time quantitative PCR, also called quantitative PCR (qPCR), combines PCR and fluorescent dyes to monitor template amplification with high sensitivity and specificity. At present, qPCR has been widely used in gene expression analyses, genotyping, microbial quantification, virus detection, and more ,2. There−ΔΔCt is commonly used to calculate the relative quantification of gene expression. However, when using this formula, there are some limitations for “2” calculated by formula “1 + e (PCR amplification efficiency)”, that is, the PCR amplification efficiencies of all primers for both the reference gene and the gene of interest (GOI) should be 100% or close to 100% at the same time, or at least between 90% and 110% (or 105%)  so that the Cq′ values and the Cq values are on the same scale [t test if only two samples are compared.For statistics, experimental design should be the starting point, such as the inclusion of at least three biological replicates for each sample and 2–3 technical replicates for each PCR reaction, ensuring that all biological replicates of all samples are on the same plate. When the experiment has a lot of treatments and one plate can no longer fit all the samples, multiple plates are needed, and each plate is best placed with one biological replicate of all samples; each plate can be regarded as a statistical block. Then, the NRQ data need to be transformed according to formula [Cq′ = logme scale . The Cq′In order to make qPCR analysis more scientific and accurate, this workflow of qPCR has been established D, which


The current paper undertakes interdisciplinary research on empathy in children by combining insights and methodological tools from the fields of psychology, education and anthropology. The researchers aim to map how children’s individual empathic abilities studied on a cognitive level do or do not coincide with their empathic expressions as part of group dynamics in daily life at the classroom level.We combined qualitative and quantitative methods within three different classrooms at three different schools. In total, 77 children aged between 9 to 12 years participated.The results indicate how such an interdisciplinary approach can provide unique insights. Through the integration of data from our different research tools we could reveal the interplay between different levels. More specifically this meant showing the possible influence of rule-based prosocial behaviors versus empathy based prosocial behaviors, the interplay between community empathic abilities and individual empathic abilities, and the role of peer culture and school culture.These insights can be seen as encouragement toward a research approach that extends beyond the single disciplinary field in social science research. Since the advent of the social brain concept, brain scientists have become increasingly interested in the social sciences, and this is an opportune time for interdisciplinary collaboration : 64.Interdisciplinary collaboration is the starting point of the current study. We aim to integrate theoretical perspectives and methodological approaches from the disciplines of psychology and anthropology to study empathy in children. Human empathy refers to the capacity to understand and/or feel what others feel, from within their frame of reference. It is essential for children’s social and emotional development and also for successfully starting and maintaining social relationships . EmpathyBefore we introduce our research questions, we will give some context on the different perspectives within the topic of empathy that we will integrate. With the integration of perspectives as mentioned above we hope to contribute primarily to the broader study of empathy by investigating empathy both as an intra-individual ability in an experimental context, and as an observable inter-individual process in a daily life context – in this case, children’s school lives. The idea of combining insights from the psychological aspects of human interaction and cultural and social real-life factors is not new . HoweverIn the current study, we investigate the inter-individual nature of empathy with qualitative and quantitative approaches. We make use of qualitative  and quantitative  measurements, but we also add the use of social network analysis (SNA) to quantify the qualitative relationships between children. SNA combines qualitative and quantitative starting points since it focuses on both relationships and computed patterns . WhereasFinally, we investigate empathy in a relatively understudied developmental population, namely children from 9 to 12 years old. In this age range children are generally capable of understanding complex social emotions, are aware of the needs of others, able to show empathic behavior, and capable of the basic reasoning associated with prosocial behavior . At the How is the child’s individual ability to empathize related to their empathic expressions as observed in the socio-cultural environment of their daily school lives?How can the use of social network analysis help us to understand the interplay between empathy as an individual construct and empathy as part of a classroom community of practice?In sum, the aim of this study was to investigate empathy as an intra and inter individual construct in middle childhood, using ability tests and questionnaires, observational methods and social network analysis. Embedded within this background, which will be further elaborated on in the theoretical framework section, two research questions form the core of the study:In the next paragraph we elaborate more on the theoretical underpinnings of this study, discussing the different approaches to empathy across fields. Next, we present the details of the methodological approach, followed by the results and discussion section and our concluding remarks.within the individual, whereas empathy is said to be both an intrapersonal and an interpersonal construct. The latter approach – in which empathy is construed as a process – is much more highlighted in anthropological work.ibid). Anthropologist fictive others or actors, anthropologists attempt to gain access to the ‘daily life’ of real others, thereby investigating expressed empathy. The weakness of this approach is that the individual ability to empathize and the developmental trajectories of children’s empathy are often not incorporated, so individual (dis)abilities, boundaries or challenges can be overlooked or wrongly be interpreted as part of an interpersonal process.In our research we want to capitalize on the strengths of both the psychological and the anthropological approaches. The context of the research is the classroom and we believe this is an ideal place theoretically and practically to execute our research. First, the focus on individual and interpersonal and their interaction fits naturally within an educational context c.f. . Expressvia non-structured participant observation.Building on an interdisciplinary design, by which we aimed to investigate empathy on different levels using research techniques from different scientific fields, the use of a mixed methods approach  was mostvia the first author – who is also a middle school teacher. Within her network we selected three schools with sufficient variation in location in terms of population density, and social and economic neighborhood characteristics. Further, it was important that principals, parents and children wanted to participate. The first author explained the research to the children in the classrooms before starting the research. Children were able to ask questions about the participation (which they did) and chose via a consent-paper if they wanted to participate themselves. School 1, Classroom 1 (Cl.1)  was in a smaller village close to a big city. Income in the school area was between 33.500 and 35.800 which is above Dutch average (26.000) and citizens in neighborhood were from 0.8% non-Western and 99.2% Western background. School 2, Classroom 2 (Cl.2) was situated in a more rural, not too small, town. Income in the school area was between 30.200 and 30.500, which is lower than in Classroom 1, but still above Dutch average. In this neighborhood 2% of the citizens had a non-Western background and 98% had a Western background. School 3, Classroom 3 (Cl.3)  was in an urban environment. Income in the school area was between 23.800 and 25.600 which is below Dutch average. In the neighborhood 28–44% had a non-Western background, whereas 56–72% had a Western background. In total our sample of three classrooms consisted of 77 children, which can be considered a sufficient relatively large sample for qualitative research (This research took place at three different schools in the Netherlands. Part of the collected data – the LEAS(C), social network analysis and observational data from one classroom – was included in a short paper on the value of a mixed-methods approach in empathy research . In the research . For theN = 77).Reading the Mind in the Eyes test for children RME-C, , investiN = 51)” (N = 77).Level of Emotional Awareness Scale for children LEAS-C,  to measuN = 51)” :579. In ibid.) and then decide how much this statement would be applicable to them: from 1 = never true to 4 = always true. The range is 0–44 points. In N = 77). To study children’s empathic expressions in their everyday context, we used social network analysis (SNA) in combination with classroom observations. By the use of SNA we investigated the social context in the classroom in a quantitative way  any behavior that benefits others, such as sharing, cooperating, including others in play, complimenting, and comforting others” , p. 527.For all schools and classrooms, we required written informed consent from both the children and their parents. We individually asked every child and parent for consent  and in Cl.1 and Cl.2 participation rate was 100%, in Cl.3 92%. The parents of two children did not want their children to participate. The study was approved by the Ethical Committee of the Faculty of Behavioral and Movement Sciences of the Vrije Universiteit, Amsterdam. The three psychological tasks and the social network task were carried out in a random order by each child individually, outside the classroom, with only the researcher present and on the basis of complete confidentiality. The quantitative measures were administered by the first author together with a colleague (Msc.) who was also trained in social science (psychology/pedagogy). Per classroom all children completed these tasks on the same day and in total, it took participants 30–45 min to complete the tasks. The observations were conducted by the first author  who was participating in the classroom for 1 day a week for a period of 3 months.all three psychological tasks  were labelled high or low scorers, respectively. To perform the social network analysis, we used UCINET . The qualitative field notes collected through observation were thematically analysed using open, axial and selective coding , version 20. Based on the means and sum scores of the three cognitive tests – LEAS-C , RME  Shared practices: classroom identity; (2) empathic practices: classroom processes; (3) individual practices: classroom cases. Second, we present children’s individual ability scores and third we present the social network analysis per classroom. Both ability scores and social network outcomes will be discussed in relation to the earlier described observational findings.Guided by the work of In Classroom 1 (Cl.1), it was important to give the right answer – “I know, I know I know” –, whether it was a mathematics-related question or a social behavior-related question. Children tended to competitively discuss their answers with each other and the teacher. One day during a change-over between two subjects – which requires changing places, using other books, etc. – was taking too much time and the teacher asked the class whether and how they could speed up the process next time. Different ideas were brought up by the children and eventually the ‘kudos system’ (Dutch: ‘pluimensysteem’) was chosen: the first subgroup (the class was divided into 7 subgroups) to be ready for the next subject would receive a ‘kudo’. Once a group collected five ‘kudos’ they would be rewarded, being allowed to choose a 15-min activity that they like. During the first subsequent change-over, the competitive drive of the children immediately guided their behavior: everyone within the subgroup helped each other to prepare as fast as possible and when the fastest group received a ‘kudo’ they celebrated loudly: “Yeahhh we are the champions!!.” Interestingly, the children came up with the ‘kudos system’ themselves, which implies that they knew how important being the best/fastest/highest was for them. Three keywords for Cl.1: competition, punishment/reward, performance.In Classroom 2 (Cl.2), the children invited the researcher to join in their play, made compliments about the researcher’s clothes – “Miss, I really like your shirt” – as they would do to their peers – “Wow I love your new hair cut” –, and were quite open in sharing their thoughts and feelings. The enthusiasm with which they approached the researcher as an adult and the character of their games sometimes gave the impression that they were younger than their peers in Classrooms 1 and 3 (which was not the case). Moreover, the tendency to give compliments rather than to make a sarcastic joke about someone’s clothes (Cl.3) or only give compliments to your friends (Cl.1 and Cl.3) gave a different feel to the classroom dynamics. Additionally, the teacher in Cl.2 had a different position in the classroom interaction compared to the other teachers: he came across as not so much an equal partner in dialog (Cl.1) or a potential power rival (Cl.3), but a good-hearted authority whom they respected, immediately listened to and with whom they shared their weekend stories. Three keywords for Cl.2: being nice, team spirit, enthusiasm/naivety.Classroom 3 (Cl.3) field note:If I were to describe this classroom, I would say it is a snowy landscape. Fickle – you can lose your way or be severely injured. You can become buried in avalanches of words and jokes. But, if the sun comes out, it is the most beautiful place.In Cl.3 often the peer-to-peer and the child-teacher interactions resembled avalanches: a child or the teacher would say something, someone else would respond, and immediately someone else would react to that response, and so on. During these interactions, power dynamics played an important role: the children who joined in the conversation often attempted to make the funniest, loudest or most shocking remark. This resulted in a certain flow of negative, sarcastic or harsh remarks at the cost of someone in the classroom. Below, is an illustrative conversation between two boys:•Yassin*•Marouan: ‘You are such a drama queen’.•Yassin: ‘Shut up you Moroccan’.However, the direct and outspoken responses could also be warm and concerned, which occurs, for example, when Issrae did not come back after school holidays, because her mother – without telling anyone – had decided to stay permanently abroad. In the one-on-one conversations between the researcher and both ‘the quiet’ and ‘the loud’, this warmth also predominated. Three keywords for Cl.3: power position/ status, competition, acting tough/two faces.In the description of the classrooms there were three themes that were of significant influence of the empathy-related processes in the classroom: (1) ingroup versus outgroup, (2) adult rules versus child rules, (3) the negative versus the positive. The differences between the classrooms in relation to these three themes seemed crucial for the different community empathic abilities that were observed when we compare the classrooms on empathy-related processes.During physical education: Inge, who is not so popular, falls and starts crying. She is clearly ignored by all children except for Marianne (her best friend), who pats her on the back.in follows, and the answer is ‘Yes, Julia is “in”’. A little later, the same girls are playing football outside. The rule is that only four people can join a team. It turns out that Julia has to leave. She walks away, angry, disappointed and with outrage on her face she shouts: ‘I will never join you again’.In the changing room : Zoë asks Bente: ‘Is Julia still with the blondies?’ There are two groups, the blondes and the brunettes – a subdivision within an ingroup of girls. A short discussion between four girls who are obviously In Cl.1, there were continuous processes of inclusion and exclusion in the ingroups, which affected empathic behaviors, especially among the girls. This can be exemplified by two situations:In the classroom: All of the children listen attentively to the talk that Yvonne gives on her favorite sport, judo. When Yvonne shows some moves on the judo mat she brought along, she needs a volunteer. Marc spontaneously pitches in to help her. Some boys joke about the girl-boy situation that appears when Marc puts on the judo kit that Yvonne brought along, but Marc does not seem to care and takes his volunteer role very seriously. The rest of the classroom ignores this possible girl-boy ‘thing’ and remains interested and Yvonne is given a high grade and generally receives positive responses from the classroom.At the playground: A mixed group of boys and girls are playing the game ‘kiss for a bliss’. Hiske quits the game because she does not feel like playing anymore and feels some boys are acting childish. She realizes, however, that Christiaan, who is apparently in love with her, might think that she quit because of him. She shares her concerns with me and tells me that she is not in love with him but she also does not want to hurt him. Christiaan stops playing the game as well and indeed looks a bit disappointed. He sits near the sandpit for a while, and Tom comes over to him with a serious face and asks: ‘… What’s the matter? … Are you heartbroken?’ Christiaan denies this and says that he lost something in the sandpit and was looking for it. Tom then leaves it at that and asks Christiaan to join in another game.The processes of inclusion and exclusion influenced the way the girls treated each other in certain situations and whether they did or did not express care, comfort or understanding. There were even envelopes with notes about other classmates that circulated among several ingroups, dividing subgroups within larger ingroups. For an outsider, this may appear quite complex, but the girls themselves seemed to know how to adapt their empathic expressions to who was ‘in’ or ‘out’ in that particular context. Generally, boys and girls tended to be in each other’s outgroup. In contrast to the strong and continuous ingroup- and outgroup dynamics in Cl.1, Cl.2 generally operated as one group of individuals. Although friendship ingroups- and outgroups, gender divisions and social exclusion were present, configurations of children who played together changed from day to day and just as often depended on the type of game that was played as on who was playing the game. Again two situations illustrate this finding.against the adult power or adult rules. In the following two subsections this will be discusses.In Cl.2 the existence and dynamics of the different in- and out-groups did not constantly define their empathic expressions. Hiske, a non-friend and a different gender, showed empathic concern for Christiaan, as did Tom, a friend of the same gender, while Marc offers his help pro-socially to Yvonne, a non-friend and of a different gender. Generally, creating groups seemed an organic process, in which the children took responsibility not to show antipathy or disappointment when put into the same group as someone who might not belong to their ingroup. In Cl.3, there was some alternation between exclusively showing empathy toward the ingroup – resembling Cl.1 – and showing empathy toward children in the classroom who are outside their particular ingroup – resembling Cl.2. An additional outgroup that is apparent in Cl.3 is the group of teachers and/or adults. Cl.3 does show struggles between children and subgroups are part of the classroom structure, however there are multiple moments during the observations in which the group acts as a whole Nynke handed a list of ‘bullies’ to the teacher and the teacher discussed the matter with the classroom.Coen: ‘Yes, but it was only meant as a joke … [he thinks before finishing his sentence] but it didn’t feel like a joke to her’ (this reflects a teacher ‘rule’: something can feel different for the other person).Teacher: ‘But if you recognize this and notice that Nynke feels bad about it, why don’t you quit and tell the others: “Guys let’s not do this”?’Steven: ‘I know why. They [classmates] will then attack or bully Coen because he is protecting Nynke. Everyone responds to each other all the time’.Teacher: Yes, that is exactly the problem’.The excerpt shows how the children do seem to have an understanding of how the dynamics work: people are hurt in their constant reactions to each other, and it would be ideal to consider the feelings of other classmates. The way in which Bente claims her innocence by saying she was not on the ‘bully-list’ exemplifies how this classroom struggles with the discrepancies between ideal behavior according to the teacher’s (adult) empathic and social rules and the children’s real behavior according to their own empathic and social rules on the peer level. The discrepancy or struggle between knowing and doing in social interactions is accurately summarized by the teacher’s remark after a bully incident: ‘You either do not remember our social rules or you refuse to behave accordingly’. In Cl.3, the children demonstrated an understanding of what the teacher wanted and regularly complied with the teacher’s ‘social wishes’; however, they also followed their own rules. In some cases, the classroom and teacher’s rules matched; for example, when someone was bullied or yelled at, it was quite common for another child to intervene, with remarks such as: ‘Stop it, that is not funny, stop!’ However, in other cases, the classroom and teacher’s rules did not match; for example, the peer-to-peer rule to ‘Not cry’ was opposed to the teacher’s encouragement to share sad feelings. The mismatch between teacher and classroom rules and ideas about what was ‘normal’ seemed related to either the difference in cultural background between the children  and the teachers (both from a Dutch background) and the difference in school-rules and street based peer-rules , but generally the children agreed with the set rules. A different pattern of incorporating the social rules was seen in Cl.1. Although the social rule to ‘Consider other people’s feelings and talk about it if necessary, even when you find this difficult’ was clearly articulated by the teacher and in word agreed upon by the children, they were exhibited far less in acts by the children in the teacher’s absence. The following conversation is illustrative:er-rules .While in Cl.2, a common remark would be: ‘Nice jacket, new one?’ (out in the open and positive), in Cl.3, a clearly sarcastic tone was apparent, for example, ‘Niceee shoes, not’ (out in the open and negative), while in Cl.1, a handwritten note about someone in the outgroup who was wearing weird socks (covert and negative) would be typical. The positive vs. negative norm influenced empathic expressions and inferences toward the feelings of others. In Cl.1 it was seldomly seen that one would overtly show vulnerability or respond to a classmate that was in pain or sad for example, whereas in Cl.2 this was much more ‘normal’. In Cl.3, numerous cases of less empathic expressions were observed: from making a harsh remark followed by a ‘do not cry’ to loudly laughing at someone who makes a mistake in a calculation or a sentence in front of the class. However, this way of openly being negative toward each other, without much consideration for someone’s feelings, seemed ‘normal’ in Cl.3: the children were used to this type of communication and often did not seem to be affected by these types of remarks. The overt expressions to each other, which could also be positive in certain situations, marked the way the class interacted. In Cl.2, the pattern of positive encouragement (even when the ‘other’ did not belong to the ingroup) seemed to stimulate prosocial behaviors among the class.In every classroom there were individual children who stood out in the observations in relation to empathic expressions, classroom dynamics and/or prosocial behaviors. Here, we describe the children who stood out for being isolated or acting prosocial. Later we will relate these observed classroom positions to measured cognitive abilities and social network scores.In Cl.1, there were three girls and two boys who match this description. One of the girls (Amy) did have a friend with whom she occasionally shared her feelings, but otherwise it was hard to tell what she was thinking. The other two (Inge and Marianne) were often together and excluded by others. One day Inge was crying – which she did quite regularly – because her friend Marianne was being bullied. In her account of the situation, she blamed Bente and Lisanne, two girls with leadership roles in the classroom. Concerning the boys in this classroom, two of them, Dylan and Finn, found themselves regularly excluded from interactive processes within the classroom. Dylan did not always seem very aware of this, but Finn did. The two boys cried relatively often and regularly called in sick. One day when Dylan did not appear at school, it was suggested by the other children that ‘He is not really sick, but does not want to come to school’. In Cl.2, a girl, Hanne, and a boy, Lars, were also excluded from social classroom processes to some extent. Hanne often interacted with the researcher rather than with other children and Lars often played alone during school breaks. Both occasionally made remarks in classroom discussions that showed a lack of sensitivity, either in being too loud, not topic related or already mentioned by someone else. Additionally, one of the girls, Maya, exhibited behavior that was slightly similar to Amy from Cl.1 – she did not appear to express her feelings toward others very often and only shared some observable thoughts and feelings with one or two friends. In Cl.3, two girls, Özge and Nazmiye, and one boy, Asaf, were often excluded – or excluded themselves – from social processes. Another boy, Hamid, did not always appear to understand the social interactions that were going on. Similar to Hanne (Cl.2) and Marianne (Cl.1), Özge showed a preference for interacting with the researcher rather than interacting with her classmates. This was not well received by the other children. Both Özge and Nazmiye decided to not participate in the class summer camp, despite the teacher’s attempts to include them.In two cases, the children who had an exemplary role in social interactions also – in their own way – showed prosocial behavior. Marouan, a boy in Cl.3, tended to support children who were not as articulate or who were yelled at, while Lieke, one of the girls in Cl.2, was often involved in helping other children, showing her own emotions, verbally and non-verbally responding to other children’s feelings and emotions, and reflecting on her own actions in terms of whether these were nice to other children or not (and then apologizing). Additionally, in Classrooms 1 and 3 there were two girls  and one boy  who helped, comforted, mediated and/or included other children despite the general tendency of the classroom to, respectively, exclude (Cl.1) or overshadow (Cl.3) other children on a regular basis. Zoë, for example, was observed helping a classmate who was sad because a mathematics exercise was not going well. Daniel mediated during a group reading exercise that almost degenerated into a fight and told the other three boys to ‘Leave it’ and ‘Let the other person go’, while he put the books back in their original place. Interestingly, Lisanne and Bente (see above) did show sensitivity toward exposed feelings from girls within their ingroup and also actively helped and comforted their ingroup peers; however, outside the ingroup, this prosocial behavior was observed far less often.Children’s individual abilities were analysed and mapped by computing z-scores for the three classrooms as a whole . The distribution of these z-scores, indicated a minority of high and low scoringBased on the computed z-scores we subsequently computed and found low and high scorers in our overall sample. To integrate the ability scores and observational findings on an individual level, we examined whether children who had relatively high and low individual ability scores also stood out in the observational findings. It became apparent that there were both matches and mismatches between individual high and low scorers and their more or less empathic behaviors as observed within the classroom.From the children who were described as ‘being isolated’, the majority had a relatively low score. However, there were also children who were not observed as ‘being isolated’ but still had a low score. Quirine (Cl.1), for example, was one of the low scorers who was regularly mentioned in social interactions, she had friends who stood up for her and she also exhibited empathic insights in group situations; for example, she allowed another child to tag her when she realized the child had been a catcher for a long time. What characterized Quirine was her imperturbability: she would go her own way and did not seem to be overly distracted by what other’s thought about her, which might be partially explained by her relatively weak empathic ability score. Interestingly, there were also children who were observed and described as ‘being isolated’, but who did not have low ability scores. The fact that Özge (Cl.3) and Marianne (Cl.1) did not belong to the low scorers, while their ‘isolated partners’, Nazmiye (Cl.3) and Inge (Cl.1) did, suggests that low ability does not always co-occur with social isolation. Another intriguing finding is that the observed reclusiveness of Amy in Cl.1 seemed unrelated to a relatively low ability, while a similar observed reclusiveness of Maya in Cl.2 did correspond with a relatively low ability score. We found that 6 out of 10 high scorers were observed and described as ‘being prosocial’. Again, the integrated findings revealed a nuanced picture about what it means to be a high scorer. In Cl.1, for example, the four high scorers can clearly not all be put into the same category. While Daniel’s and Zoë’s prosocial behavior and Lisanne’s ambivalent mix of understanding and helping her ingroup peers and manipulating and bullying her outgroup peers was already evident in the observational findings (see above), Floor’s behavior was much less apparent. Floor’s observed behaviors could be characterized as friendly but calm, not that expressive and going with the flow. In the rough data, there are descriptions of her being ‘helpful’ and ‘chatty’, but this was far less noticeable than in the cases of Zoë and Daniel. A similar point can be made about Benno in Cl.2, who was calm, friendly and helpful when needed, but in no way remarkably present in empathic interactions or prosocial actions. Interestingly, there were children in Classrooms 1 and 2 whose prosocial/helping/expressive empathy behavior was far more visible than Floor’s and Benno’s, but whose ability scores were not as high. Clearly, there is not a single type of ‘high scorer’ which was also found to apply to Cl.3.Interestingly, in Cl.1, some children with average to good ability scores were excluded from the social interactions and empathic processes in the classroom, while in Cl.2, only a few children who had low ability scores were sometimes socially excluded. Moreover, in some cases, an individual’s ability score was relatively high or low but this did not directly relate to more or less empathic behaviors, respectively, as observed in the classroom. This relation between being a low or high scorer and standing out in the observations (or vice versa) was much higher in Classrooms 1 and 3 compared to Cl.2. In Cl.1, 75% of low scorers and 75% of high scorers were also observed as either ‘isolated’ or ‘prosocial’; in Cl.2, 60% of the low scorers and 0% of the high scorers were mentioned as ‘isolated’ or ‘prosocial’, respectively; and in Cl.3, 100% of the low scorers and 60% of the high scorers were mentioned. A possible explanation for the unique position of Cl.2 can be that the strong community ability to take care of each other and be positive toward one another makes prosocial behavior the norm. Children who act prosocial do not stand out, since it is a community ability. The community ability overrules the individual ability except for the ‘outliers’ whose individual ability developmentally differ from their peers in the same age group thus. In this type of classroom children’s individual abilities matter less, since the driving force behind expressions of empathy is the community ability.In the social network analysis , we compingroup and outgroup dynamics, in combination with a focus on the negative. Interestingly, the focus on the negative was also present in Cl.3; however, in this case, it did not seem to be directly related to disliking others. A possible reason for this is that the behavior of the children observed by the researcher was experienced and understood differently by the children themselves. Children in Cl.3 may have been used to blunt remarks such as: ‘Shut up you cow!’, or perceived these as regular classroom dynamics that did not directly imply deeper relational problems. Interestingly, the importance of ingroup vs. outgroup processes in Cl.1 generated a context in which whom to ask was more important than what to ask. Additionally, we see in Classrooms 1 and 2 that children who were asked for help were all part of the ‘plusklas’, which means they participated in alternative lessons to remain cognitively stimulated. Who the children would choose to go to for help thus seemed related to two observable factors: a willingness to ask another child based on the relationship; and the perceived cognitive ability of the other child to help with school work. Motivations relating to whom to go to and for what reason thus also clearly differed in each classroom. In summary, part of the social network results can be directly related to the shared empathic practices and norms as observed in every classroom. However, whereas in the observations Cl.2 stood out as compared to Cl.1 and 3, with Cl.2 showing much more overt and positive empathic practices on group level, here it is Cl.1 that stands out showing significantly more dislikes and less willingness to help. Cl.3 thus, seems to have indeed two different faces (see earlier) which we will come back at in the Discussion section below.The significant differences between the classrooms were striking particularly in the dislike- and the help-network Moreover, the effect sizes turned out to be medium-large which confirms a relevant  difference in social network composition between the classrooms. Cl.1 stands out in comparison to the other two classrooms: there were relatively more dislikes, and relatively fewer reported help requests, which means that the frequency of asking and being asked for help is relatively low in Cl.1. Moreover, the mean score for dislikes (indegree and outdegree) in Cl.1 was more than twice as high as in Classrooms 2 and 3. In Cl.1, this could be clearly linked to the observed How is the child’s individual ability to empathize related to their empathic expressions as observed in the socio-cultural environment of their daily school lives?How can the use of social network analysis help us to find the interplay between empathy as an individual construct and empathy as part of a classroom community of practice?The main purpose of this research was to explore how the combination of the theoretical frameworks and methodological tools of two disciplines – anthropology and psychology – can provide new insights on children’s empathy. The key findings of our study came from the integration of the three levels of investigation – observational data, psychological tasks and social network data. Main research questions (RQ) were:Below we answer these research questions in three detailed subsections. It should be kept in mind that our primary aim at this point is not to provide generalizable insights on the construct of empathy in children, but to explore how our multidisciplinary approach can be applied within this topic and what kind of new insights this can potentially generate.ibid: p 744). Could it be that in the one classroom, or the one case, prosocial behavior is rule-induced  and in the other it is more empathy-induced (Cl 2. in which cooperation seemed an inbuilt behavior)? This might explain part of the discrepancy between empathic ability scores and empathic expressions and prosocial behaviors in our study. Especially in the age group of our study (9–12) it is said that autonomy is still developing even far into adolescence  tells us an exciting additional story. In Cl.2 children’s relative individual ability score had a markedly smaller effect on the possibility that this child would stand out as either prosocial (high score) or isolated (low score) than in Cl.3 and 1. This finding suggests that the shared practices and the accompanying community norms  within tibid p.635). In Cl 2 the need to power play did not play such a significant role. In Cl 3 children were not at all short of direct confrontation (ibid p.632), however the power play was often seen in relation to the teacher’s role and did not result in a relative high amount of dislikes. This brings us to an interesting second line of thought: the difference between peer culture and school culture. It has been suggested that children either feel motivated to participate in the school culture and climb on the school ladder or they feel more motivated to participate in the peer culture – which is related to street culture – and climb on the peer-ladder  showed that it was Cl.1 that significantly differed from the other two classrooms in both the dislike- and the help-network. At first sight this was unexpected. It was Cl.2 that was distinct from Cl.1 and Cl.3 in how prosocial behaviors were showed and how community abilities prevailed over individual abilities. It was Cl.3 that was distinct from Cl.1 and Cl.2 as related to SES: the geographical area and its related income level which was below national average in Cl.3 and above average in Cl.1 and Cl.2 and cultural background was not so diverse and mainly Wester in Cl.1 and Cl.2 and super diverse and partly non-Western in Cl.3. So how could it be that in the SNA Cl.1 significantly differed from the other two Classrooms?. Two lines of thought are possible to grasp the meaning of this finding. First, we see in the extensive work of r-ladder . In Cl 3By answering the main research questions we hope to have made a convincing case about the quality and contribution of this interdisciplinary study to the field of children’s empathy and the context of the classroom. However, this research also has limitations. First, there will always be missing information in ‘real-life’ research: the researchers were not in the classroom every day and there will always be events, discussions and interactions that are not observed. Second, the psychological tasks tests in the current research included mainly cognitive empathy tasks whilst the mapped expressions and behaviors include cognitive empathy and affective empathy, concern and emotional contagion. Third, in terms of interpreting and using our quantitative data it would have been better to have a larger group sample. Due to the setup of this research, in which we combined our quantitative dataset with long-term observations which had an essential role in our exploration of the topic, this was not feasible. Fourth, the internal consistency of the RME-Child turned out to be low which has been reported earlier : 2. HoweThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethical Committee of the Department of Psychology and Education of the VU University. Written informed consent for participation was not provided by the participants’ legal guardians/next of kin because: Written informed consent was provided for 2 of the 3 classrooms. Teachers of the other classroom chose - in accordance with the first author - to work with passive written and oral consent. The main reason for this type of consent was that some of the parents of the children who participated were not able to read the Dutch consent form, since their lingual background is non-Dutch.SR developed the concept of the research in collaboration with LK, SE, and FW. The data collection was done primarily by SR. SR and FW analyzed the data, supervized by LK. SR, FW, SE, and LK interpreted the results. SR wrote the manuscript guided by LK and FW who also contributed. AM, LK, FW, and SE provided critical comments on the manuscript at several stages. AM and LK provided comments at the last stage of the manuscript. All authors contributed to the article and approved the submitted version.LK was funded by a VICI grant from the Netherlands Organization for Scientific Research. Grant number 453-11-005.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.