This study aims to identify a novel potential use for web portals in health care and health research: their adoption for the purposes of rapidly sharing health research findings with clinicians, scientists, and patients. In the era of precision medicine and learning health systems, the translation of research findings into targeted therapies depends on the availability of big data and emerging research results. Web portals may work to promote the availability of novel research, working in tandem with traditional scientific publications and conference proceedings.This study aims to assess the potential use of web portals, which facilitate the sharing of health research findings among researchers, clinicians, patients, and the public. It also summarizes the potential legal, ethical, and policy implications associated with such tools for public use and in the management of patient care for complex diseases.This study broadly adopts the methods for scoping literature reviews outlined by Arskey and O’Malley in 2005. Raised by the integration of web portals into patient care for complex diseases, we systematically searched 3 databases, PubMed, Scopus, and WestLaw Next, for sources describing web portals for sharing health research findings among clinicians, researchers, and patients and their associated legal, ethical, and policy challenges. Of the 719 candidate source citations, 22 were retained for the review.We found varied and inconsistent treatment of web portals for sharing health research findings among clinicians, researchers, and patients. Although the literature supports the view that portals of this kind are potentially highly promising, they remain novel and are not yet widely adopted. We also found a wide range of discussions on the legal, ethical, and policy issues related to the use of web portals to share research data.We identified 5 important legal and ethical challenges: privacy and confidentiality, patient health literacy, equity, training, and decision-making. We contend that each of these has meaningful implications for the increased integration of web portals into clinical care. New wweb portals as a general category, by which we mean web resources that aggregate health information for a specific purpose, and therapeutic portals, by which we mean web portals designed to aggregate health research findings and make them available to a diverse array of researchers, clinicians, and the general public. Therapeutic portals may be contrasted with one prominent type of web portal, the patient portal. This is a system typically used to share individual patient data, facilitate clinical interaction, and record specific health outcomes [therapeutic portal in an attempt to capture nuances that are not fully expressed in discussions on the use of web portals for managing and sharing health research findings. In the era of precision medicine and learning health systems, as interactions between clinicians, researchers, and the public take on a unique and pressing character, we are of the view that the language of therapeutic portals better fits the potential emerging use of portal technology in these contexts. Although the distinction between these kinds of web portals is subtle, it has potentially important implications for the provision of care and for the legal and ethical obligations of clinicians in health care systems increasingly modulated by the internet.This study aims to identify one such novel potential use: the adoption of web portals to rapidly share health research findings with clinicians, scientists, and patients. In the era of precision medicine and learning health systems, the translation of research findings into targeted therapies depends on the availability of big data and emerging research results. Web portals may work to promote the availability of novel research, working in tandem with traditional scientific publications and conference proceedings. Web portals raise the possibility that important research findings will be shared efficiently not only with scientists and clinicians but also with patients and members of the public. This study aims to examine how web portals can be used to facilitate such sharing. We seek to preliminarily outline how web portals can be used to advance research sharing objectives and to identify legal and ethical barriers that might challenge these functions. We will distinguish between outcomes . For theOur interest in studying the feasibility of therapeutic portals is motivated by an ongoing multidisciplinary molecular genetics research project to better characterize and categorize the incidences of acute myeloid leukemia (AML) . The LeuIn this regard, this review aims to explore the potential use of web portals that work to share research results in the context of complex diseases with the research community, clinicians, and patients. In particular, we set out to understand whether such tools are presently in use, how they may be implemented, and how we might account for the pressing policy challenges they raise. This study will help contextualize and support the development of web portals intended to promote information sharing in health care systems by increasingly applying precision-medicine approaches to combat complex diseases. This review examines the potentially expanding scope and utility of web portals and highlights the policy challenges associated with this expansion. This will be achieved by outlining the results of a scoping literature review attempting to ascertain the extent to which web portals have been considered to facilitate communication between researchers and clinicians. Therapeutic portals are internet-enabled tools for sharing information between health researchers conducting basic science research and clinicians implementing best health practices. Tools of this kind expand on the increasing reach of patient portals by broadening their scope of application and inflating their role in patient care. Although there is a sense in which the use of web portals for sharing health research and disease data among clinicians and investigators is a logical extension of the form and function of existing tools that bring together patients and care providers, little direct consideration of such platforms appears to be present in the literature. This review poses 2 questions: (1) Are therapeutic portals being developed and used in health systems? (2) What legal and ethical issues might be raised by the use of therapeutic portals for sharing health research and disease data with researchers, clinicians, and the general public? This study will address these questions in 3 sections. First, we outline the methods used to preliminarily survey the literature in consideration of the questions above. Second, we summarize our results and describe how they apply to the development and use of therapeutic portals. Third, we discuss our findings with a broader literature on web portals and health research dissemination. We also note the limitations of our research and suggest that more work on this topic is needed.the key concepts underpinning a research area and the main sources and types of evidence available [online portal AND health AND communication AND research* AND clinic*. Our search strategy initially focused on web portals as a general category, noting that scholarly sources describing portals used primarily for communicating research findings to a wide audience were not organized using discretely identifiable terminologies. We refined search terms iteratively and scanned source references to broaden the scope of the review. A primary search was conducted in April 2019, and a final search was conducted in March 2020. We did not time limit our search to obtain the widest possible array of sources. Initially, we identified 719 articles and papers from each source. Third, we selected studies for inclusion according to the criteria developed post hoc, as we became increasingly familiar with the literature. Owing to the nature of the research questions, as well as inconsistent language in the literature for explaining the function of web portals, determining which sources to include in our analysis sample proved to require a delicate balance. We worked with a set of flexible inclusion criteria. We included sources that met any one of the following broad criteria: (1) description of a web portal in actual use for the purpose of sharing research findings or non–patient-specific data; (2) description of a potential use case for web portals that share research findings or non–patient-specific data among researchers, clinicians, and the public; (3) description of a potential use case for web portals that permit access to health research findings or lay explanations of health research findings for patients or the general public; and (4) descriptions of legal and ethical issues associated with any of the above criteria. We excluded (1) duplicate sources, (2) sources not available in English, and (3) sources that primarily discuss the use of web portals for purposes other than the sharing of health research. Exclusion criterion 3 resulted in a large number of sources being screened out. In particular, numerous sources focused narrowly on the development and implementation of patient portals were generally not included in the review. Of the 719 sources initially collected, 22 (3%) sources were retained for the final review. Fourth, we charted source data for each retained resource, including the author, year of publication, and conclusions. These data are outlined in We designed this scoping literature review following the theoretical model set out by Arskey and O’Malley . Scopingvailable . Scopingvailable . We adopWe selected 22 sources for the final review. Of the 719 sources initially obtained, 25 (3%) were eliminated as duplicates and 2 (0.2%) were unavailable in English. This left 96.2% (692/719) of papers for which we conducted a title and abstract review. Of these, we found that a high number primarily outlined work on the adoption of patient portals. Following exclusion criteria 3 above, those sources that did not include discussion about the potential communication of research findings, in addition to patient data such as testing results and treatment plans, were generally determined to fall outside the ambit of this review. We eliminated 93% (671/719) of sources that were determined not to meet the inclusion criteria described above. Operating on a relatively narrow conception of therapeutic portals, we did not expect to find a large number of sources that would meet the inclusion criteria outlined above. Nevertheless, we determined that the 3% (22/719) included sources provide an overview of this emerging field and suggest that the adoption of web portals for sharing research findings will become increasingly prominent in the coming years. This limited overview of the early literature in this space may work to ground subsequent discussions. do contemplate use cases to facilitate access to health research findings. We believe that these sources fall under inclusion criteria 2, describing a potential use case for web portals that share research findings or non–patient-specific data among researchers, clinicians, and the public. We explore these themes in greater detail in the Discussion section.The sources retained for the final review were relatively varied in their theoretical and methodological orientations. Several studies, for example, described patient portals enhanced by the inclusion of health data that would not be included in patient charts. One such approach is exhibited in a work by Nordqvist et al , who outWe charted our overarching results in This review demonstrates that web portals are presently being used for a wide range of functions and in a variety of clinical and research settings. Ling Cai et al , for exaNotably, we have also found that therapeutic portals have generally not received attention as a phenomenon that is conceptually distinct from the emergence of the patient portal. An extensive literature has been published on the development and use of patient portals in recent years , as wellOur findings suggest that therapeutic portals are likely to raise a number of important legal, ethical, and social issues. In particular, our review highlights 5 particularly prominent issues: (1) privacy and confidentiality, (2) patient health literacy, (3) equity, (4) training, and (5) decision-making. In this section, we outline how each of these issues is contemplated in our review and suggest policy and regulatory approaches that may be considered to address them.The treatment of privacy and confidentiality issues in the sources identified in this review focused largely on the necessity of ensuring that personal data stored on a web portal is protected, and that data made available to third parties through a web resource cannot be used to identify individual research participants or patients . One souability to access timely, relevant, and reliable information is a vital component in patient empowerment. Access to high-quality health information can improve patient outcomes by facilitating decision-making and better treatment compliance [eHealth literacy is conceived as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to address or solve a health problem” [Several articles assessed in this review described the potential health literacy and patient health literacy functions of publicly available web portals for managing and interacting with health data. Indeed, 2 of the 9 papers we found to have discussed patient health literacy, those by McKemmish et al  and Kuijmpliance . Similarmpliance  outlinedmpliance  noted thmpliance , whereasmpliance  focused mpliance . On the problem” . In thisproblem” ,32. SourOne possible effect of increased health literacy facilitated by web resources is the generation of greater equity in access to care. Several studies alluded to this point, although we did not find extensive discussion of health equity promotion in the sample of resources we reviewed. Melchart et al , for exaimplications for educators designing physician training and policymakers considering public access mandates for research. Moreover, empirical work suggests that training may be a significant barrier for clinicians to more broadly pursue the use of novel web resources in their practice. Nordfeldt et al [Further challenging the implementation of novel web health resources is the issue of training. Several of the sources we reviewed detailed the particular training challenges associated with the development of tools intended to be used by clinicians, researchers, patients, and the public. For example, Das et al  emphasizdt et al  wrote thdt et al , for exadt et al  noted thdt et al , the devdt et al . Our finshared decision-making, in which therapeutic decisions are reached through dialog between the clinicians and their (informed) patients. Christensen et al [based on socially constructed content rather content provided by experts in the field. Although portals have important implications for the manner in which medical decisions are made, they might raise questions about who makes decisions in complex health contexts. According to Das et al [Our review found that of the 22 sources, 10 (45%) discussed issues related to decision-making. Although this is somewhat an imprecise consideration, in need of greater specificity, it has potentially far-reaching legal, ethical, and policy implications for the use of web portals for health. We discovered that a number of studies gave varying degrees of attention to the ways novel web systems affect clinical and other health-related decision-making. Web resources may affect patient and public decision-making about health simply by influencing the information to which such persons have ready access. Kohler  made thien et al  noted thas et al , portalsThis review attempts to collect preliminary data concerning proposals to implement therapeutic portals. This research encountered 3 important limitations that should be addressed in future work. First, the search terms employed in this review may not have been maximally targeted to the phenomenon under consideration. The reason for this is that the precise area of research with which we were interested remains relatively gestational and the terminology surrounding web portals that incorporate health research and patient perspectives has not yet been settled. It may also be that a number of therapeutic portals under development have not been described in published articles. This being the case, we hope that it will become increasingly commonplace for scholars and researchers to publish their experiences and perspectives on web portal design and implementation. Second, we did not specifically seek to include gray literature sources in this review. It is highly likely that some sources on therapeutic portals have been communicated outside of traditional academic settings. As our review focused on articles published in peer-reviewed periodicals, we did not assess any potentially pertinent gray literature sources. Future research on this topic should be expanded to include consideration of published works outside of traditional academic settings. Third, this review was limited by language and jurisdiction. Each of the 22 sources we reviewed was published in English and obtained from the English search databases. Moreover, most sources were written by scholars working in North America. These factors likely limited the scope of our search. Future research should explicitly engage with research published in languages other than English and by scholars in a more diverse set of jurisdictions. Despite these limitations, we believe that this study provides a useful overview of the landscape for therapeutic portals, including their specific potential objectives and legal, ethical, and policy challenges they are likely to face.therapeutic portals are a potentially promising but largely underexplored area of study. Of the 22 studies reviewed, 8 (36%) contemplated therapeutic portals were defined. The portals we reviewed took a variety of forms and covered a range of medical issues. The absence of extensive literature on portals that specifically integrate uses from clinical, research, and public settings indicate that such systems have not been implemented on a large scale. We found that developing therapeutic portals would raise a number of important legal, ethical, and social issues, including those surrounding privacy and confidentiality, patient health literacy, equity, training, and decision-making. Each of these considerations should be given careful attention through the implementation of robust policy frameworks for managing the functions of novel portals, especially those that are of a form that has not yet been widely adopted. Further research is critical to better understand the perspectives of clinicians, researchers, patients, and members of the public on the contours of possible therapeutic portals. Although web portals that interface the numerous vital constituents in health research are, in principle, highly promising, any novel system must account for the various legal, ethical, and social challenges that they will present.This paper communicates the findings of a scoping literature review on the potential development and implementation of what we have called therapeutic portals, web systems that facilitate the sharing of health information among researchers, clinicians, patients, and the public. Such portals differ from patient portals in several important respects. First, the role of researchers directly communicating novel findings with clinicians and the public could be significantly enhanced. This approach could help promote the growth of precision medicine as a response to complex diseases. The main aim of this study was to assess the primary legal, ethical, and policy issues associated with the development and use of web portals that facilitate information sharing between researchers, clinicians, patients, and the general public. Our findings indicate that It is noteworthy that, although several of the papers included in the final review are several years post publication, those that more recently entered the literature express concern for the same kinds of issues and potential concerns. This indicates that the policy considerations identified here have not yet been fully addressed in policy development over the last decade. This underscores the responsibility for developers of the next generation of web portals to rededicate themselves to the challenge of implementing web tools that account for the serious legal, ethical, and social issues identified in this study.This review is situated within a broader discussion in the literature on patients and other portals for managing health data and sharing information with patients and the public. The rapidly expanding use of web systems has generally been held out as a success that has contributed to improved outcomes and greater patient empowerment ,44. Our


I have reviewed studies on neural responses to pictured actions in the action observation network (AON) and the cognitive functions of these responses. Based on this review, I have analyzed the specific representational characteristics of action photographs. There has been consensus that AON responses provide viewers with knowledge of observed or pictured actions, but there has been controversy about the properties of this knowledge. Is this knowledge causally provided by AON activities or is it dependent on conceptual processing? What elements of actions does it refer to, and how generalized or specific is it? The answers to these questions have come from studies that used transcranial magnetic stimulation (TMS) to stimulate motor or somatosensory cortices. In conjunction with electromyography (EMG), TMS allows researchers to examine changes of the excitability in the corticospinal tract and muscles of people viewing pictured actions. The timing of these changes and muscle specificity enable inferences to be drawn about the cognitive products of processing pictured actions in the AON. Based on a review of studies using TMS and other neuroscience methods, I have proposed a novel hypothetical account that describes the characteristics of action photographs that make them effective cues to social perception. This account includes predictions that can be tested experimentally. I will introduce action photographs  as visual cues that evoke neural activations in the action observation network (AON) of viewers and address controversial explanations of the cognitive products of these activations. In the first section, I will briefly define two concepts that play a central role in many of the studies reviewed in this paper: action representation and knowledge of actions. Then, I will give an overview of findings on the cognitive products of the activations in the AON, coming primarily from studies in which live actions or video clips of actions were used as stimuli. Next, I will address the cognitive responses to action photos and the particular social perception that they convey. In the following section, I will analyze the particular representational characteristics of action photos that are assumed to be the most relevant to this particular perception. I will illustrate these characteristics with some picture examples, in which action photos have been modified so that only the picture information which is relevant with regard to the processing in the AON in the first 300 milliseconds after picture onset could be seen. I will conclude by addressing questions for future research.The present review is based on the following assumptions: Action photos convey to viewers a similar particular social perception as observing live actions. This social perception is based on neural activities in the AON and physiological excitation states in the body outside the brain. Within a few hundred milliseconds of processing, seeing action photos conveys to viewers a specific motor and somatosensory knowledge. Only a part of the components or elements of the actions depicted are relevant with regards to this knowledge. To examine these assumptions, I have reviewed studies on the AON that provides relevant information.The AON is a network of regions in the occipito-temporal, temporal, parietal, and prefrontal cortices ,2. NeuraThere is a broad consensus in the research literature that the processing of observed live actions in the AON provides observers with knowledge of what others are doing and that this is a key skill of social cognition ,38,42,43This question is also relevant with regards to action photos. Do the AON responses convey knowledge of the specific properties of the concrete pictured actions ,54,55,56To the best of my knowledge, no hypothetical account has been proposed to date that has identified the representational core characteristics of action photos and the specific perception they convey. Based on a review of TMS studies on AON responses as well as investigations using a wide range of neuroscientific methods, the present article intends to fill this gap. The proposed characteristics of action photos and cognitive processes correspond to predictions that can be tested experimentally.In this section, I will briefly define key terms and concepts that many researchers use or refer to when studying the cognitive functions of neural activity in the AON. The first subsection describes properties of neural representations that are relevant with regards to the particular perception conveyed by action photos. The second subsection describes the knowledge of actions that is represented by fast AON responses to action photos and the key elements that this knowledge encompasses.Little is known about how motor actions are represented in the brain ,79,80,81According to the engram theory of memory ,84, memoRepresentations of actions are presumably carried by neural engrams that span widely and are distributed in cortical and subcortical regions . CorticaThe word knowledge means “to be in possession of information”  (p. 148)The processing of visual information by the AON provides people with knowledge of actions being seen . AccoThe knowledge of actions comprises neural or mental  represenMovements of body parts and the spatial and temporal properties of these movements, such as distance, direction or trajectory, speed, acceleration, or duration ,91,92.Internal models for the control of the muscle activities that generate the movements. Various scholars have described the control of actions by signals from the brain using motor programs  or on thSomatosensory processes or sensations, for example, in relation to proprioception, the processing of haptic or tactile information, heat, cold, or pain ,92,95,96Objects and contexts associated with actions ,94. ActiKnowledge of the desired outcomes of movements, that is, of action goals . KnowledKnowledge of the relevance or emotional value of actions or contexts of actions ,55. The Before I address findings on the specific cognitive operations that take place in viewers of action photos, I will give a brief overview of explanations of the cognitive correlates or products of the neural activities in the AON, coming primarily from studies in which live actions or video clips of actions were used as stimuli. These studies suggest five cognitive products: (1) action understanding, (2) knowledge of specific properties of the observed actions, (3) changes in motor and somatosensory excitability, (4) activation of a motivational or emotional state, and (5) experiences that are accompanied by conscious awareness.The word “cognitive” is used in a broad sense here. It denotes processes in the nervous system that are related to the use of information for the selection of adaptive behavior or problem solving. What is generated through cognitive processes is meaning. The term “cognitive function” describes a specific contribution of neural information processing to the well-being, prosperity, survival, or reproductive success of individuals .Research on the neural processing of visual information about actions has focused on understanding ,103,104.In explanations of AON responses that focus on action understanding, generalization and categorization play a central role ,5,15. InFast motor categorization is presumably based on signals from the magnocellular system. This is a special processing pathway from the retina to the cortex ,111,112.Generalization and categorization can be achieved by the activities of AON neurons with motor properties . Such caExplanations of the cognitive products of the processes in the AON or the mirror neuron system in connection with semantic processes are questionable . The actThe question of whether the processing in the AON causally provides specific knowledge about observed actions that is not conveyed through conceptual or semantic processes is difficult to investigate. The processing of conceptual action-related information in the ventral visual stream also leads to activations in the AON ,119. In Categorization involves generalization and a massive reduction of the information that is received and processed. Neural responses in the AON presumably also reflect the formation of motor and/or somatosensory activation patterns that represent specific properties of the observed actions more comprehensively than categories ,44,50,54The first set is related to features and functions of the brain areas included in the AON. The inferior parietal cortex and the ventral premotor cortex contain a high proportion of visual neurons, as well as many visuomotor and visuo-somatosensory neurons ,6,42,120The second set of evidence is related to findings of studies in which the neural processes in certain areas of the AON were disturbed by TMS during action observation ,74,122. Many researchers have used TMS in conjunction with electromyography (EMG) to investigate the effects of action observation on the excitability in the corticospinal tract and muscles . For revIf the MEPs are larger than in the baseline condition, this indicates an excitatory process. Action observation, in this case, results in a “facilitation” effect . There iAn increase in muscle-specific excitability during action observation reflects cognitive functions related to the preparation or effective execution of observed movements, imitation ,72, or eFacilitation effects occur not only in muscles, but also in the muscle spindles, the proprioceptive receptors, that would be involved in actually performing the action . In addiWanting to achieve a goal through body movements includes a motivational component. Facial expressions, as well as body and hand postures, may also provide emotional information to viewers ,106,107.Actions with a higher emotional value evoke stronger responses in the AON of observers than actions with a smaller emotional value ,131,132.Motor and somatosensory responses to observed actions in the AON and at the corticospinal and muscular level, as well as emotional reactions, can result in experiences or feelings  that are accompanied by awareness. For a review, see . ExperieThe AON has evolved as a brain system that processes visual information related to movements of other individuals. Photos are static pictures. Nevertheless, they evoke similar neural responses in the AON as live actions or video clips of actions . These rPhotos of events can generate retinal images similar to events that take place in the real world. Events depicted in photos share a large number of visual stimulus features with the relevant events that took place in real life. Photos are realistic images, yet they only represent a fraction of the multimodal sensory information received by people who observed a real-life event that was photographed. The recording of photos involves a tearing off of information, that is, abstraction, but there are also two significant properties that have been added to the events depicted: duration and interpretation. In photos, changing visual patterns have been given a duration. A depicted event that, when it actually took place, only lasted 1/1000 of a second, can be viewed for any length of time. A photo represents a complex dynamic event through a single image. Viewers of the photo see the visual appearance that the real event conveyed at a certain moment, at a certain point in space, and limited by a certain frame. The meaning that this temporal and spatial extract from the overall information suggests, stands for the entire complex event. Photos allow viewers to gradually “unpack” the information contained in such images and to reconstruct the depicted event in their imagination. In this sense, events that are depicted in photos can be processed and understood through different cognitive activities: rapid perceptual processing, step-by-step conceptual and semantic decoding, or imagery. All of these cognitive activities can be linked to neural activations in the AON of people who are looking at action photos. If action photos convey a similar social perception to seeing live actions, the AON responses to photos must primarily be perceptual processes. In the following, I will briefly discuss the different possible cognitive activities with which AON responses to photos can be related.Viewers can recognize action photos by associating pictured elements with action-related concepts and integrate these concepts into a representation of an action. The processing of the motor and somatosensory aspects of the concepts involved induces top-down activations in the AON ,65,119. Another reason for AON responses to action photos may be that these responses are related to voluntary cognitive operations that occur after the picture has been recognized, based on processing in the ventral visual stream. Such cognitive operations may be motor imagery ,69,70, mThe findings on AON responses to specific properties of actions depicted in photos in the early processing time window suggest that these responses are related to perceptual processes ,105,141.The present review suggests six major representational characteristics of action photos, which influence the strength of the motor and somatosensory neural activations in the AON and the associated corticospinal downstream projections.A clearly recognizable visual representation of movement is difficult to achieve with static pictures ,143. In Pictured movements are generated by muscle activities. These activities, muscle contractions, or deformations of the skin can be represented visibly in photos . Muscle Skin, deformations of skin, muscle contractions, body or hand postures, and facial expressions provide clues about the somatosensory processes involved in an action. The somatic component of the activations that photos evoke in viewers can relate, for example, to touch , pain 2,37,39, oThe meanings of pictured graspable, familiar objects are presumably also processed in the areas included in If viewers easily recognize the pictured body parts, their movements, and interactions with another individual or object, they can quickly associate the pictured information with an action goal ,148: “thRecognizing the goal of a pictured action implies anticipating the final state of the action . Photos The goal of an action does not have to be the most important information in a photo. What is most relevant to viewers can also relate to special muscle activities , intenseFacial expressions ,150, visOther factors may also influence the emotional value that viewers assign to pictured actions, such as the view from which an action is represented. Viewers may find an action seen from the first-person perspective more relevant than the same action from the third-person perspective ,155,156.Descriptions of the specific characteristics of action photos, the brain responses they evoke, and the cognitive abilities that such pictures convey are highly speculative at the present time. There is still little knowledge about the properties and processing of action representations in the human brain. There are only a few data on responses of individual neurons to action observation in humans that come from single-unit recording. There are still no data from experiments in which optogenetics was used within the human brain to research the processing of specific action-related representations by neural ensembles ,84. TMS What are the properties of modulations in corticospinal excitability in people who see a photo of an action, compared to modulations in corticospinal excitability in people who observe the same or a similar action while it is actually being performed? What are the time courses of the modulations? Are there similar excitatory or inhibitory effects on the motor activity in both conditions? Is there a similar muscle specificity?Do visual, motor, and somatosensory neurons in the AON independently categorize elements of complex motor actions depicted in photos taken in natural situations? Do such categorization processes persist if the processing of the visual input through the ventral visual stream is perturbed by the use of TMS or transcranial electrical stimulation (tDCS)?Does looking at photos activate neural ensembles in viewers that represent specific properties of the concrete actions depicted more comprehensively than through categorization? If so, how high is the degree of specificity that is achieved in the first 150 ms after picture onset, and how high is it after 300 ms? Do the proposed six representational core characteristics of action photos actually correspond to the elements that most strongly influence the strength of the activations in the AON? Is this list complete?Does the amount of detail in action photos influence the strength of the neural responses in the AON in the first 150 ms after picture onset? Is there an optimal amount of visual details in action photos in order to achieve maximum activation of the AON in the time window of processing of up to 300 ms?I reviewed studies that investigated AON responses to pictured actions to examine the assumption that action photos convey special socio-cognitive skills to viewers. Findings from studies that used TMS and EMG, as well as a wide variety of other investigation techniques, suggest that seeing action photos conveys similar processes of social perception as observing live actions. Six representational characteristics of action photos are most relevant in terms of this particular social perception: the clarity of the pictured movements, the visibility of muscle activities and skin, the visibility of somatosensory activities or sensations, the clarity of the involved object or context, the clarity of the action goal, and the emotional value of the pictured action or sensation. People generally use photos for social purposes, such as relating to other people, animals, plants, things, and places or making sense of a complex social world . Viewing


Alexithymia is a construct defined as the inability to differentiate between emotional experiences and bodily sensations. According to existing knowledge, alexithymia may have a major effect on the process of treatment and the outcome of the hemodialysis disease. The objective of this literature review was to determine the significance that alexithymia has for compliance and variables of clinical and mental health in the population of hemodialysis patients. For the above purpose, bibliographic databases “MEDLINE” and “Web of Science” were searched. The matrix method was used in analysis of articles. Searching both databases resulted in 248 articles. After applying exclusion and inclusion criteria, we included results of 13 articles in the literature review. The results of the search are findings regarding the prevalence and correlation of alexithymia with variables of clinical and mental health in hemodialysis patients. Alexithymia is significantly more common in the population of hemodialysis patients, and it has a negative effect on their mental and somatic health. Alexithymia levels in hemodialysis patients are more pronounced in cases where there is a greater number of comorbidities. Alexithymia is the predictor of high mortality rate in the population of hemodialysis patients, independent of other comorbidities. In patients with CKD, there are signs of electrolyte imbalance and fluid overload with oliguria or anuria. With the aim of surviving and ensuring good-quality continuation of life, patients with this stage of CKD commence treatment with hemodialysis, a treatment method based on the physical process of diffusion of metabolic waste through the semipermeable membrane of the dialyzer.End-stage chronic kidney disease (CKD) is a disease defined as a state of reduced glomerular filtration rate with a creatinine clearance lower than 15 mL/min/1.73 mThere is no clear consensus about dialysis adequacy, but according to the most recent guidelines, to be effective, hemodialysis should be performed several times a week for several hours . A patieAlexithymia may be primary, i.e., conditional on characteristics of the individual’s personality, or secondary, i.e., a consequence of continuous psychosocial stress and somatic disorders . SecondaAccording to previous research, HD patients are more prone to somatization and projection than the general population. Somatization is an immature defense mechanism in which frustration-induced discomfort manifests through feeling of somatic symptoms, and projection occurs when HD patients attribute their own unacceptable thoughts and desires to others  Given thFor the above reasons, alexithymiacs may continuously report symptoms of “non-existent diseases or fail to report a significant physical problem to the competent medical staff, which makes them fit for development of complications of bodily disorders” .Due to the great importance of alexithymia and its potential consequences on physical health, and because of the wide limitations and obligations of HD patients, alexithymia may have an exceptionally negative effect on mental health, compliance with treatment and the clinical status of HD patients. Since there are no literature reviews concerning this significant matter, we believe that the questions of significance of alexithymia in HD patients and its relationship with other factors of psychosocial and physical health must be answered.Therefore, our aim with this review article was to answer questions concerning correlation and influence of alexithymia on a somatic and mental health of patients, on a chronic hemodialysis treatment program by searching through cross-sectional and longitudinal studies.The matrix method was used for searching for articles in the databases. The matrix method represents a clear, organized plan for searching the literature using keywords with the aim of finding relevant articles, which are then organized in a table for the purpose of adequate overview and insight into data. Data on an article, including objectives, methods, results, strengths and weaknesses of individual studies, represent a guide for organizing information from the literature into chapters of the literature review . In thisThe databases that were searched were the bibliographic databases MEDLINE, National Institutes of Health, Bethesda, Maryland, USA and Web of Science, Clarivate Analytics, Philadelphia, United States and the last search was run on 20 April 2021. We used the keywords that were selected via the SPICE method . The keySelection of studies for further data analysis was done by mutual consensus of the authors referring to earlier defined inclusive research criteria. Studies that were obtained by searching the above databases, but whose titles and abstracts did not contain the above keywords, were excluded from further study. Studies comparing HD patients with patients undergoing peritoneal dialysis or with former HD patients who received transplants were included in the matrix if the findings regarding alexithymia in HD patients in such studies were obtained on an adequate sample of HD patients, i.e., if they had sufficient statistical power or provided useful qualitative results. The matrix method was used to extract data for each study individually. Data of participants, study design, outcomes, limitations and strengths of studies were all arranged (see Table 1), enabling a better insight on the quality of the data of selected studies. Selection of data for presentation in results was done after all authors agreed to the selection process.According to well-defined inclusion criteria, data on the prevalence of alexithymia in HD patient samples were analyzed, including their age and duration of dialysis, relationship of alexithymia and other comorbidities, laboratory variables and correlation and the influence of alexithymia mental health factors like depression and quality of life.Risk of bias on a level of individual study was analyzed with the participation of all authors and after agreement, we excluded negative results of studies based on small samples from further analyses because these studies: had type two statistical errors, did not have an accurate study design according to planned aims, had longitudinal results that did not adequately measure comorbidities as confounding factors or because they which had completed ambitiously performed statistical analyses without an adequate number of participants for that level of evidence.The results of the preliminary search of the above databases were 248 articles. Articles were excluded based on the above exclusion criteria, as were articles that did not contain the above keywords in their title and abstract and articles that were repeated across different databases. The above process narrowed the selection of literature to 35 articles, of which 13 were included in this literature review. The remaining 22 articles were excluded because the subject of the study was patients who had received transplants or patients undergoing peritoneal dialysis. Of the selected 13 articles, 3 were longitudinal studies and 10 of them were cross-sectional studies .In the reviewed literature, assessment instruments for personality traits characteristic of alexithymia were self-assessment scales with good internal consistency. However, the downside of all studies is the self-assessment character of the questionnaires, since personality traits characteristic of alexithymia are not easy to identify for an alexithymiac, which likely decreases the actual levels of alexithymia. In studies conducted before and during 1992 and 1993, the “Beth Israel Questionnaire” (BIQ) and “MMPI alexithymia scale” (MMPI) were used, while newer research applied the generally accepted “Toronto Alexithymia Scale 20” (TAS-20) and “Bermond-Vorst Alexithymia Questionnaire” (BVAQ), which include a scale for measuring reduced fantasizing, an alexithymia component that was left out of TAS-20 .Characteristics of individual studies and their limitations in terms of bias at individual study level are presented in a matrix of studies and indicated by date of publication, allowing for better understanding and simpler evaluation of selected studies .The results of the conducted search are factual findings on alexithymia in HD patients, which are grouped into sections on prevalence of alexithymia and its correlation with clinical and psychosocial factors.The prevalence of alexithymia in HD patients ranges from 13.9% to 83% ,19. The A prospective study conducted by De Santo et al. showed that the prevalence of alexithymia was 83% in the sample of HD respondents with severe secondary hyperparathyroidism . High leSeveral studies established higher levels of prevalence of alexithymia in HD patients above the age of 60, as well as in HD patients above the age of 65 whose treatment lasted longer in comparison with HD patients of the same age whose hemodialysis treatment had just begun ,26.Alexithymia established in the samples of HD patients was correlated with several different laboratory variables and clinical factors.Tayaz et al. also proved the negative correlation of TAS-20 scores with creatinine levels in HD patients . A negatThe “TAS-3” subscale of the “TAS-20” questionnaire, which measures externally oriented thinking has a negative correlation with the values of serum potassium immediately prior to the day of hemodialysis treatment . Also a Certain studies proved a higher prevalence of alexithymia in diabetic HD patients compared to other groups of HD patients , such asIn HD patients with alexithymia, social support has a protective effect on the development of a depressive disorder, noting that at the start of development of a depressive disorder in HD patients, the item “satisfaction with social support” is more relevant, while subsequent worsening of depression symptoms is prevented by the number of individuals providing support to the depressed individual . A mutuaSinatra et al. established significantly higher levels of depression symptoms and scores of subscales of alexithymia, which led to difficulty describing and identifying feelings that predicted depression positively in patients undergoing hemodialysis treatment for a period shorter than four years . After tHigh levels of alexithymia are also correlated with a higher prevalence of bulimia in the sample of HD patients, especially if nephropathy is of a diabetic etiology .The fact that HD patients with alexithymia show lower levels of conflict and extroversion in comparison with HD patients without alexithymia and members of their own family, although there are numerous objective reasons for emergence of conflicts, is likewise interesting .The prevalence of alexithymia in HD patients, which ranges from 13% to 83%, is significantly higher in comparison with alexithymia levels in the general population, where the prevalence of alexithymia ranges from 4% to 13% . The onlAdvanced age is a factor that is related to higher levels of alexithymia in the general population as well, and a potential reason for that are functional changes to the brain’s frontal lobe. Persons over the age of 65 with no comorbidities or signs of dementia show significantly higher levels of alexithymia in comparison with younger persons, and the greatest contribution to high levels of alexithymia is given by reduced cognitive function of the right frontal lobe, visual memory and nonverbal intelligence . Due to A low socioeconomic status of HD patients may be one of the causes of extremely high levels of alexithymia, since working-age HD patients regularly have reduced physical and mental capacity, while the time-consuming nature of treatment imposes additional restrictions on finding adequate employment . PersonsAlexithymia is a predisposing factor that leads to the development of mental and somatic disorders; the significant role that this construct plays in functional gastrointestinal disorders, but also eating disorders such as bulimia and anorexia has been confirmed ,34. HoweWe have already mentioned that an increase in levels of alexithymia in HD patients occurs through a synergic connectedness of physical and mental limitations and various comorbidities arising from chronic kidney failure and its cause. Hemodialysis treatment may be seen as a repetition of physical and mental trauma due to frequent complications, muscle cramps, hypotension and discomfort ,32. LongThe inability of HD patients to accept and identify negative affect leads to the development of a depressive disorder, which again has a negative impact on the quality of life of HD patients and the emergence of comorbidities . AlthougUnlike newer studies, in which alexithymia was measured using the TAS-20 questionnaire and where there was a clear positive correlation between alexithymia and depression, results of older studies  refer to a negative correlation between these two separate nosological terms . HoweverKojima et al. established that, independent of depression levels, alexithymia is the predictor of a 3.62 times higher death rate in HD patients . The aboGiven the findings on the prevalence of alexithymia in the HD patient population, the question arises whether it is possible to influence the prevention and treatment of alexithymia in HD patients. To that end, we propose a number of methods. One of them would be more adequate treatment of all other somatic diseases that HD patients suffer from, with a focus on better diabetes control, better secondary hyperparathyroidism treatment and treatment of mental disorders such as depression. Given that the aforementioned diseases are associated with higher levels of alexithymia and that their better management would likely result in lower levels of alexithymia, the vicious circle in which severe somatic and mental states of HD patients lead to decreased cognitive emotion assessment would be broken. The results in the available literature demonstrate that treating depression and eating disorders such as bulimia and anorexia result in decreased alexithymia levels, even when psychotherapeutic methods are not specifically aimed at alexithymia . The onlThe results of this literature review should be taken with a grain of salt, because the studies included in the review have certain flaws. A number of older studies included in the review had a small number of respondents, which is likely due to the fact that hemodialysis treatment was limited by age group at the time, resulting in a generally low number of HD patients. Still, in the absence of findings about alexithymia, we included the above studies in our review because there were significant differences in the observed variables, even for such a small sample. Taking the type 2 error rules into account, it is likely that such differences would exist even if the number of respondents was larger. Furthermore, older studies measured alexithymia using the MMPI scale, which has poor psychometric properties; such articles thus considered the results obtained using other questionnaires as well. Thirdly, all the results were obtained using self-assessment scales, which is questionable, because in the questionnaires, the respondents are supposed to report on their emotions and bodily sensations despite the fact that alexithymia is, in fact, a concept that refers to a lack of insight into one’s emotions and bodily sensations.Alexithymia is a factor that negatively affects mental health and quality of life of HD patients . AlthougGiven the small body and low strength of evidence from previous research on alexithymia in HD patients, future studies should examine the association and causality between alexithymia and laboratory electrolyte values , hypervolemia and systemic inflammation, other somatic comorbidities as well as mental health factors, to determine the mechanisms through which alexithymia has such a strong impact on HD patient mortality . Future


The role of the learning space is especially relevant in the application of active pedagogies, for example those involving collaborative activities. However, there is limited evidence informing learning design on the potential effects of collaborative learning spaces. In particular, there is a lack of studies generating evidence derived from temporal analyses of the influence of learning spaces on the collaborative learning process. The temporal analysis perspective has been shown to be essential in the analysis of collaboration processes, as it reveals the relationships between students’ actions. The aim of this study is to explore the potential of a temporal perspective to broaden understanding of the effects of table shape on collaboration when different group sizes and genders are considered. On-task actions such as explanation, discussion, non-verbal interaction, and interaction with physical artefacts were observed while students were engaged in engineering design tasks. Results suggest that table shape influences student behaviour when taking into account different group sizes and different genders.  In the field of education, there is ongoing discussion about the meaningful effect that learning spaces seem to have in facilitating and supporting learning scenarios and as a relevant element of the learning design ,2. In paIndeed, transforming traditional classrooms into spaces that support active learning models, where collaboration plays a major role, requires adapting the space to them ,6. CollaA previous study  examininTemporal perspective analysis has been adopted in a number of studies, in which various techniques such as temporal pattern analysis , variablThe aim of this study is to investigate to what extent a temporal perspective in the analysis of student behaviours can improve our understanding of the potential influences of learning space elements in collaborative learning activities. By adding another explanatory factor, the temporal perspective, this study could contribute with clarification of previous findings on these differences and how the characteristics of learning space play a role in students behaviour. Therefore, we use ENA for the analysis of temporal correlations between students’ on-task actions. The aim is not to label one space as better or worse, but rather to investigate whether an analysis of temporal dynamics in collaboration can provide evidence of the potential influences and thus facilitate informed decision making in learning space design that is aligned with a specific pedagogical intent and its related learning design facets.To achieve this aim, this paper focuses on table shape (round vs. rectangular tables) as a relevant element in the design of learning spaces and on group size as a key design facet in collaborative learning. In addition, the paper also explores the gender perspective in a study of the effects of different table shapes.(RQ1) What can a temporal analytics perspective tell us about the effect of table shape on student behaviour in different group sizes (dyads and triads) during a collaborative activity?(RQ2) What can a temporal analytics perspective tell us about the effect of table shape on the behaviour of different genders  during a collaborative activity?Therefore, this paper presents an analysis of the impact of table shape on student behaviour, with a focus on the temporal component of collaboration. Using ENA as a tool that incorporates the temporal component into the analysis of coded actions by modeling co-occurrences of action bypasses the classical approach of coding and counting and provides a deeper understanding of collaborative development over time. In comparing two conditions—round and rectangular tables, and their interaction with group size and student gender—the aim is to identify potential differences. The second section surveys the literature relevant to this study, which includes indicators of collaboration, learning space, group size and gender in interaction with learning space, temporality in the analysis, and ENA. The third section outlines the research aims and questions while the next covers the methods used in applying ENA in this study. The fifth section presents the findings of the analysis, while the sixth section discusses the results. Finally, the seventh and eighth sections consider the limitations and conclusions of the study as well as future work.In order to ground the analysis of the learning space in which we examine the student behaviour during collaborative learning activities, it was necessary to blend several different domains that converge in the field of learning analytics. This study referred to previous work on the indicators of high-quality collaborative learning, impact of learning space on behaviour, temporality as the focus of analysis, and finally, ENA. Indicators of productive collaboration can be found in the actions that students perform during collaborative learning activities. Those actions may be categorised into two groups: on-task and off-task. Students engaging in actions or interactions that are unrelated to the task is considered to be off-task behaviour , whereasexplaining represents a passive action and refers to reading out loud or talking with the objective of clarifying instructions or ideas. This is considered beneficial as it reorganises the material in a new way, develops new perspectives, and resolves inconsistencies, which would not be accomplished as comprehensively when done individually [discussion is considered an active social on-task action that engages more than one person in dynamic interaction [To define the analysis of on-task actions, the classification of activities based on their characteristics plays a major role. Two main characteristics of on-task actions may be distinguished: active and passive ,36. The vidually ,36. Addieraction  which iseraction  demonstreraction . OverallAlthough progress in the development of in-person learning models has been evident over recent decades, new learning spaces often neglect the pedagogical vision . With thFurthermore, Beckers et al.  found thNewly-configured learning spaces that are becoming more prevalent in practice incorporate recently developed teaching practices and emerging technologies that are dedicated to team-teaching and collaboration between students . These cGroup size and gender have been present in the research of collaborative learning for quite some time as moderators of collaboration. When considering the different group sizes proposed for collaborative learning activities, opinion is divided as to whether dyads or triads develop better collaborative strategies. Carvalho et al.  point ouHowever, when dealing with collaborative learning, research suggests that dyads should be considered as peer learning, while triads involve real collaboration . In thisWhen considering another common moderator of collaboration, gender, previous research has yielded interesting findings. Gender differences have been studied in various educational approaches such as formal learning, informal learning, game-based learning, collaborative learning. Differences between male and female subjects appear to be existing throughout these approaches and at various ages. A study examining gender differences in the achievement of kindergarten children in robotics and programming had the aim to establish if boys and girls at this age have equal successful rates . The youWhen observing usage of tangible interfaces in collaborative activity, Sapounidis, et al.  reportedFurthermore, a study examining women’s lower interest in video games compared to men, conducted in Germany, shows an association between gender and personality traits . Namely,Moreover, the gender composition of groups tends to be a relevant factor in collaborative learning processes. Wiley and Jensen  report tGiven the need to explore the impact of learning space in more detail and taking group size and gender as factors through which it may be examined, finding a method that would provide useful results in such a complex context was necessary. A temporal analysis perspective offers an interesting opportunity to examine the development of actions in different conditions over time and the differences that occur in them when different group sizes and genders are considered. Temporality as an element of analysis will be discussed further in the following section.The importance of the temporal perspective in learning, as a developmental process, has long been established ,55,56. HNumerous studies have investigated the development of collaborative learning activity over time and the importance of the order of events in order to better understand the process of collaboration. Reimann  points oQuantitative ethnography (QE) is an approach that merges quantitative and qualitative approaches to uncover meaningful patterns in data . The larENA generates dynamic network models using discourse data through several steps. First, for a given unit of analysis , ENA accumulates the co-occurrences of codes within a defined conversation. This results in the creation of dynamic network models that visualise the structure of connections between coded elements in discourse . DynamicIn the domain of learning analytics, ENA is a tool that provides exceptional opportunities due to its ability to quantify qualitative data and provide an overview of the entire process in terms of the connectivity of its data over a period of time . CurrentIn the context of CSCL, ENA has been applied for different modelling purposes. For instance, Shum et al.  have proThe experimental setup for authentic collaborative learning activity was organised in a motion capture laboratory, where students were invited to participate in an extracurricular activity. In the recruiting process, from more than 150 volunteers who expressed interest in the training, 36 university students with no prior knowledge of the topic were selected from different engineering degrees and different years, with an equal number of male and female participants. These 36 students (aged 18–24) formed 12 jigsaw groups, from which we analysed the data of 8 groups comprising 24 subjects. The subject selection criteria for analysis was: good camera coverage in order to obtain valid data, balance of gender as much as possible, and balance of table shapes. Of the 24 subjects selected for the data analysis, 12 subjects used rectangular tables and 12 round ones . Within Students participated in a collaborative problem-solving activity in which specific physical computing artefacts were to be designed. Following a jigsaw method , each seThe participants were asked to design, programme, and build an interactive toy that was to be designed using electronics connected to an open-source electronics platform and additional elements such as cardboard and paper. The difficulty level was adapted to the student profiles (who had no experience with this specific electronic platform) and they were provided with the information necessary for each step of the process. Students were informed of the data collection and analysis that followed this experiment, which was approved by an ethics committee. Informed consent was obtained from the students before the experiment.Data collection was performed with two video cameras used to record the experiments. They were positioned to cover the activity from different angles and at a height of two meters so as to avoid occluding student actions as much as possible. All sessions of the experiment had the same lighting, room temperature, surrounding furniture (except tables used for the activity), researchers present, and sounds in the laboratory (caused by the air conditioning system).The analysis was based on coding of student actions, where the coding system of on-task activities was established by overlapping information from literature used in similar scenarios and observations of participant behaviour ,49,50. AENA was used to model student behaviour in two different learning environments, which were defined by the shape of the table that students used during the collaborative activity. Two group sizes (dyad and triad) as well as two genders  were observed in both conditions. Student activities were coded and epistemic networks were generated for each of the cases analysed. In order to examine the differences between conditions, a difference network was generated by subtracting the average connection strengths for actions in each condition. The sections below present the results for the four cases analysed, with two considering the effects of table shape on different group sizes and two considering the effects of table shape on different genders. In each of the cases analysed and presented, the networks nodes represent each coded action, while the edge weights represent the relative amount of mutual co-occurrence of each of the actions. The network centroids can be described as something similar to the centre of the mass of an object  and eachx-axis, indicating differences in the arithmetic mean of the edge weights for both conditions. This denotes an overall difference in edge weights suggesting that the most frequent co-occurrences between actions under these two conditions are not the same. The strength of the connections between the actions in the case of triads is different between round and rectangular tables. It should be noted that, for round tables, stronger edges exist between interaction with physical artefacts (IPA) and discussion (Ds). This implies that students took turns performing these two actions more often than taking turns with other actions. The proximity of the centroid also confirms an overall prevalence of action co-occurrences under this condition, favouring the alternation of two actions  and discussion (Ds)) that are positioned on the far edge of the projection space. The position of the centroid for rectangular tables is closer to the centre of the projection space than that for round tables, which indicates less pronounced co-occurrences of a certain pair of actions. However, difference networks show how certain co-occurrences of actions are more present than others. For rectangular tables, the most frequent co-occurrence was between the action of non-verbal interaction (Nv) and discussion (Ds) see . This shIn the case of dyads , the netFurther analysis focused on the influence of table shape on the behaviour of students of different genders when working in groups of two or three members. In the case of male students, as in the previous cases, the positions of the centroids for both conditions also indicate differences between the conditions . The rouThe overall aim of this study was to evaluate whether the adoption of the temporal perspective in the analysis offers insights into how different table shapes affect collaboration with different group sizes and different genders. More specifically, the study aimed to answer two research questions: (1) What can a temporal perspective tell us about the effect of table shape on student behaviour in different group sizes (dyads and triads) during a collaborative activity? and (2) What can a temporal perspective tell us about the effect of table shape on the behaviour of different genders )? To answer the research questions, the study focused on using ENA in order to better understand the effects of the learning space through modelling of co-occurrences of actions, given the limitations of traditional coding-and-counting approaches . Our finThis study presents a different approach from previous ones adopted to date in the analysis of learning spaces. ENA has been employed in collaborative learning as well as in other areas ,62, but Starting with the first research question, the differences between conditions are visible both with dyads and triads, with a more pronounced difference in the case of dyads. Interestingly, the temporal analysis perspective yields different findings for these two group sizes. In dyads, students combine physical artefacts and non-verbal interaction more frequently when using round tables, as opposed to engaging in explanations and discussion while interacting with physical artefacts when working at rectangular tables. On the other hand, in triads, the round tables tend to foster more alternations between discussion and use of physical artefacts, and rectangular ones induce more co-occurrences of discussion and non-verbal interaction. While it cannot be said that the effects are explicitly opposed, it can be seen that the effect of more frequent co-occurrences between discussion and interaction with physical artefacts is caused by rectangular tables with dyads and by round tables with triads. Building on existing studies on the differences between dyads and triads, this study contributes by adding another explanatory factor that may shed light on previous findings on these differences and how the affordances of the space play a role in their behaviour ,9. The cIt should be observed that dyads and triads do not behave in the same way when the same table shape is used. The results, which show behavioural differences between dyads and triads, can expand previous research on this topic. Specifically, studies that deal with the differences between these two group sizes and report on the potential effect of the educational context ,69 may bFurthermore, the findings that the use of physical artefacts, which co-occurs more frequently with some actions  when both round and rectangular tables are used in dyads, as opposed to the same action’s co-occurrences with discussion in triads only when round tables are used, align with the literature . That isConsidering the second research question and the effects of table shape on genders, the results suggest differences under varying conditions. The findings in the case of female students show more frequent co-occurrences of interaction with physical artefacts (IPA) and non-verbal interaction (Nv) when round tables are used. Conversely, male students at round tables exhibit more alternation between interaction with physical artefacts (IPA) and discussion (Ds). This behaviour of male students contrasts with the lack of verbal communication among female students under the same conditions, which indicates that the learning space exerts a different influence depending on gender. This difference may also be observed with rectangular tables, at which there are frequent co-occurrences between non-verbal interaction and off-task actions with female students, while more co-occurrences between non-verbal interaction and discussion occur with male students. Once again, the differing influences of table shape can be noted. The behaviour of female students confirms the findings of previous studies, in which the inequality between male and female group members engaged in engineering tasks like this one was evident . PossiblThe study has several limitations. One, common to studies in the field of educational technology in complex contexts , is the Another limitation is that the activity was specifically designed with a Jigsaw collaborative script that makes it difficult to generalise the findings to other collaborative learning designs. However, the activity was open-ended, which is common to a wide variety of collaborative activities. Furthermore, the jigsaw scrip allowed for the possibility to test dyads and triads during the same experiment in a structured way, while balancing each students’ load to provide the most similar conditions for each student as possible. Even so, collecting additional surveys from students on aspects such as the workload and emotional stress they experienced would be beneficial. Furthermore, pre- and post-surveys would be useful for understanding to what extent their behaviour was influenced by previously acquired experiences.This study adds evidence to the fields of learning space design and collaborative learning by providing a setting for data collection and an analysis that enables observation of the interplay between table shape, group size, and gender, and their effects on on-task actions during collaboration. The results indicate the influence of table shape on student behaviour with different group sizes and different genders. Based on the ENA results, the different effects that different table shapes have on the course of student actions during collaboration have been identified. This study supports previous findings in the literature and extends them by providing further evidence that, due to its impact, the learning environment should not be overlooked as an important part of learning design. The temporal analysis perspective of collaborative behaviour adopted in this paper has been shown to be useful and meaningful in examining the varying effects of table shapes on different group sizes and genders. With this approach, the study contributes by applying known analysis methods in a new context. Namely, examination of temporal perspective has been shown to be meaningful in collaborative learning space analysis conducted in this study and a promising research direction for the future. Furthermore, the relationship between group size, gender and table shape, as a novel research perspective has the potential to further explore and contribute to research in collaborative learning fields. Regarding practical implications, more experimental research of table shape should be conducted in order to further clarify its role in the field of learning space research. In this way, the contribution will be made also in the field of learning design, by achieving adequate guidelines, especially when it comes to the size of groups and student behavior related to gender.


The objective of this study is to explore the mediator role of cognitive fusion and chronic pain acceptance on the effects that the walking pattern, following an established clinical guideline for physical exercise, can have on fatigue  in patients with chronic pain. The sample consisted of a total of 231 women with fibromyalgia with a mean age of 56.91 years . The results show a significant indirect effect of the walking pattern on both physical and mental fatigue through cognitive fusion and chronic pain acceptance. Specifically, walking predicted less cognitive fusion, which predicted greater chronic pain acceptance, which, in turn, predicted less mental and physical fatigue . It can be concluded that the walking pattern is linked to both physical and mental fatigue through cognitive defusion and chronic pain acceptance. These cognitive abilities would allow fibromyalgia patients to perceive an improvement in both physical and mental fatigue by carrying out the walking pattern. Emphasizing the training of cognitive defusion and pain acceptance would improve the adherence of these patients to walking. Physical therapy is chosen by health professionals as one of the main interventions to mitigate some of the symptoms associated with fibromyalgia (FM) ,2. HealtRecently, a model of psychological flexibility has been proposed as a unifying framework that could help understand this question. Psychological flexibility refers to the ability of an individual to consciously stay in touch with the present moment . This abAmong the studies carried out in patients with chronic pain, it has been found that cognitive psychological processes play an important role in the daily functioning of women with fibromyalgia and in how they relate to their disease . SpecifiThe sample consisted of 231 women with FM with a mean age of 56.91 years . Eligibility criteria to participate in the present study included having a diagnosis of FM according to the criteria of the American College of Rheumatology (ACR) ,29, haviAn ad hoc question was used. Taking into account the fact that this population is sedentary, the guideline established by Gusi  for patiThe total score of the Chronic Pain Acceptance Questionnaire (CPAQ) was used . This inThe Spanish version of the Cognitive Fusion Questionnaire was used ,31. ThisThe Physical Fatigue and Mental Fatigue dimensions of the Spanish version of the Multidimensional Fatigue Inventory (MFI) were used . This quAn ad-hoc questionnaire was used to evaluate the age, marital status, educational level and employment status. Regarding clinical variables, the duration of fibromyalgia was recorded.A total of 685 members from eleven Spanish fibromyalgia associations, which collectively comprise 1471 members with a clinical diagnosis of fibromyalgia (a compulsory requisite to join the association), satisfied the inclusion criteria for this study. Recruitment was made via mail and phone. Out of the 685 eligible participants, we were unable to contact twelve and 122 refused to participate. Thus, our population comprised of 551 women with fibromyalgia who were all contacted by ordinary mail, email and phone through the associations. Finally, 231 attended the appointment (41.92%).Researchers traveled to the associations and cited patients in groups of 10–12 patients (3 researchers per group). The patients received a protocol with the questionnaires that measured the variables of interest, and the researcher was present in case there was any difficulty in completing it. Finally, the researcher reviewed the protocols once they were completed to ensure that there was no missing data. Completion of the protocols lasted between 30 and 45 minutes.p value of less than 0.05.The analyses were performed with the SPSS 22 statistical package . First, p-value of > 0.05, a comparative fit index of > = 0.95, and an approximation of the mean squared error of <0.06 , p = 0.003) and a total effect  of the predictors was found on physical fatigue. Furthermore, there was a significant indirect effect of walking on physical fatigue through cognitive fusion and chronic pain acceptance   . That isThe main objective of this study was to analyze the relationships established between walking  , cognitiAnother of the obtained findings shows that there were no simple indirect effects of walking on the fatigue components through any mediator acting independently. There was also no direct effect of walking on mental fatigue. Although there are a number of professionals who recommend physical therapy as a strategy to alleviate mental fatigue , the resAn interesting piece of information from this study is the differences between the direct effects of walking on physical and mental fatigue. While the results do not show a significant direct effect of walking on mental fatigue, a significant direct effect of walking was found on the physical fatigue component. As established in the previous literature, the results indicate that the performance of the aforementioned gait pattern with the aim of performing physical exercise reduces the perception of self-reported fatigue . On the While it is true that this study has important practical implications, a number of limitations must be taken into account. First, the results are based on women with FM, and though they constitute the most common sex for this condition, more research in other populations with chronic pain and in men is considered necessary to see if the found results are generalizable. Second, this is a cross-sectional design, so it does not allow one to infer cause–effect relationships between walking pattern, fatigue, cognitive fusion and acceptance of pain. Longitudinal studies are encouraged in order to investigate the causal relationships. Third, the assessment instruments are self-report measures, so they are subject to response bias. In future research, it would be interesting, especially in relation to the pattern of walking, to carry out longitudinal studies, completing the information with accelerometers/pedometers. Finally, it is important to note that the study included two mediators, defusion and chronic pain acceptance, in relation to the cognitive abilities of the patients, but the list is far from complete, and other psychosocial factors  could also be investigated in future research.Taking into account the above limitations and paying special attention to those related to the study design, it could be hypothesized that the performance of structured physical activity could predict improvements in physical and mental fatigue through cognitive defusion and chronic pain acceptance. Therefore, it is recommended that one carry out multicomponent interventions that integrate structural physical therapy and therapies framed within the model of psychological flexibility. This could also have a positive influence on patients, who could interpret physical exercise as beneficial for their physical and mental health and thus improve their adherence to walking.


Pregnancy leads to several skin changes, but evidence about structural and functional skin changes is scarce. Findings on skin structure and function in children in their first year reveal rapid skin maturation, but evidence indicates that in particular, water holding and transport mechanisms are different from adults. Important questions include whether maternal cutaneous properties predict infant skin condition, and if so, how. This is especially relevant for the skin's microbiome because it closely interacts with the host and is assumed to play a role in many skin diseases. Therefore, the study objective is to explore characteristics of skin and hair of pregnant women and their newborns during pregnancy and in the first six months after delivery and their associations. n = 100 women is the target. We perform noninvasive, standardized skin, hair, and skin microbiome measurements. We establish the baseline visit during pregnancy until at the latest four weeks before delivery. We schedule follow-up visits four weeks and six months after birth for mothers and their newborns. We will calculate descriptive statistical methods using frequencies and associations over time depending on scale levels of the measurements. Discussion. The majority of previous studies that have investigated infants' skin microbiome and its associations used cross-sectional designs and focused on selected characteristics in small samples. In our longitudinal study, we will characterize a broad range of individual and environmental characteristics of mothers and their newborns to evaluate interrelationships with skin parameters and their changes over time. Considering the combination of these multiple variables and levels will allow for a deeper understanding of the complex interrelationship of the newborn's skin maturation. This trial is registered with ClinicalTrials.gov (Identifier: NCT04759924). The study has an observational longitudinal design. We are recruiting pregnant females between 18 and 45 years using advertisement campaigns in waiting areas of gynecologists and hospital's outpatient services. A final sample size of  The skin is widely considered the largest organ of the human body, and it fulfills a variety of essential functions. One of the most important functions is protection. However, there are certain periods in life when skin health is challenged . Two of In contrast, evidence about skin function and skin structure in newborns and infants is more common. Immediately after birth, the rapid skin barrier maturation is well studied , but eviIn recent years, there has been an increasing interest in associations of the skin microbiome and skin health . The aboUntil now, few studies have explored possible associations of skin function and microbiome between mothers and newborns. Dominguez-Bello et al. showed that the method of delivery  is linked to the diversity of the cutaneous bacterial colonization . AdditioHowever, most study results are based on cross-sectional study designs, ignoring changes over time. Because of the multiple interactions between skin structure, function, and microbiome, it is necessary to consider and measure all aspects over time.The aim is to measure skin and hair characteristics of mothers and newborns over time and determine demographic, environmental, and health characteristics associated with skin microbiome development.Are there associations between health, skin, and hair characteristics of mothers and newborns?How does the skin microbiome change during pregnancy and after birth?Do maternal health and skin characteristics predict the skin characteristics of newborns and infants?Therefore, we will answer the following research questions:We perform a longitudinal, descriptive cohort study including females during pregnancy and puerperium, and their newborns until six months of age shown in We invite women after the first pregnancy trimester from the federal state of Berlin (Germany) during their visits to gynecologists and/or midwives. We conduct inclusion and all study visits and measurement procedures at the Clinical Research Center for Hair and Skin Science at the Department of Dermatology at the Charité–Universitätsmedizin Berlin (Germany). If they meet the eligibility criteria, women are included in the study. Upon inclusion in the study after the baseline visit, we follow up with the women and their newborns four weeks after delivery and again six months after delivery.Participants are pregnant females between 18 and 45 years old and residing in Berlin (Germany). Prerequisites for study inclusion are individual written informed consent, clinically healthy skin and hair appearance, as well as being free of any dermatological condition. Skin afflictions, which may interfere with the study assessments, especially atopic dermatitis, scars, or other lesions at the investigational site result in exclusion. Women must be of general good and stable health as confirmed by medical history and by a physical examination. They must accept to abstain from sunbathing and solariums and to agree to stay consistent in using their individual skin cleaning and caring routines during the study.Women are excluded due to regular smoking, regular alcohol intake, or criteria related to diseases such as any dermatological condition or skin affliction, which may interfere with the study assessments. These could be any inflammatory dermatosis  or clinically significant, possibly unstable medical conditions due to pregnancy such as gestosis, eclampsia, or thrombosis. Criteria related to treatments and products such as current topical or systemic treatment possibly affecting the skin  during the past four weeks are further exclusion criteria. Additionally, therapeutic ultraviolet radiation or increased ultraviolet exposure within six weeks before inclusion leads to exclusion. For safety, other medical reasons, and any individual reasons, study participation can be stopped.Due to the descriptive and exploratory nature of this study, we assess a broad range of characteristics and variables. Skin structure is measured by means of skin surface topography, epidermal thickness, skin stiffness, and skin elasticity. Skin function is measured by means of stratum corneum hydration (SCH), TEWL, and skin surface pH, which are established parameters to characterize the skin barrier function. Skin microbiome is defined as bacterial diversity, and in this study, the relative abundance of phylotypes,  will be measured. Hair growth is measured on the central and occipital scalp by means of hair density and hair widths. The definitions of the variables are shown in We train all data collectors in accurately obtaining the variables of interest. We use paper source data and electronic case report forms to document all study variables of interest.The investigator performs the dermatological examination during the visits together with a subject's interview on medical history and treatments to check the subject's eligibility.We measure the physiological skin parameters of the females and the newborns at one area of the right inner forearm. All measurement procedures are based on internal standardized operating procedures as part of the quality management system of the study site. Before the assessment measurements, subjects rest for 30 minutes in a room with controlled environmental conditions  for acclimatization. During acclimatization, the skin of the investigational sites is uncovered and exposed to ambient air. The parameters are measured in the following order: skin swab, TEWL, SCH, pH, Cutometry, OCT, and Visioscan. The order and exact skin areas are arranged in such a way that any measurement procedure will not affect the readings of the subsequent measurement .Based on the definition of the EEMCO guidance , the skiOptical coherence tomography  allows for a noninvasive imaging of the epidermis , 28. BasThe total extensibility of the skin  is measured using the “Cutometer MPA 580”  according to guidance by the EECMO group for the assessment of biomechanical skin properties .g per hour per m2) is measured using the “Tewameter TM 300” . This is an open chamber method, and the results are compared to published reference values in adults and newborns [TEWL . This investigation is highly reliable at the volar forearm  when appSCH is measured by using the “Corneometer CM 825” . The measurement is based on the differences in the dielectric constant of water and other substances within the stratum corneum. The arbitrary units for SCH measurements range from 0 to 120, with higher readings indicating higher SCH .We follow the analytic test methods put forward by McInnes and Cutting in the “Human microbiome project,” for describing the microbiome distribution of bacterial species in this study . Accordi2, sum of hair width per cm2, terminal to vellus ratio, and average hair width (μm). Additionally, the hair colour is estimated by a 10-point hair colour scale [Hair measurements are taken on the central and occipital head area in women and on the central head area in newborns/infants. Standardized macro photographs are taken to measure hair growth and structure. We use the Visiomed D200 evo camera of Vectra H1 Hair Metrix, Canfield Scientific, Fairfield, USA. The camera is placed on the selected area of the participant's scalp to take a picture as a noninvasive method. At the selected area , the hair is parted with a comb, preparing the hair region for investigation. The following quantitative hair measurements are calculated automatically by the software system: hair count per cmur scale .During the study period, the risk of losing participants is addressed with proper information and close support in the beginning and throughout the study. An expense allowance is provided. If a woman is included during the early phase of pregnancy, a phone call is scheduled three months after inclusion or at the latest one week before the due date. This phone call allows us to check the current situation, as well as to check the date for the second visit (t1). Similar to this procedure, the women are called one week before the scheduled third visit (t2). If the women are not reachable, phone calls are repeated twice, and in addition, emails are sent and repeated twice. If there is no response, a letter by registered post is sent. If there is no response after all contact attempts, the woman is then excluded from the study.In order to estimate the outcomes accurately, all investigations are following internal standardized operating or technical procedures, with staff exclusively allocated to the study performing them.Due to the sampling of eligible women restricted to one geographical area, a potential sampling bias is addressed by comparing all relevant characteristics of the included women with national data. Due to the voluntary nature of inclusion in the study, a sampling bias might occur. Therefore, relevant characteristics of the included women are compared to the study population to evaluate potential differences. To address a potential response bias, the age distribution and the number of pregnancies of the included women are considered and compared to national data of the mean age of women at delivery of their first child.n = 150 mothers to be included.Due to the exploratory character of this study, formal sample size calculation is not performed. We aim to include 100 pregnant females and their newborns/infants to obtain means and proportions with an acceptable range of uncertainty. A loss-to-follow-up of one-third is assumed resulting in a total of t tests (metric observations) will be used to compare paired data. Confidence intervals (95%) will be computed for the effects of interest. Due to the explanatory character of the study, all statistical analyses are exploratory, and thus, all P-values and confidence intervals are considered descriptive. If missing values occur, we discuss them on an individual level and use all available cases in the analysis. All statistical methods will be performed using validated software.We will describe the demographic characteristics of the subjects, using absolute and relative frequencies, means, and standard deviations (SD). Metric outcomes will be described using means, SD, medians, and interquartile ranges (IQR) per group and time point. Ordinally, scaled outcomes will be described using medians and IQR per group and time point. Associations of skin parameters between mothers and their newborns/infants will be described using correlation coefficients . Linear mixed models , as well as nonparametric rank-based methods for longitudinal data , will be used to assess differences between groups over time (and possible interactions). Furthermore, the Munzel test r (nonparametric) or paired The following subgroup analyses are planned: according to age groups of the females, comparisons will be made for Q1/Q4-age-related groups. Due to the predisposition for atopic dermatitis (AD), an analysis for existing or non-existing AD will be made. Because of a possible association between mode of delivery and the skin microbiome, comparisons will be made for vaginal and cesarean delivery.n = 150 women, we assume the number of dropouts to be n = 50. Because this is a single cohort of women and their newborns, missing data will not be dependent on different exposures. However, we will compare the groups of subjects with missing data and groups of subjects with complete data regarding main outcome variables to estimate potential bias. Secondly, we will estimate the influence of main predictor variables, such as age, on the occurrence of missing data. Based on the proportion of missing values and the assumed bias, appropriate multiple imputation methods for categorical and continuous variables will be applied [Because of the long individual follow-up, the attrition rates are difficult to predict. After the inclusion of  applied .Subjects or parents/guardians have the right to ask the investigator for a summary of the study results, as soon as they are available. Results are planned to be published in an international peer-reviewed scientific journal. The content and structure of the manuscript will follow the STROBE statement for observational studies , 39. AutMost of the previous studies investigating the infant's skin microbiome and its associations were conducted using cross-sectional designs and focused on selected characteristics in small samples. In our longitudinal study, we are characterizing a broad range of individual and environmental characteristics of mothers and their newborns to evaluate interrelationships with skin parameters and their changes over the period of at least eight months. Because it is well known that cutaneous changes occur rapidly during and after pregnancy and after birth, the chosen times for measurements are likely to capture these changes. Connecting demographic, environmental characteristics, as well as biophysical skin parameters and the skin microbiome has never been done in this setting to date. Considering these multiple variables and levels together will allow for a deeper understanding of the complex interrelationship of the newborn's skin maturation and allow generating hypotheses to be tested in larger confirmatory studies. By analyzing factors influencing the cutaneous microbiome of the newborns, the results can support recommendations for environmental or individual living conditions and may help predict cutaneous risk in newborns and infants based on their mothers.The study is based on the study protocol, from 21 October 2020, Version No. 2. The recruitment phase started on 10 March 2021. The approximate month when recruitment will be completed is estimated to be June 2022.