In primary care, a shift from a disease‐oriented approach for patients with multimorbidity towards a more person‐centred approach is needed.To transform a self‐report questionnaire for patients with chronic conditions in primary care, the Primary Care Functioning Scale (PCFS), into an understandable, visually attractive and feasible consultation tool for patients and health care providers. The consultation tool consists of a web‐based version of the PCFS, which is filled in by the patient and is processed to a feedback report that summarizes and visualizes the main findings. The feedback report can be discussed with the patient to facilitate a more person‐centred conversation for patients with chronic conditions and multimorbidity in general practice.In this qualitative study, we developed the consultation tool by using design thinking in a participatory developmental process.In the first phase, we constructed five different feedback report templates to summarize and display the results of a completed PCFS questionnaire in a series of two expert meetings with patients and general practitioners (GPs). In the second phase, we performed an exploratory qualitative interview study involving dyads of patients with chronic conditions and their practice nurses. In an iterative process, we explored their experiences with the consultation tool.Patients, as well as GPs, preferred a clear manner of presenting the results of the questionnaire in a feedback report. In 18 interviews with patients and practice nurses during three different interview rounds, we adjusted the feedback report and consultation tool based on the input from patients and practice nurses. After the final interview round, patients and practice nurses consented that the consultation tool was useful for having a more in‐depth consultation about functioning and patients' preferences when integrated into the regularly scheduled consultations.We were able to develop an understandable and feasible consultation tool that is applicable in already existing chronic disease management programmes in general practice in the Netherlands.To increase the understandability and feasibility of the consultation tool, we collaborated with end‐users and actively involved patients, GPs and practice nurses in a participatory development process. The consultation tool consists of a web‐based version of the PCFS, which is filled in by the patient and is processed to a feedback report that summarizes and visualizes the main findings. The feedback report can be discussed with the patient to facilitate a more person‐centred conversation for patients with chronic conditions and multimorbidity in general practice.22.1The consultation tool was developed by using the principles of human‐centred design; that is, a participatory development process, with the active involvement of patients, GPs and practice nurses.In the first phase (A), patients, GPs and researchers developed different feedback report templates that provide a summary of the results of the PCFS questionnaire. In the second phase (B), these feedback report templates were tested in consultations among patients and practice nurses in an iterative interview study.2.2For the development of the feedback report template in Phase A, six patients with chronic conditions included in chronic disease management programmes in their general practice were invited to participate in two expert panel meetings. These patients were selected by their GP and we asked the GPs to maximize the variance in age, education, life experience and estimated level of functioning of their patients. The patients were age 50 years or older with the presence of DM 1 or 2, COPD/asthma or a CVD and already familiar with the PCFS from a previous validation study. They consented at that time that they may be contacted for follow‐up studies.For the interview study among patients and practice nurses in Phase B, we recruited 18 participants (nine dyads of a patient with multiple chronic conditions and their practice nurse) from seven different primary care practices located in urban and rural areas within the Radboudumc Practice‐Based Research Network, The Netherlands. Patients had to participate in chronic disease management programmes for DM, COPD/asthma or CVD.Nine practice nurses each randomly invited one patient with DM, COPD/asthma or CVD above the age of 50 years to participate in this study. The study was carried out according to Dutch legislation and the declaration of Helsinki. The accredited Medical Research Ethics Committee Radboudumc Nijmegen gave clearance to conduct the study (registration number 2017‐3936).From every patient and practice nurse, informed consent was obtained; patients and practice nurses were able to withdraw their consent at any time.2.3In a series of two subsequent expert meetings, patients and GPs collaborated within an expert panel and discussed key features of the results of the questionnaire that were deemed relevant for the feedback report template. To identify the feedback report's user needs, patients and GPs were asked which results from the questionnaire were important to report for the patient and the professional. Also, they were asked to illustrate in drawings using colours, figures, tables, graphics and emoticons, how the results of the questionnaire are preferably reported. After the second expert meeting, on the basis of the discussions, five different feedback report templates could be constructed for use in the second phase of this study Figure .2.4Patients participating in chronic disease management programmes were asked by their practice nurse to complete the PCFS questionnaire at home. Next, patients discussed the results of the questionnaire and feedback report templates within 2 weeks in a 20‐min consultation with the practice nurse. After the consultation, patients and practice nurses were interviewed separately about the experiences with the use of the questionnaire, feedback report templates and the consultation.2.4.1An interview guide was developed for the interviews with the patients and practice nurses based on the Consolidated Framework for Implementation Research  answers scored with a problem and (2) answers scored with dissatisfaction. Most patients and GPs preferred that the results of the PCFS were reported in written text (vs. the use of images and figures). Regarding the content of the presentation in the feedback report of the results, there was a variety of opinions among patients and GPs about (1) whether the level of the problem should be reported (from a mild problem to severe problem), (2) the need for a sum score of the items, (3) the use of colour in expressing the level of problem and satisfaction, (4) the use of symbols to illustrate the item, (5) the use of symbols with a facial expression  to illustrate the level of satisfaction and (6) whether to display changes over time in the level of functioning. After the second expert meeting, based on the input from patients and GPs, five different feedback report templates were constructed to use for further development in the subsequent testing with patients and practice nurses Figure .3.2In total 18 participants (nine dyads of one patient and one practice nurse) consented to participate. They were interviewed in the period from October 2018 to March 2020. The participants' characteristics in relation to the chronic disease management programme are presented in Table We could identify four relevant main themes of experiences with the consultation tool in general practice: (1) content of the questionnaire, (2) feedback report template , (3) communication about functioning during a consultation and (4) applicability of the consultation tool in daily practice. In the following section, the results of the different interview rounds will be presented per theme and which identified difficulties, problems and suggestions resulted in a revision of the consultation tool after an interview round.3.2.1Extensive. So, clearly quite different areas: psychosocial, emotional and physical too. That diversity was very clear in the questionnaire. Well, it really gives you more information about the patient. I've actually known this patient for years, but I really learned new things […]Of course, when you have a short consultation you always discuss a small, specific subarea, mainly to do with the disease and the disorders. And now I have a bit of a better picture of ‘hey, who is she exactly? What does she do in her spare time?’ So it helped me get to know her a bit better. All patients and practice nurses were positive about the content of the PCFS questionnaire consistently through every interview round. Also, all practice nurses indicated that the PCFS is a complete, extensive and broad questionnaire capturing the relevant aspects of functioning. The questionnaire provided the practice nurses with more knowledge about their patients' daily functioning, and this was regarded as an additional value in the care for their patients.All patients indicated that the PCFS provided a good and complete impression of the different aspects of their own functioning and that the items of the questionnaire captured important, personal and relevant information for the health care professionals about themselves.3.2.2Right, then I start to get doubts because I thought ‘I sleep well, so that's the smiley’ but that's apparently not the function. So that might get a bit confusing. The analyses of the first six interviews with patients and practice nurses demonstrated important difficulties and problems with the interpretation of the different feedback report templates. For example, one template illustrated problems in functioning in the first column and satisfaction levels with emoticons in the second column Figure . PatientThe younger generation will like that symbol smiley with a ‘zzz’ (sleeping symbol). An elderly, or my father, would not understand what it means. Also, patients and practice nurses found the addition of the use of symbols in the templates confusing, or difficult to understand what the symbol was representing or of no added value.Based on the emerging difficulties and problems with the understandability of the feedback report templates in all of the first interviews with patients and practices nurses, we constructed a new feedback report template that included only the basic requirements mentioned by patients and GPs in the preceding development of the feedback templates: A written feedback report, including items scored with a problem and/or items scored as dissatisfaction, in addition to the levels of the problems in functioning and satisfaction. After the adjustments made in the feedback report, no more difficulties and problems nor new suggestions were mentioned by patients and practice nurses in the following interview rounds regarding the understandability of the feedback report or preferences in the layout of the feedback report.3.2.3It was much more personal. We got to talk about things that I've often thought I'd like to say something about but didn't come up in the check‐up because you just got those ‘yes’, ‘no’, ‘yes’, ‘no’ questions, right? […] For example, I had this pain in my body and I'd mentioned it a couple of times but then you got the next question so you never got an answer to it. Patients experienced that the consultation focused on the various aspects of functioning and that this differed from the regular follow‐up consultations. They regarded this as a positive change of the consultation and mentioned the consultation as being pleasant, personal and relevant.You can give people this very clear feeling of ‘I see you, you haven't come here because…, I see what you're struggling with, what's important to you’. […] I think that could be really nice for people. […] That they definitely feel someone is listening and that they say that too. Practice nurses considered the results of the PCFS as a useful tool to reach a more in‐depth consultation about functioning. In general, practice nurses found that the consultation provided more information about the different aspects of a patient's functioning, also for practice nurses with a long‐term nurse–patient relationship.3.2.4So I do think it is important for the nurse practitioner to get some instructions in advance. […] But it did cost me quite a lot of time. Twenty minutes? With these questions—so many? I definitely can't manage that. [Laughs]. During the first round of interviews, practice nurses indicated that they found it difficult to structure the consultation and it was not clear what needed to be discussed exactly during the consultation. The consultation lengths exceeded the suggested duration of 20 min because all the problems and dissatisfactions were discussed, and in general the practice nurses were missing clear instruction.After round 1 of the interviews, based on the experiences and suggestions from the practice nurses, clear instructions for the consultation for the practice nurses were created in which the consultation should clarify the patient's: (1) current problems, (2) needs  and (3) preferences to change certain specific limitations of functioning and help to set achievable goals with defined actions necessary to reach these goals. After the second round of interviews, practice nurses were satisfied with the instructions that helped them to structure their consultation with the patient in approximately 20–30 min. In relation to the instructions, after interview round 2, it was suggested that the consultation should focus on one or two problems in functioning from the feedback report that is chosen in a consensus between the patient and the practice nurse because of the limited time of the consultation to discuss all problems. After the new adaptations of the practice nurses' instructions, no new problems and suggestions were mentioned in the third round of interviews.I would link it to the regular consultations. […] yes, with some diabetes patients I reckon you can say, hey, I see this, or I think that's related to the diabetes or even a consequence of it, so let's talk about that next time. Practice nurses indicated that the conversation about functioning should be integrated with the existing regular follow‐up consultations of the chronic disease management programmes to be able to stimulate improvement in certain aspects of functioning.Then you have indeed covered everything at that point, otherwise you have to come back for something else in two weeks' time, let's say, and I can imagine that being a problem, people saying ‘what, do I have to come again?’ […] I would indeed prefer… right, that it should fit in with that overall… right, so you say, now I know where I'm at. Patients also argued that an integration of the consultation with the existing regular follow‐up for the chronic disease is preferred because of better time management.I basically just went through the annual check‐up calmly and at the start I began with ‘right, you filled in the questionnaire and that showed two highlights, right?’ and then I basically incorporated those two points in the conversation. And I found the annual check‐up didn't feel that different at all to normal. I had the feeling that we covered a lot of ground but those points that he'd suggested, you could delve into them more specifically. I found the explanation I read in advance very clear, the instructions were clear, I really liked that summary, it was very workable, those results. In the third round, the consultation about functioning was integrated into the existing follow‐up consultation for the chronic disease. Patients indicated that it felt in place to discuss problems and difficulties in their daily functioning in combination with their regular consultation with the practice nurse and no new problems, difficulties or suggestions were mentioned by patients. Also, the instruction to integrate the consultation with the scheduled chronic disease management consultation was clear for practice nurses. A practice nurse from the last interview round indicated that she experienced the combination of the consultation tool and the annual check as ‘normal’.44.1In this study, we developed a consultation tool to assess and discuss the functioning of patients with chronic morbidity in the general practice. Through different steps according to the participatory developmental process and by using design thinking we transformed the PCFS questionnaire into an understandable, visually attractive and feasible consultation tool for patients and health care providers. Patients and practice nurses were positive about the added value of a consultation that focuses on the functioning and should be integrated with the regular follow‐up consultations of the chronic disease management programmes in daily practice.4.2A number of studies to date have explored the effectiveness of interventions that aim to support the management of multimorbidity in primary care for improvement in health outcomes.It is known that health‐related self‐report questionnaires can motivate patients to reflect on their own health and help to discuss these issues with their clinicians ‘in their own words’, which supports the communication process and can improve health care outcomes.In this study, we have demonstrated that the results of the PCFS questionnaire can be used as a consultation tool by the patient and the health care provider incorporating the consequences of chronic conditions and multimorbidity on daily life functioning, thereby stimulating personalized healthcare. Practice nurses indicated that they found it useful to connect the problems raised by the PCFS questionnaire with the patients' known chronic diseases and this was an important added value of the consultation tool to their regular care.The involvement of patients and/or end‐users in a participatory process is widely accepted and is known to be important for developing a successful intervention.Practice nurses indicated that an important added value of the consultation tool is the connection of the raised problems in functioning with the patients' chronic diseases. However, practice nurses, as well as patients, doubted whether the consultation tool would have this added value when it would be used apart from the existing regular follow‐up consultation.4.3The most important strength of this study is that the consultation tool was developed in collaboration with all stakeholders involved, such as patients, GPs and practice nurses. This is in line with the development and validation of the PCFS in which patients were also actively involved.Next to the participatory development process, we used the CFIR framework for the qualitative interviews. The CFIR provides a framework of constructs to increase effective implementation of interventions in healthcare that can be used as a practical guide for systematically assessing the potential barriers and facilitators to overcome potential barriers for implementation at a later stage.4.4Alongside this study, we refined the consultation tool, which now automatically generates a personalized feedback report based on the patient's self‐reported answers to the questionnaire. The final version of the feedback report is presented in Figure 5With the involvement of the stakeholders, we developed an understandable, visually attractive and feasible user‐centred consultation tool for patients and health care providers, which supports the integration of the different aspects of health‐related functioning in existing chronic disease management programmes. The consultation tool can be used in the general practice to shift the regular follow‐up consultations for patients with chronic conditions, that is still mainly focused on single disease outcomes measures, towards a more person‐centred consultation taking the consequences of chronic suffering on health‐related functioning into account.Conceived and designed the analysis: Simone Postma, Henk Schers, Tom van de Belt, Kees van Boven, Huib ten Napel, Hugo Stappers, Debby Gerritsen and Tim olde Hartman. Collected the data: Simone Postma, Henk Schers, Tom van de Belt, Kees van Boven, Huib ten Napel, Fedor Hagema and Tim olde Hartman. Contributed data or analysis tools and performed the analysis: Simone Postma, Henk Schers, Tom van de Belt, Kees van Boven, Huib ten Napel and Tim olde Hartman. Wrote the paper: Simone Postma, Henk Schers, Tom van de Belt, Kees van Boven, Huib ten Napel, Hugo Stappers, Debby Gerritsen and Tim olde Hartman.The authors declare that there are no conflicts of interest.


Inefficient practices and lack of competition are common problems in public procurements. In this study, I examine the effects of a procurement practice reform in the Finnish rehabilitation markets where providers are acquired in a repeated manner through competitive bidding scoring auctions. Until recently, the largest public procurer did not use any systematic criteria for accepting providers, and only a few providers did not receive a contract. After the reform, providers were systematically accepted based on their capacity and the local demand. I analyze the effects of the reform on prices in physio, speech and occupational therapy services with data that covers five subsequent procurements. I use the pre‐reform differences in local competition within the markets in a difference‐in‐differences setting. The descriptive evidence shows that the reform slowed down the rapid increase of prices in all three services. The regression analysis indicates that effects are strongest in the most competitive local physiotherapy markets. This suggests that increasing entry and competition in the less competitive services and local markets would benefit the public procurer. The study focuses in outpatient physio, speech and occupational therapy markets, which are the three largest therapies of individual rehabilitation. All of these services are intended for persons under 65 years of age with disabilities, who face problems managing daily activities and fulfill the criteria defined by the law. The services are provided based on a written rehabilitation plan drawn up with a physician for one to 3 years at a time. Patients do not pay anything out of pocket and have free choice among the accepted providers. Typical therapy sessions last 45 or 60 min and are scheduled a few times a week, depending on each patient's individual rehabilitation plan. Some patients may receive the therapy for several years. The services are organized either at the provider's facilities or remotely in a familiar environment such as the patient's home, school or kindergarten.Kela organized and financed these three services for a total of 38,762 patients at a total cost outlay of 159.3 million euros in 2018. Figure 3.2Kela's insurance districts are responsible for organizing the three services for their local populations.However, prior to 2018, the districts did not apply systematic acceptance criteria or rules in the competitive bidding, and the most common acceptance threshold was below the provider ranked last. Therefore, very few providers that fulfilled the minimum requirements failed to receive a contract offer in each of the three services. For example, out of 25 districts in the 2010 procurement, only three rejected at least one provider in physiotherapy and occupational therapy services, and only two in speech therapy service. A previous study jmt is a natural logarithm of provider j's price located in municipality m in procurement year t. Treatmentm takes value 1 for providers in the treatment group and 0 for providers in the control group. Reformt takes value 1 if the observation is from the 2018 procurement and 0 if from the pre‐reform procurements prior to 2018. Thus, the interaction Treatmentm ∗ Reformt takes value 1 if the observation is from 2018 and the provider belongs to the treatment group, and 0 otherwise. The DID coefficient β is the parameter of main interest, measuring the price effect of the reform in the treatment group relative to the control group. Variables μj, δt and γd are provider, year and district fixed effects, and εjmt is an error term. Standard errors are clustered at provider‐level. The main specifications are estimated using data from all five subsequent procurements in 2003, 2006, 2010, 2014 and 2018.I use variations of the following provider‐level DID model separately in the three services to analyze the effects of the reform:As Roos et al.  discuss,The definition of the treatment and control groups naturally has some caveats. First, geographical boundaries such as municipalities are often not considered as good local market definitions because they are either too small or large (Dranove & Ody, Finally, even though most providers participate in subsequent procurements, new providers may enter and incumbent providers may exit the markets in between the procurements. For the robustness of the empirical results, it is important that the composition of treatment and control groups remains stable over time. For example, if the number of bidders per municipality has increased after the reform in 2014, the control group could have been directly affected by the reform. Table 55.1Figure Most providers in all three markets have participated in subsequent procurements. For example, 80% of physiotherapy providers in the 2014 procurement had participated also in 2010. The right‐hand side of Figure Figure More detailed evidence on prices and price changes is presented in the online Appendix. Tables Figure 5.2Table The results indicate that especially physiotherapy providers in initially more competitive areas responded to the increased risk of not being included in the pool of providers. There are at least three potential explanations why similar statistically significant effects are not found in the speech and occupational therapy markets. First, the empirical approach offers a lower bound estimate for the effect of the procurement practice reform. Second, the treatment and control groups are small compared to those in the physiotherapy markets, which produces large confidence intervals. For example, the descriptive evidence (see Figure The negative effect of a little under four percent in the physiotherapy market corresponds to an average price decrease of around 2.3 euros in the treatment group. Because the reform had a smaller but still negative impact on prices also in the control group, and the two groups share similar pre‐trends, the empirical strategy should fulfill the two assumptions discussed by Fricke . Thus, t5.3Table The primary treatment group consists of providers that are located in municipalities where the number of bidders in 2014 was at least two in speech and occupational therapy services, and at least four in physiotherapy. Figure 6This study provides evidence on the effects of a more efficient procurement practice on providers' prices in Finnish rehabilitation markets in 2018. The reform brought three changes: A more rule‐based acceptance criterion based on capacity and demand in a municipality, a decrease of quality‐weight from 50% to 20%, and the centralization of the process to a specialized procurement unit. Nearly all bidders received a contract under the previous procurement practice, which resulted in rapidly increasing prices (Pitkänen et al., The analysis shows that the reform affected prices and costs via three channels: First, the descriptive evidence shows that the reform had a clear negative effect on prices in all three markets. The strong growth rate of prices declined sharply in 2018, and providers that participated in subsequent procurements increased their prices significantly less than in previous procurements. Second, the reform had a direct impact on costs because most providers with relatively high prices were not offered a contract. Pitkänen et al.  calculatEven though the reform increased price competition and generated cost savings for the procurer, the welfare implications of the reform are ambiguous: Limiting the number of contracted providers forced several patients to switch their incumbent provider for the new contract period. For some patients finding and choosing a new suitable provider can be challenging and may also increase their travel time and costs. On the other hand, the new pool of accepted providers consists mainly of higher quality providers, which may benefit some of the switching patients. Changes in the pool of providers and the resulting search costs for patients are the main disadvantage when repeatedly organized procurements are used in health services that patients receive frequently and for a long time.for the market and the new quality‐price scoring rule may also influence providers' quality, especially in the long term. The effects on quality competition in the market are also unclear, as a smaller number of providers now compete for patients, many of whom are forced to choose a new provider at the start of the contract period. The reform may also have spillover effects to other markets, such as the procurements organized by Finnish municipalities. For example, increased competition in one market may also increase competition and decrease prices in other markets (Baicker et al., Naturally, the study has some limitations as the analysis concentrates solely on the immediate price effects of the procurement reform. In time, providers will likely learn about the risk of not receiving a contract in their service and local markets, which may increase prices in future procurements. Increased competition Maintaining a competitive market environment will be necessary for successful future procurements. After the reform, several providers found themselves without a contract from the largest service purchaser. If these providers do not find new markets and patients, the potential number of bidders may decrease in future procurements. A lower number of contracted providers may also decrease providers' expectations and incentives to participate in future procurements (McCombs & Christianson, The author receives a salary from Kela, which organizes and finances the studied services and procurements. The paper represents the views of the author and does not necessarily represent the official views of Kela.Supplementary Material 1Click here for additional data file.


Upon publication of the original article, it was noticed that in the HTML version, the winter and summer symbols of Figs. The corrected Figs.


We report on an optimization study of percussion drilling thin metal sheets employing a high repetition rate, high power femtosecond laser with respect to the resulting heat accumulation. A specified simplex algorithm was employed to optimize the spatial drilling sequence, whereas a simplified thermal simulation using COMSOL was validated by comparing its results to the temperature measurements using an infrared camera. Optimization for drilling borehole matrices was aspired with respect to the generated temperature across the processed specimen, while the drilling strategy was altered in its spatial drilling sequence and by using multi-spot approaches generated by a spatial light modulator. As a result, we found that an optimization strategy based on limited consecutive holes in a Moore neighborhood led to reduced temperatures and the shortest process times. Ultra-short pulsed (USP) laser machining processes are, in general, associated with low thermal input into the processed work piece and thus a negligible heat affected zone, often referred to as cold ablation ,2. Howev2) during a drilling process without impairing the quality. These experiments indicate a decreasing influence of the applied fluence for very high repetition rates and a decreasing ablation threshold as a result of heat accumulation  was reduced from nine possible holes to a smaller number. The same procedure was carried out for each 5 × 5 field and each time window , where theoretically, 25 holes would be possible. The allowed numbers become smaller with increasing time as the whole metal sheet becomes warmer.Several additional conditions were added to prevent heat accumulation in the metal sheet. For each 3 × 3 array, the number of possible holes drilled in time window  was set to 5 at the beginning, 3 after time t = 11, and 2 after time t = 21. For each 5 × 5 array, the number was three times as large. As a result of the optimization strategy, there were times t when no hole was drilled and the process was interrupted by a waiting period.Here, the number of drilled holes allowed in each 3 × 3 array in time window [Further drilling tests were carried out with the 2 × 2 beam splitter shown in For further comparison and evaluation, data from the thermal simulations and experiments are shown for a 20 × 20 array drilled with a 2 × 2 beam splitter in As can be seen in the diagrams, the maximum temperature could be reduced by about 75 °C to almost 360 °C using the optimized strategy. This and the significantly lower occurrence of annealing colors indicate a lower heat input in the component. When drilling with the optimized drilling strategy, there was also a constant increase in temperature up to the last hole, but this was much less pronounced. However, the behavior of a line-by-line increase in temperature was interrupted by the change in the drilling sequence. This resulted in the standard strategy with a decrease in the temperature after each drilled line, whereby, however, the temperature was higher with each line beginning than with the previous. This confirms the assumption that the material is not able to dissipate all the heat into the surrounding material and into the air after a line has been drilled, and this leads to heat accumulation. In addition to the optimized drilling strategy, the 25% longer process time caused by the break times could be another reason for the qualitatively better drilling result. In order to reflect this increased process time in the initial sequence, and thus to exclude any effects that may occur, a corresponding delay of 1 ms was inserted between the drilling of the individual holes.The experimental results of the drilling test with the corrected process time by the inserted delay are shown in In the next step, the experiments were scaled up to a 48 × 48 array. The optimization of the drilling sequence was again calculated according to the Moore neighborhood. The obtained results, with the corrected process time by the inserted delay, which are shown in Thermal simulations and a specified simplex algorithm were used to study and optimize the spatial drilling sequence of metal sheets using a high repetition, high power femtosecond laser in an up to 48 × 48-times multi-spot approach provided by a spatial light modulator. To increase the process efficiency while minimizing the generated temperature increase across the processed specimen, a Moore neighborhood was found for the drilling sequence to result in minimized accumulated temperatures with the inevitable being limited to a range of 45 °C to 75 °C, depending on the number of multi-spots.


We present RootPainter by training models for root length extraction from chicory (Cichorium intybus L.) roots in soil, biopore counting, and root nodule counting. We also compare dense annotations with corrective ones that are added during the training process based on the weaknesses of the current model.We evaluate RootPainter with corrective annotations created within 2 h produced measurements strongly correlating with manual measurements. Model accuracy had a significant correlation with annotation duration, indicating further improvements could be obtained with extended annotation.Five out of six times the models trained using RootPainter, for many datasets it is possible to annotate, train, and complete data processing within 1 d.Our results show that a deep‐learning model can be trained to a high accuracy for the three respective datasets of varying target objects, background, and image quality with < 2 h of annotation time. They indicate that, when using R Plant set al., et al., et al., et al., et al., Convolutional neural networks (CNNs) are a class of deep‐learning models that represent the state of the art for image analysis and are currently among the most popular methods in computer vision research. They are a type of multilayered neural network that uses convolution in at least one layer and are designed to process grid‐like data, such as images  optimizing the parameters of a model such that the error is reduced. The error, commonly referred to as the loss, is a measure of the difference between the model's predictions and the correct labels for the training data examples. A separate validation dataset, consisting of similar examples, is used to provide information on the performance of the model during the training procedure on examples that have not been used as part of SGD optimization. Validation set performance may be used to decide when to stop training or assist in tuning hyperparameters, which are variables controlling fundamentals of the model that are not directly optimized by SGD.Developing a CNN‐based system for a new image analysis task or dataset is challenging, because dataset design, model training, and hyperparameter tuning are time‐consuming tasks requiring competencies in both programming and machine learning.Three questions that need answering when attempting a supervised learning project such as training a CNN are: how to split the data between training, validation, and test datasets; how to manually annotate or label the data; and how to decide how much data needs to be collected, labelled, and used for training in order to obtain a model with acceptable performance. The choices of optimal hyperparameters and network architecture are also considered to be a ‘black art’ requiring years of experience, and a need has been recognized to make the application of deep learning easier in practice Smith, .et al., The question of how much data to use in training and validation is explored in theoretical work that gives indications of a model's generalization performance based on dataset size and number of parameters Vapnik, . These tet al., et al., Manual annotation may be challenging, as proprietary tools may be used that are not freely available .Growing legumes with N‐fixing capacity reduces the use of fertilizer  on a more computationally powerful server. The client and server can be used on the same machine if it is equipped with suitable hardware, reducing network input/output overhead. Instructions are sent from the client to server using human‐readable JSON (JavaScript Object Notation) format. The client–server communication is facilitated entirely with files via a network drive or file synchronization application. This allows utilization of existing authentication, authorization and backup mechanisms whilst removing the need to setup a publicly accessible static Internet Protocol address. The graphical client is implemented using PyQt5 which binds to the Qt cross‐platform widget toolkit. The client installers for MacOS, Windows, and Linux are built using the PyInstaller build system, which bundles all required dependencies. As opposed to the more generalist annotation software napari  text files.Rinux command line, so should be completed by a system administrator. The server setup involves specification of a sync directory, which must then be shared with users. Users will be prompted to input the sync directory relative to their own file system when they open the client application for the first time and it will be automatically stored in their home folder in a file named root_painter_settings.json, which the user may delete or modify if required.A folder referred to as the ‘sync directory’ is used to store all datasets, projects, and instructions that are shared between the server and client. The server setup  can slow down training in proportion to image size and hardware capabilities. Second, recent results , which specifies the details in JSON, and a project folder containing relevant data. The options to create a project or open an existing project are presented when opening the Ret al.  for a pixel in the input data as the one found in the corresponding location of an annotation. The annotations are created by the user and include pixels annotated as foreground, pixels annotated as background, and pixels without annotation. Only the pixels annotated as foreground or background are used in training. This is achieved by setting the pixels without foreground or background annotation to 0 in both the network prediction and associated annotation. The distance between the annotated pixels and network predictions is computed using a loss function, which is a combination of dice‐loss and cross‐entropy taken from Smith et al.  at a field trial of the University of Bonn in 2012; see Han et al.  for a deersoft software  was used for biopore quantification. Using the eclipse function, the visible biopores were marked, and then the count number was generated as a CSV file. Pores < 2 mm were excluded from biopore counting.Bimp  in order to calculate pore diameter. We split the images into two folders: BP_counted, which contained 39 images and was used for model validation after training, as these images had been counted by a biopore expert, and BP_uncounted, which contained 54 images and was used for training.We restricted the analysis to images with a suitable resolution and cropped to omit border areas. For each image, the number of pixels per millimetre was recorded using GTrifolium resupinatum) were acquired at 800 DPI in colour using a water‐bed scanner after root extraction. We used a total of 113 images that all had a blue background but were taken with two different scanners. From the 113 images, 65 were captured using an Epson V700 scanner  and appeared darker and underexposed, whereas 48 were captured using an Epson Expression 12000XL Photo Scanner and appeared well lit, showing the nodules more clearly. The blue background was obtained by blocking the scanner transparency unit with nontransparent blue paper to create a background that provided contrast to the root nodules. Blocking the scanner transparency unit meant that the only light source was from the document table (the lower part) of the scanner.Root images of Persian clover . Image sections were enlarged, and nodules were selected manually by clicking. Then, the total number of marked nodules were counted by the software. We manually cropped to remove the borders of the scanner using Preview  and converted to JPEG to ease storage and sharing. Of these, 50 were selected at random to have subregions included in training, and the remaining 63 were used for validation.They were counted manually using Wet al.  to give us an indication of model progression over time with the two different annotation strategies.et al., ootPainter, which are obtained from the segmentations using skeletonization and then pixel counting.For each project we obtained correlations with manual measurements using the portion of the data not used during training to give a measure of generalization error, which is the expected value of the error on new input . This corrected segmentation is then used to evaluate the predicted segmentation, which is stored in the segmentations folder.In order to obtain segmentation metrics, we used the extract segmentation metrics function available from the RWe investigated the effect of filtering out nodules less than a certain size by computing the correlation between the automated and manual nodule counts as a function of a size threshold. The size threshold meant that counted nodules would include only those above a specific area in pixels. We computed the correlation with each size threshold from 0 to 400 px. We did this for the model trained by user b only.R2 for each annotation strategy for each user and dataset (Table R2≥0.7) between the automated measurements and manual measurements five out of six times. The exception was the nodules dataset for user b with an R2 of 0.69 . We plot the mean and SE at each time point for which multiple R2 values were obtained . There was no significant correlation between annotation time and R2 values for models trained using dense annotations.The observed R2 for each project after training was completed along with the R2 obtained with training done only on annotations at restricted time limits, and refer to these as trained to completion, along with the models saved at that time point during the corrective annotation procedure as it happened, which we refer to as real time  for the models trained using corrective annotation. For both dice and accuracy, the running average shows both large fluctuations and a trend of continuous improvement as more images are annotated. The performance of the biopores model being trained by user b is an outlier, as it appears to decrease in accuracy and to a lesser extent dice score towards the end of training. For the nodules and roots datasets, towards the end of corrective annotation, the dice score is approximately 0.9 but with larger fluctuations, whereas for the biopores the dice score appears to stay consistently above 0.9.We plot the number of labelled pixels for each training procedure over time for both corrective and dense annotations Fig. . With coIn this study, we focused on annotation duration, as we consider the time requirements for annotation rather than the number of available images to be more relevant to the concerns of the majority of plant research groups looking to use deep learning for image analysis. Our results, for corrective training in particular, confirm our first hypothesis by showing that a deep‐learning model can be trained to a high accuracy for the three different datasets of varying target objects, background, and image quality in < 2 h of annotation time.et al., et al., R2 for corrective training had a significant correlation with annotation duration, indicating that spending more time annotating would continue to improve performance.Our results demonstrate the feasibility of training an accurate model using annotations made in a short time period, which challenges the claims that tens of thousands of images  contained many roots that were bunched together more closely than what was typical in the dataset. We suspect this had confused the trained network and could be mitigated by using a consistent and reduced amount of roots per scan, whilst using more of the images for training and annotating for longer to capture more of the variation in the dataset.Although strong correlation was attained when using the models trained with corrective annotation, they in some cases overestimated Fig.  or underR2 was 0.69. We suspect this was partially due to the limited number of nodules in the training data. Many of the images in the dataset created for training contained no nodules and only included the background. This also meant the annotation was able to finish in less time. We consider this a limitation of the experimental design, as we expect that a larger dataset that allowed for annotating nodules for the full 2 h time period would have provided better insights into the performance of the corrective training procedure.In one case, training with corrective annotation failed to produce a model that gave a strong correlation with the manual measurements. This was for the nodules data for user b, where the Fig. The problem with small false positives may have been mitigated with the dense annotations as a larger amount of background examples are added, suppressing more of the false‐positive predictions that arise in the limited training time.R2 when removing small nodules may also be due to differences in subjective interpretation of what is a nodule, between the original counter and annotator training the model.The improvement in R2 as dense annotation time increased, shown in nodules b . We suspect this is due to dense annotation having an advantage at the start as the user is able to annotate more pixels in less time using dense annotation with no overhead caused by waiting for segmentations from the server. We suspect in many cases that corrective annotation will provide no benefits in terms of efficiency when the model is in the early stages of training, as the user will still have to apply large amounts of annotation to each image whilst being slowed down by the delay in waiting for segmentations. Later in training (e.g. after 1 h 40 min), corrective annotation overtakes dense annotation in terms of mean R2 performance  should be directed to the Click here for additional data file.


One maythink that the sudden increase in the temperature step could indicate that the heat capacityof the system suddenly decreased. For a superconducting transition, this is in fact expected:the specific heat jump at the critical temperature is given by(R ∼ 1 cm from the sample, the temperature measured would correspondto that of a volume of order ∼107 times larger than the volume of the sample, so itcannot possibly be influenced to the degree shown in the figure by a change in the heatcapacity of the sample at the assumed transition temperature.However, the temperature sensor cannot be placed in the diamond anvil cell next to thesample; that is physically impossible. Assuming that the temperature sensor is located at adistance I found a similar anomaly in the raw data for the susceptibility measurements for pressure130 GPa, for which the inferred superconducting transition temperature was 55 K. Data for 149and 155 GPa also showed such anomalies, to a smaller degree, right at the assumed transitiontemperatures.We have to conclude that the sudden changes in the temperature increments coinciding with theassumed critical temperatures are experimental artifacts. They imply that the observed changesin slope in the ac susceptibility observed at those assumed critical temperatures are aconsequence of the same experimental artifacts and cannot be taken as evidence ofsuperconducting transitions. There may have been unwanted/uncontrolled variations in thetemperature steps, as well as discrepancies between what were the actual values of thetemperature at the sample position versus what the thermometer measured at a differentposition, that account for these anomalies .My findings here highlight the importance that authors make available their raw data forother scientists’ examination. Huang and coworkers did that exemplarily, as also did M.Debessai and coworkers recently for their ac susceptibility measurements of the elementeuropium . Upon exThe results discussed here, as well as recent analysis we ,13 and o


A Lego Serious Play (LSP) ‐ based exercise was developed to support student engagement with learning consolidation at the end of a first‐year undergraduate cell biology course. The exercise was offered in addition to a regular revision session in preparation for the summative exam. Students were studying four‐year BSc (Hons) degrees in: Animal Biology, Environmental Biology, Marine and Freshwater Biology, Biological Sciences, Biomedical Sciences, Microbiology & Biotechnology in Scotland, UK. Although many students studied Human Biology at High School, in‐depth cell biology was studied for the first time by the majority of students during this course. The LSP process was adapted for use in the classroom. Core concepts were identified from the twelve‐week cell biology course as the basis for LSP build challenges and incorporated into LSP build – share – reflect cycles by students individually and then joined together by the group to explore the interconnected nature of cell biology processes. Student and lecturer evaluations were thematically analyzed to explore the impact of the technique on student engagement. Results indicate that the method supports student cognitive and affective engagement who report improved and understanding of the topic, and enjoyment and interest. In addition, behavioral engagement such as learner interaction, independence, and empowerment were revealed by the lecturer interview. Identified barriers to the adoption of LSP include perceived issues around creativity, play and exploration and scientific identity, together with a lack of evidence of efficacy. This study seeks to remedy that gap. This context presents constraints, because less time, larger group sizes and a desire to improve accessibility prevent the use of the standard LSP technique.22.1All data were collected with University Research Integrity Committee approval [RIC0036].2.2Modifications from the standard LSP method are required to make the approach feasible in a classroom setting. For example, 3–6 groups were facilitated simultaneously as is usual for HE tutorials in order to manage large student numbers and listening circle approach was adopted to support this.2.3course were consolidated in the session:LO1: Describe the structure and function of prokaryotic and eukaryotic cells and their component parts.LO2: Outline the role of key processes within the cell, including cell division, and the role of metabolic pathways in the normal functioning of the cell.LO3: Describe mechanisms by which information is processed, transferred and utilized to control cellular processes with special reference to cell signaling and transport.LO4: Describe specialized adaptations of cells, both prokaryotic and eukaryotic, to their environments.The aim of the formative LSP exercise was to provide an additional, engaging, opportunity for consolidation at the end of the course as a voluntary revision exercise. This provided students with an opportunity for formative feedback to support their learning on the Cell Biology course in preparation for the summative exam. Four out of five of the learning outcomes for the 2.4Participants were informed of the voluntary nature of the project and their right to withdraw at any time via the use of participant information sheets and informed consent. Students who did not wish to participate in the evaluation were free to take part in the exercise with no penalty. Participants were selected on a voluntary basis from the attendees of three, two‐hour long end of term formative (unassessed) LSP revision tutorials. In total 26 students took part in the exercise at the end of the spring trimester of 2017 together with their class lecturer. The 21 participants undertook the evaluation.Participants were asked to revise at least one of the key concepts of metabolism, cell division, cell signaling, gene expression, cytoskeleton and transport before the session and were given no further prior knowledge of the exercise.Students were divided into three tutorial groups of 40 students each for timetabling purposes. Student engagement with the tutorials was ~20%, in common with other formative end of term revision sessions within the programme. Participants were asked to sit in three self‐selected groups of 2–7. Each group had their own large table and LSP Lego set.2.5Once students were settled at their tables, the facilitator introduced themselves and the purpose of the session, taking care to explain that they were not a trained LSP facilitator and that the LSP method had been modified. Each table received a printed ‘about this session’ summary sheet . Next, tThe exercise began with timed ‘build a tower’ and ‘build a duck’ classic LSP skills building challenges that students undertook individually, sharing and reflecting within their groupsbold) they felt most confident with and spend 10 min building:Metabolism: chemical processes that maintain lifecell division)Reproduction: production of new cells Adaptation to the environment: gathers information and responds (cytoskeleton and transport)Homeostasis: maintains a constant internal environment , as this was out of scope.2.7A research assistant observed the LSP tutorials from the opposite side of the room and kept brief field notes. At the end of the tutorial the author/ facilitator distributed an anonymous paper survey to participants once the session had concluded Survey questions about the participants (questions 1–4) and expectation/ understanding of tasks (questions 5–7) were mapped to structural and psychosocial influences on student engagement, with questions about the experience of the task itself mapped to the states of engagement . Therefore, a lack of understanding is not expected to negatively influence student experience of engagement with the task.3.3The experience of engagement with the LSP revision tutorial was very positively evaluated by the students, indeed all would recommend the tutorial to others (median score = 6), and two students requested more, similar tutorials in their feedback comments. The tutorial proved to be most effective at encouraging students to think creatively about biology (median score = 7), with positive impacts on all aspects of student engagement , understanding (n = 5) and interaction/collaboration (n = 4) reported in the closed survey questions (Table n = 6). Comments were largely positive, and most were coded to the cognitive (n = 18) and affective (n = 16) domains of engagement, with five coded to the behavioral domain, and mostly related to interaction/ collaboration (Table n = 6), interesting (n = 5) and different (n = 5), showing that students were also experiencing affective engagement. Negative comments were few  and none were aggregated into subthemes, indicating that negative experiences were not widespread, nor attributable to a specific cause , who facilitated all the sessions. Therefore, when applying a similar method elsewhere, facilitators are reminded that empathy and care must be taken to focus feedback correction on the scientific content of the student's Interestingly, LSP has been used in education to explore professional identity,The evaluation in this study was carried out immediately after the activity and indicated that the method supports positive student engagement experiences. This warrants a follow up study to evaluate whether this experience of the task has a positive impact on long‐term student engagement outcome measures such as achievement of learning outcomes or satisfaction.Identifying whether the cell biology build tasks utilized in this study relate to any underlying threshold concepts in the course could open the door to the use of the Threshold Concepts framework to understand the processes at play during the exercise. Threshold concepts are those troublesome aspects of a discipline that, when crossed, are transformative for learning.AppendixS1: Supporting InformationClick here for additional data file.


This review summarizes the current state of research aiming at a description of the global heliosphere using both analytical and numerical modeling efforts, particularly in view of the overall plasma/neutral flow and magnetic field structure, and its relation to energetic neutral atoms. Being part of a larger volume on current heliospheric research, it also lays out a number of key concepts and describes several classic, though still relevant early works on the topic. Regarding numerical simulations, emphasis is put on magnetohydrodynamic (MHD), multi-fluid, kinetic-MHD, and hybrid modeling frameworks. Finally, open issues relating to the physical relevance of so-called “croissant” models of the heliosphere, as well as the general (dis)agreement of model predictions with observations are highlighted and critically discussed. Voyager 1 (V1) and Voyager 1 (V1) , started only some six decades ago with the discovery of the solar wind (SW) itself by the Luna-1 and Mariner spacecraft and the ensuing theoretical considerations by E. Parker, V.B. Baranov and others relating to the interaction of this wind with the ISM. As an astronomical topic, the outer heliosphere is unique in that it marks the most distant region of space that can still be observed in situ, most notably by the two spacecrafts The topic to be covered is obviously a vast one, and this review will necessarily remain incomplete. It also naturally reflects the respective views and fields of expertise of the various authors who contributed to it, which has undoubtedly lead to many interesting and relevant works being left unaddressed. As authors, we jointly regret this, and refer the reader to the accompanying chapters of this topical volume, particularly to the papers by Fraternale et al.  on turbuThis paper is organized as follows. After this introduction, Sect. At its most basic level, the heliosphere is classically defined as the circumsolar region of space which is influenced by the solar wind (SW), a thermally driven plasma flow emanating radially away from the Sun that was first modeled by Parker  in a nowThe terminology for these regions is unfortunately not consistent throughout the literature. Some authors . Therefore, the heliosphere inside the TS is predominantly shaped by solar influences, most notably its magnetic field, as well as by the influx of interstellar hydrogen, whose number density exceeds that of SW ions beyond about 10 au.The magnetic field at the solar ‘surface’ is structured on a multitude of spatial and temporal scales. Of these, the variations throughout the solar cycle are certainly of pivotal importance for the magnetic structure of the heliosphere. The global photospheric field is observed to alternate between a dipolar configuration, whose axis of symmetry is approximately coincident with the axis of solar rotation, prevailing during solar minimum, and a more irregular distribution of magnetic flux without discernible symmetry during solar maximum. The polarity reverses during the eleven-year period between consecutive minima (Schwabe cycle), only returning to the same polarity after a full Hale cycle of Close to the Sun, the global minimum field is largely dominated by an equatorial belt of so-called helmet streamers, and a set of more radial field lines near the polar regions, a setting that was first numerically modeled by Pneuman and Kopp . This reAs a result of the interplay between solar rotation and radial advection , large eruptions on the photosphere that travel through interplanetary space at high speeds, sometimes interacting with planetary magnetospheres. These will not be covered further in this chapter, though more details on these may be found, e.g., in the recent reviews by Archontis and Syntelis , Temmer Historically the first, and therefore understandably the most basic theoretical model of the solar wind was developed by Parker . It assuws Bondi  as unphymentclass2pt{minimws Bondi  and, morws Bondi , may eitws Bondi . This so1 Parker , Chap. 51 Parker  and Shiv1 Parker , when acWeber and Davis  used theThe shape of the magnetic field lines resulting from a given distribution of flux density entclass1pt{minimaquations  as 5\docnd Davis  model, tIt should be noted that many authors  larger than j et al. , is cleaentclass1pt{minimaequation  poses noequation . For insA frequently used model for the flow in and around the heliosphere is that of the Rankine half-body1y Parker  and usedy Parker . It consSince the Rankine flow  derives A kinematic MHD solution for the magnetic field in the HS and heliotail can in principle be found by solving either the stationary  or time-n et al. , though The Rankine flow model  is partiAnalytical models for the large-scale magnetic field beyond the heliopause are equally sparse, any may be grouped into two classes. First, the so-called “shape models” work by prescribing a heliopause geometry, and then construct a magnetic field which is both tangential to this surface and tends to the undisturbed homogeneous ISM field far away from this surface, thereby exploiting a concept also used, for instance, to model planetary magnetospheres  ideal induction equation  for the This long-standing problem was only recently addressed independently by Röken et al.  and IsenIn both cases, a crucial step is to obtain an expression to quantify the total travel time While both expressions in Equation  are equimentclass2pt{minimsee Fig. , who usen et al.  to derivBeing an exact solution to the ideal, stationary induction equation, the full solution is very similar to its upstream boundary value in both direction and magnitude, and only starts to drape around the HP in the immediate vicinity of the latter. On the HP itself, the field is parallel to the former and reaches infinite field strength. This is an unavoidable consequence of idealness and stationarity, which forces incoming magnetic flux to pile up ahead of the HP indefinitely. In a more realistic, non-ideal setting, an equilibrium between advection and diffusion would cause the field magnitude to remain finite. This could in principle be modeled by adding a resistive term entclass1pt{minimaSince the infinitely high magnetic “wall” around the HP is not only nonphysical but also poses practical problems, e.g. for the simulation of cosmic-ray particles who cannot cross this boundary, a viable method to arrive at a finitely-amplified field without compromising either Equation  nor 3)  3) was eSince the underlying flow field  has \docn et al.  presenten et al.  solutionandAs already stated in Sect. entclass1pt{minimaquations  exactly.entclass1pt{minimaquations  unchangen et al.  were useIt should be noted that, since this relatively simple choice of distortion flow does not vanish at large crosswind distances  mission  Helioseismic and Magnetic Imager (MDI), the National Solar Observatory Global Oscillation Network Group (GONG), and the Solar Dynamics Observatory (SDO) Helioseismic and Magnetic Imager (HMI). These data can be used as boundary conditions for solar coronal models which propagate the SW beyond the critical sphere to 1 au, where the results can then be used as boundary conditions for simulations in the outer heliosphere. The V1 and V2 spacecraft  spacecraft  since 2009 , which can propagate to near-Earth distances from their birth locations beyond the TS. The fluxes of ENAs were measured in the past by IMAP observations  are aimed at obtaining a quantitative understanding of the dynamical heliosphere, from its solar origin to its interaction with the LISM, thus providing the heliospheric community with a data-driven suite of models of the Sun-to-LISM connection. The heliospheric model describes the relevant physical processes and helps interpreting spacecraft observations of turbulent plasma in the SW and LISM. It involves a coronal model, which in turn is driven by measured solar magnetic fields. MS-FLUKSS makes it possible to investigate physical phenomena affecting the measured ENA fluxes and their evolution in time for all observed energy ranges. MS-FLUKSS modeling accounts for substantially non-Maxwellian distributions of neutral atoms and plasma in the presence of discontinuities, turbulence, and ion acceleration effects. Validated by observational data, theoretical and modeling results obtained with MS-FLUKSS link kinetic and fluid physical scales, help interpret those observations, and build a framework for the interpretation of future The coronal models typically provide us with the time-dependent boundary conditions on a sphere of about ACE and Ulysses  self-consistently connected by the source terms responsible for ionization-recombination and charge exchange between these particles. Such terms have their components in the hydrodynamic part of the MHD system for the ion mixture – mass, momentum, and energy conservation equations: One of the capabilities implemented in MS-FLUKSS is related to tracking of surfaces that propagate passively through the computational regions. These can be the HP, the heliospheric current sheet (HCS), the boundary between the sector and non-sector magnetic field regions in the HS, etc. The tracking is performed with the level-set method  derive information necessary for updating the properties of the LISM in a way appropriate for modeling the SW–LISM interaction. Figure B–V plane. The heliospheric model and its implementations in MS-FLUKSS address the complexity of the ISMF–heliospheric magnetic field (HMF) coupling at the HP and charge exchange between neutral and charged particles  of Fraternale et al. . The coupling of the coronal and heliospheric models in MS-FLUKSS opens opportunities to reveal the fundamental physical phenomena occurring in heliosphere and LISM surrounding it.We use in situ measurements from IBEX ribbon position on full-sky maps and the orientation of the V1  data-driven simulations of Borovikov et al. , PogorelThe charge-exchange coupling between SW plasma and neutrals from the LISM creates ENAs within the heliosphere. These ENAs inherit a velocity that is a combination of the plasma bulk flow and thermal speed. As a result, ENAs born in the supersonic SW move out radially with the SW speed and escape the heliosphere, penetrating several hundred au into the LISM. This flux of ENAs from the supersonic SW is sometimes referred to as the neutral SW Gruntman . In the IBEX-Hi instrument , which corresponds to primary ENAs born with typical supersonic SW speeds of 300–750 km/s.By carefully tuning simulations to match ENA data from IBEX data, we must use a model heliosphere that includes at least a simple solar cycle such that tailward lines of sight contain regions of fast, low density, SW at high latitudes, and slower, more dense, SW at equatorial latitudes. Once the cycle has propagated through the heliosphere, we can collect ENA fluxes using Equation , ions of interstellar helium, and alpha particles in the solar wind. The dynamic role of interstellar helium ions and SW alpha particles has been explored by Izmodenov et al. . Since tOther components have small cosmic abundances and do not have a dynamic effect on the global heliosphere. The distribution of these components can be calculated in non self-consistent manner, as it has been done for atomic and ionized interstellar oxygen , although the processes of photoionization and ionization of H atoms by electron impact can be important in some regions of the heliosphere . The significant effect of resonant charge exchange is connected with the large cross section of such collision, which is a function of the relative velocity of colliding particles.The interstellar neutral component should be calculated in the frame of the kinetic approach because the mean free path of the hydrogen atoms (with respect to charge exchange) is comparable with the size of the heliosphere  are considered as a single-fluid, ideal, perfect, mono-atomic gas. The fluid approach is valid for interstellar plasma because this medium is collisional. Indeed, the mean free path of interstellar protons with respect of Coulomb collisions is about or less than 1 au  protons are picked up by the heliospheric electromagnetic field, so all components move together with the same bulk velocity. The second assumption is that the velocity distribution function of pickup protons becomes isotropic (in the bulk plasma rest frame) very quickly (as compared with the characteristic time of convection). With these assumptions, single-fluid equations remain valid. However, the right parts of these equations should include the distribution function for pickup protons ).).20)).Furthermore, one should either calculate the distribution function for pickup protons by solving corresponding kinetic equation for pickup protons, as it was done in the papers by Malama et al. , Chalov Due to the charge change the fluid equations for the plasma component and the kinetic equation for the neutral component are coupled. The right sides of the fluid plasma equations contain source terms which are integrals of the velocity distribution function of the H atom component. Also, the collision term in the kinetic equation for H atoms depends on the plasma gasdynamic parameters. Therefore, the fluid equations for plasma and the kinetic equation for neutrals need to be solved self-consistently. This makes the problem quite complex.In the considered mathematical model the magnetic fields are treated in a non-dissipating approach. This means that the magnetic diffusion and Hall terms are neglected in the equation for the magnetic field, and the system of ideal MHD equations are solved. Such a theoretical approach is also employed in the models of other groups  from the OMNI 2 database. The OMNI 2 data set contains hourly resolution solar wind magnetic field and plasma data from many spacecraft in geocentric orbit and in orbit about the Heliolatitudinal variations of SW speed are taken from analysis of the interplanetary scintillation (IPS) data. The results of Sokół et al.  for one-Heliolatitudinal variations of SW mass flux are derived from the analysis of SOHO/SWAN full sky maps of the backscattered Lyman-alpha intensities  has been studied by Alexashov et al. . The papIt is important to note that the work of the Moscow group has been mainly focused on the obtaining and analyzing stationary or periodic solutions. The study of instabilities was less explored until recently. This is connected with the fact that analytical studies are extremely difficult  in the vicinity of these discontinuities. The example of a typical numerical grid in the mentclasspt{minimaThe question of the outlet boundary conditions in the tail is also important. In the case of pure gasdynamics the SW outflow is subsonic in the tail. This requires to set the value of the Riemann invariants for the incoming  characteristic. Fortunately, this problem does not appear in the self-consistent kinetic-gasdynamic problem because it has been shown by Izmodenov and Alexashov  that theThe convergence of the numerical solution has been verified by changing the grid resolution up to two times in all directions and by changing cell sizes specifically in the vicinity of the discontinuities. Also, the numerical solution has been tested on the extended grids where the size of the computational domain was increased up to two times. In particular, the tail region varied in these calculations from 1000 au up to 5500 au.The kinetic equation for the H-atom component has been solved using a Monte Carlo method with spatial and physical splitting of the particle trajectories. The employed method is very similar  to the one described in Malama . Monte CThe main idea of the geometrical splitting consists in the following. All space is divided into The results obtained using the framework of the Moscow model have been used in the analyses of various observations. The most pronounced one, perhaps, is the prediction of the hydrogen wall around the HP. This wall was firstly reported by Baranov et al.  and thenand Wood . Later tand Wood , 2014. Aand Wood  discoverand Wood , 2010. Tand Wood . Furtherand Wood , Galli eand Wood , Herbst and Wood , and Baland Wood  from thiV1 direction and an oblong shape in V2 direction. Therefore, V1 and V2. This case is in agreement with Voyager observations. Since the model is time-dependent through the solar cycle, the fluctuations of the TS and the HP are shown in Panels C and D. The TS fluctuates by V1 direction and V2 direction. These distances do not exactly coincide with the distances of actual HP crossings by the Voyagers, but are still quite close. The model results show that the HP moves inwards from 2009 to 2016 and then outwards. This is surely connected with the minimum of the SW dynamic pressure from 2007/2008 to 2015.Examples of the results obtained with the modern version of the Moscow model are shown in Fig. Voyagers (Panels E and F). Data for V1 are restricted by the closest vicinity of the crossing, while V1 magnetometer data after the HP crossing are publicly available from 2012 until the end of 2017. It is seen that the V1 trajectory may be connected with the time-fluctuations. Indeed, when the heliopause moves in and out it acts as a piston. Moving in it compresses the magnetic field lines. Therefore, the tangential component of the interstellar magnetic field increases. The radial motion of the heliopause should increase the V1 data and in the model results (Panel A). However, the level of fluctuations in the model is somewhat smaller than in the data. This may be connected, with the dataset for the solar wind parameters that has been employed in the model. For example, it may be due to 27 day time averaging that has been performed for the solar wind parameters in the model. Averaging, of course, reduces the level of fluctuation. In addition, some instabilities may occur at the heliopause which are not considered in the model.The model vs. data comparison shows that just beyond at the HP all three components of the IMF obtained in the model match those measured by both There are several MHD models in the community currently. In this section we cover the Boston University (BU) model. One important aspect is that MHD models make several assumptions in solving the equations. In order to understand the solutions and the comparison with observations, it is important to take into account the assumptions each model makes. The BU group chose to simplify the solutions and each factor included in the model to understand the main physical drivers of the heliosphere that is still not well understood. Several outstanding questions relating to the heliosphere are present. One of them is the shape of the heliosphere that is being actively debated (see Sect. Space Weather Modeling Framework (SWMF), which is a modeling tool that is able to evaluate different regions of the heliosphere at varying scales. Within the SWMF is the OH component, which is based on the Block-Adaptive Tree Solar wind Roe-Type Upwind Scheme (BATS-R-US) solver , and finally dissolve relatively quickly due to the onset of turbulence. At this point, the community has not reached a consensus on whether the actual shape of the heliosphere is more appropriately described by these “split-tail,” or the more traditional “comet-tail” models. To properly reflect the state of this debate, arguments in support of the former are summarized in Sect. IBEX-Hi cannot distinguish between the two solutions. We expect that higher-energy  in the energy range 3–88 keV. It was found that the ENA flux from the tail dominates at high energy . At low energy, the “comet-like” model produces ENA fluxes of similar strength from the upwind and downwind directions, which was earlier used as an argument for a bubble-like heliosphere.The complexity of the problem is that there are no direct observations in the heliotail. On the other hand, no existing indirect measurement seems to require the heliosphere to acquire a croissant shape  sets of boundary conditions. In principle, such a situation is not acceptable and discredits the numerical models in the eyes of heliospheric community. It is highly necessary to understand the reason of the difference. Possible physical and observational arguments for tube-like (croissant) and comet shapes of the heliopause were laid out in previous subsections. However, it is important to underline that numerically we solve a mathematical problem that is determined by the set of equations and the boundary conditions. All physics is determined by the equations. Since the ideal MHD equations do not take into account viscous or magnetic dissipation, the argumentation that these processes influence the global structure is beyond the mathematical problem solved. It is quite apparent that the reason of difference between models is to be found in the numerical approaches. Direct detailed comparison of the numerical BU and Moscow models have been done recently  step is to study the bifurcation in the model which includes the interstellar magnetic field. From the first view it seems unrealistic that the interstellar magnetic field may change the critical Mach number from 0.3 to zmodenov  demonstrzmodenov . In ordeThe fourth step consists in exploring how interstellar neutrals influence the critical parameters of the bifurcation. Currently, such exploration has not been done. Single calculations with the realistic heliospheric parameters performed allows us to conclude that the heliosphere has a comet-like shape. However, it is currently unknown how close the actual heliospheric parameters are to the critical parameters of bifurcation.Finally, we suggest that other groups perform the parametric study in the frame of simplified model as it has been done by Korolkov and Izmodenov . Since nIBEX Galli et al.  for particles accelerated to about a few MeV/nuc , that remained unchanged for several years after the TS crossings. Furthermore, observations from V1  measurements  pressure in the HS in the direction of V2 is IBEX  by V1 and V2, over a period of a few weeks before an abrupt change that occurred in the HP region  due to the slow weakening of the magnetic field.The crossings of V1 showed that the HP may be a region that involves an interchange instability  subset of the methods employed to model the properties of the global heliosphere and its interaction with the interstellar matter through which it moves, and of the results which these works have produced so far. The first decades of heliospheric research were, quite naturally, dominated by theoretical considerations which relied on analytical methods, and many of the concepts and findings from this stage continue to be relevant today. Our knowledge of the heliosphere’s physical properties received a major boost when in situ observations from the Although the complexity required to explain the intricate details of the contemporary wealth of heliospheric observations can arguably be appropriately addressed only with equally complex simulations, analytical solutions are not just intellectually rewarding but also useful for simpler or more general considerations, where the full computational machinery is either not available or not deemed necessary. This may lend support to the notion that the interplay between and the complementary nature of analytical and numerical modeling is well-suited to advance our understanding of the heliosphere in which we live.


This does not affect the findings or interpretation of the study. Figure 5 has been updated with the correct image in 5B; there were no other changes to the figure.This change has been reflected online, and the authors apologize for this error.


A Qualitative Space paper explores the role, strengths, and weaknesses of narrative research, before outlining the ways in which composite narrative has been defined within existing research. Distinctions between the various approaches to creating composite narratives are discussed, highlighting the differences in the types of data utilised, and the approaches taken to data analysis and presentation. A key distinction is identified between the use of composite narratives as part of an integrated methodology and as an approach to the presentation of data. Finally, issues relating to trustworthiness, reflexivity, and implications for researchers are considered.Narrative research approaches provide the opportunity for constructing a detailed understanding of lived experiences relevant to medical education, in areas such as illness narratives, explorations of doctor-patient relationships, and the development of professional identities in students and educators. The benefits of the depth of data gathered in narrative research are, however, counterbalanced by possible weaknesses relating to a focus on individual cases and the risk of identification of participants where subjects are sensitive or unique. To address these concerns, researchers from a variety of social science disciplines, carrying out research employing a range of methodological approaches, have begun to use ‘composite narratives’ in which the commonalities in the experiences of research participants are combined to create joint narrative or narratives which illustrate participants’ shared experiences. Composite narratives have been used both as a component of the methodological approach and as a method of presenting the results of research in a variety of methodologies. This  A Qualitative Space may: advance new ideas about qualitative methodologies, methods, and/or techniques; debate current and historical trends in qualitative research; craft and share nuanced reflections on how data collection methods should be revised or modified; reflect on the epistemological bases of qualitative research; or argue that some qualitative practices should end. Share your thoughts on Twitter using the hashtag: #aqualspaceA Qualitative Space highlights research approaches that push readers and scholars deeper into qualitative methods and methodologies. Contributors to The use of narratives in medical education is well established. Case histories and patient narratives are frequently used in clinical teaching and reflective educational practices such as reflective portfolios and Balint groups . NarratiDistinct from narrative-based medicine is narrative research, a group of qualitative methods that use the storied accounts of participants to explore the research question . NarratiIn social science research there has been an increase in the use of composite narratives to present research findings. Whilst this has, to date, been a little used method in medical education research, more recently composite narratives have been used in research exploring the experiences of academic GPs , and of In this paper we explore composite narratives. Firstly, we examine the context in which this method has arisen, considering narrative research more broadly. We then focus on composite narratives including the various definitions, approaches to production and uses, and opportunities for their use in medical education research.‘Narrative’ as a term has a multitude of meanings and is used differentially between disciplines . It can The distinctiveness of narrative inquiry relates to its purpose to convey the narrative ‘sense making’ of an experience individuals engage in through the telling of their story. In this way, stories can act as ‘a portal through which their experience of the world is interpreted and made personally meaningful’ , p. 375.Researchers have, however, highlighted several challenges associated with conducting narrative research. These include the difficulties of interpreting the data and conflicts over the ownership, presentation, or interpretations of the story(ies)  which caQuestions also exist in relation to the trustworthiness or validity of the interpretation in the stories . Of partNarrative approaches to research have traditionally focussed on individual stories to allow for voices not usually heard to be prominent . In contResearch utilising composite narratives comes from a range of different disciplines and explores experiences ranging from chronic illness to career transitions. Authors use a variety of terminologies to describe this approach. Tab. The central purpose of social research is to illuminate what has been previously hidden or unexplored in order to aid understanding and, in some cases, create change. Using composite narratives may increase the possibility of gaining access to hard-to-reach groups, such as senior politicians , 39, andWhilst some approaches to the analysis and presentation of research, such as thematic analysis, can isolate the understanding of experience from its wider social milieu, composite narratives can situate experience within a context . Some reA further proposed reason for using composite narratives is to increase a reader’s engagement with the lives and experiences of research participants , 43. TabThe construction of composite narratives as a research output has been employed by researchers using a variety of qualitative approaches and methodologies  and a range of methods of data collection such as interviews , 36, 39,—such approaches requiring the bracketing or separation of the researcher’s influence on the results.Composite narratives can be used either as a methodological approach integral to the research design, analysis and outputs , 37, or Examples from the literature of ways in which composite narratives are constructed include first-person narratives , 42, 43,Researchers in the phenomenological tradition use composite narratives as a way of conveying both the structure (the themes characterising the phenomenon) and the texture (the richness of the experiences of the participants) of the research findings , 34. ThiNarrative research sets out to explicitly gather data with an emphasis on the story of an aspect of an individual’s life and is a natural environment for the evolution of the composite narrative as a research output , 42, 43.A different approach was taken by Willis , in her In their ethnographic study exploring the experiences of teachers wrongly accused of sexual abuse of pupils, Piper and Sikes describe the creation of ‘composite fictions’ which they describe as ‘bring[ing] the written product of social research closer to the richness and complexity of the lived experience’  as set out by Lincoln and Guba  are impoReflexivity is also vital in ensuring the trustworthiness of this method and the researcher’s role should be acknowledged and accounted for. In some methodological approaches, such as interpretative phenomenology and those that combine autoethnography with other participant data, reflexivity is explicit in the method. In interpretive phenomenological research, the interpretation by the researcher of the phenomenon described is a vital aspect of the research  and the Composite narratives have recently started to be used in medical education research, both as a component of the methodological approach , and as In medical education research, composite narratives are valuable in disseminating findings to those out with the field but with key interests in shaping policy, for example, by illustrating the multiple challenges faced by doctors in training in a pandemic in a way that isolated quotes might not . The potAs we have outlined earlier in this paper, narrative can be used in research in a multitude of ways: as a methodological approach, a means of data collection, and as a way of representing research findings. The creation of composite narratives can be employed in the analysis of the data , 37 as wResearchers using composite narratives should be clear about their reasons for choosing this approach and ensure transparency and rigour in their use of the method to ensure trustworthiness. It should be clear whether the production of composite narratives was integral to the research design and whether the intention to present findings as composite narratives was explicit to research participants at the outset. Transparency is also vital as to whether the construction of narratives was intrinsic to the analytic process or decided on after analysis was complete as a means of disseminating data. If the production of composite narratives was decided on as a means of presenting findings after analysis of the data, researchers should make it clear why this approach was chosen, particularly if chosen to address challenges such as the presentation of sensitive or personally identifiable data. Researchers should clearly describe their approach to construction of their composite narratives, making it clear to readers how the data has informed the narratives, to counter criticisms of the narratives being so far removed from the data as to be untrustworthy.A potential criticism of the method is the role of the researcher in the creation of the narratives and the threat to trustworthiness that this could pose. For this reason, researchers should be clear about their own positioning and role in the narrative production, and ensure reflexivity by acknowledging and accounting for their role and background. Where reflexivity is not explicit in the methodological approach, such as when researchers have decided to create composites from a body of data they have collected to increase accessibility or to tackle a problem such as ensuring anonymity, researchers should take care to describe their involvement in the research and narrative construction and ensure reflexivity is incorporated.Finally, the accessibility of findings presented as composite narratives makes member checking a more realistic proposition as the blending of accounts from multiple participants could mitigate some of the ethical concerns raised regarding the ownership of the narratives and the imposition of the researcher’s interpretation . Member These considerations of epistemological and methodological coherence, trustworthiness, and reflexivity will be vital in the development of the composite narrative as an accepted methodological approach in medical education research. As this is very much a developing approach within the field, the authors advocate a considered approach to employing composite narratives in research design, in order to better develop the trustworthiness and acceptability of this novel narrative research method in medical education research.