The research team, led by Johanna Johansson together with Caroline Fischl and Susanne Gustafsson at Jönköping University, conducted semi-structured interviews with fourteen occupational therapists recruited through purposive and network sampling designed to capture geographic variation across the country. Each interview lasted between 24 and 55 minutes, averaging 46 minutes, and followed an interview guide built around the Occupational Therapy Intervention Process Model, a framework that structures the therapist’s work into phases emphasizing the therapeutic relationship and collaboration with the patient. The transcribed material ran to 117 A4 pages and was analyzed using systematic text condensation, a qualitative strategy in which meaning units are identified, coded, grouped, condensed into artificial quotations, and then recontextualized against the original transcripts to ensure the participants’ voices remain intact.

The analysis converged on three overlapping domains through which the therapists organized their thinking: telehealth considered through the lens of the patient, through the lens of their own profession, and in relation to the surrounding context. Within the patient-centered domain, a striking ambivalence emerged around energy. For patients with stress-related illness or fatigue, telehealth conserves resources by eliminating travel and preparatory effort, allowing rehabilitation to begin earlier than an in-person visit would allow. Yet the therapists also described video meetings as potentially draining in their own right, noting that the blue light of screens, the association of computers with workplace performance pressure, and the sheer cognitive load of mediated communication can tax patients in ways a quiet clinic room does not.

Accessibility was the strongest argument in favor of the technology. Therapists reported that telehealth allowed patients to connect from home or even their workplace, saved time for relatives, reduced cancellations, and made group interventions feasible for so-called highly sensitive patients who otherwise spend energy reading the moods of others in a shared room. But preferences told a more complicated story. Most patients, the therapists observed, still prefer to meet in person, and few ever ask for a digital appointment, a pattern one participant called quite odd given the assumed demand for remote services. The therapists admitted their own preconceptions had been overturned: older patients, whom they expected to resist technology, often accepted telehealth willingly, while some patients in their thirties insisted on physical meetings, and patients with neuropsychiatric problems generally did not choose the digital route despite expectations to the contrary.

The professional lens exposed the deepest tensions. Occupational therapy rests on two pillars that telehealth strains: the therapeutic relationship and the performance analysis, the structured observation of a patient doing real activities in a real environment. Building trust through a screen proved slower, and for some therapists impossible, because body language is harder to read, eye contact is compromised, the reassuring gesture of a hand on a shoulder vanishes, and the small talk that lubricates human connection simply disappears in sessions that feel permanently on and off. Observation fared somewhat better. The therapists saw genuine opportunity in virtual home visits, which let them glimpse the patient’s actual living environment, something organizational structures had long prevented. Still, they worried that patients control what the camera shows, act less naturally when they know they are being watched, and that the crucial interplay between person, environment, and activity can be invisible in a framed video feed.

Hands-on elements of the profession proved the hardest to translate. Cognitive assessments, joint walks, ergonomic demonstrations, and hand evaluations that require the therapist to feel and grasp the patient’s hand resist digitization entirely. Some therapists managed to mail assistive devices such as orthoses to patients’ homes, but they described the risk of rehabilitation delays and the difficulty of teaching device use remotely, and others judged remote prescription impossible without direct demonstration. Even the creative scaffolding of therapy, writing with pen and paper, drawing schedules, sorting needs on a whiteboard, loses something on screen; as one therapist explained, writing by hand forces both patient and therapist to slow down in ways that benefit the work. The therapists also recognized that their own attitudes, from self-described pioneers to self-described reactionaries, shaped whether they experienced telehealth as liberation or loss.

The contextual domain revealed that the barriers are not merely technical but structural and political. All participants reported good access to equipment on their side, yet patients often had to use smartphones with small screens, lacked the electronic identification some platforms demand, or suffered unstable internet connections. Platforms showed inconsistent screen displays, made document sharing insecure or impossible for paper-based self-assessments, and forced therapists to guard against other patients’ data appearing on screen. Regionally, management actively promoted telehealth, and some therapists felt real pressure to match private digital providers, even as their immediate supervisors insisted that patient needs must guide practice. This dissonance matters because person-centred care, by definition, requires adapting services to individual needs, preferences, and resources, and a top-down push toward digital delivery risks overlooking exactly those individual differences.

The workload question cut against the efficiency narrative that often justifies digitalization. Therapists described double booking systems, more administration, fewer pauses, and heavier concentration demands during screen-based sessions, with one noting bluntly that although she could save time, she did not take on two patients instead of one. Those who used telehealth heavily found themselves teaching colleagues, adding further burden, while others lacked adequate training altogether. The study’s authors are careful to note that they did not set out to measure whether performance analysis through telehealth is clinically inferior; rather, they mapped how therapists justify their choices. Even so, the findings expose a clear knowledge gap about how the quality of observation-based assessment can be maintained across different modes of service delivery, a question the authors flag as a priority for future research.

The significance of the study extends well beyond Sweden. Most prior telehealth research in occupational therapy has been conducted outside Europe, much of it spurred by the pandemic-era scramble to keep services running, and this investigation is the first to document therapists’ reasoning within Swedish primary care specifically. Its central conclusion is measured rather than polemical: conventional occupational therapy is not always feasible through telehealth, so realizing its full potential will require genuinely new ways of working, not merely transplanting old routines onto new platforms. The therapists uniformly insisted on retaining in-person meetings while embracing further developed telehealth as a valuable complement, one that can extend access, enable environmental observation, and support continuity for patients who cannot travel. For policymakers racing toward integrated, person-centred care, the message is that the digital transition will succeed only if it bends to the grain of the profession’s craft, and to the very human preferences of the patients it serves.

Subject of Research: Occupational therapists' reasoning about telehealth use in Swedish primary care

Article Title: Telehealth within occupational therapy in primary care settings – an interview study

Article References: Johansson, J., Fischl, C., & Gustafsson, S. (2025). Telehealth within occupational therapy in primary care settings – an interview study. Scandinavian Journal of Occupational Therapy, 32(1), Article 2611542. https://doi.org/10.1080/11038128.2025.2611542

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2611542

Keywords: telehealth, occupational therapy, primary care, digitalization, person-centred care, telerehabilitation, integrated care, Sweden, qualitative interviews, therapeutic relationship, remote OT, within

The study, published in the journal Ocean Microbiology, drew on the metaPR2 database, a curated collection of processed 18S rRNA gene metabarcodes from more than forty studies spanning thousands of samples worldwide. The researchers classified roughly 47,000 marine protist amplicon sequence variants, or ASVs, into functional categories using the Mixoplankton Database, a resource that catalogues known mixotrophic species and their trophic strategies. Four mixoplankton types emerged as the focus of the analysis: constitutive mixoplankton, which build their own chloroplasts; generalist non-constitutive mixoplankton, which steal chloroplasts from a broad range of prey; plastidic specialist non-constitutive mixoplankton, which selectively retain plastids and even nuclear material from specific prey for weeks or months; and endosymbiotic specialist non-constitutive mixoplankton, which harbor long-term photosynthetic symbionts inside their cells.

These distinctions matter because each strategy carries different physiological costs and ecological consequences. Constitutive mixoplankton, which include familiar dinoflagellate and haptophyte genera such as Alexandrium, Karlodinium, and Karenia, can photosynthesize continuously while opportunistically consuming prey. Generalists of the non-constitutive kind, such as ciliates in the genera Strombidium and Laboea, must feed frequently, on scales of hours to days, because their stolen plastids degrade quickly. Plastidic specialists such as Mesodinium and Dinophysis can maintain sequestered photosynthetic machinery for extended periods, while endosymbiotic specialists like Ornithocercus and the green form of Noctiluca scintillans sustain stable partnerships with algal cells that contribute sugars and recycle nutrients derived from prey digestion.

After filtering the data to euphotic-zone samples, those from the upper 200 meters where light penetrates, the final dataset comprised nearly 44,000 ASVs and more than 366 million reads from 4,190 samples reaching latitudes from roughly 74 degrees south to 89 degrees north. Mixoplankton appeared in 94 percent of the samples, confirming their global ubiquity. Overall, mixoplankton accounted for about 7 percent of protist ASVs, corresponding to 3,537 sequence variants and 192 species, which represents some 44 percent of the species listed in the Mixoplankton Database. Protozooplankton and parasites dominated the ASV counts at 38 and 24 percent respectively, while diatoms made up 8 percent and other phytoplankton 22 percent.

To untangle the patterns hidden within this enormous dataset, the team turned to self-organizing maps, an unsupervised machine learning technique that condenses thousands of ASV abundance profiles into two-dimensional neuronal grids that can then be hierarchically clustered. Because sequencing methodology, particularly the choice between the V4 and V9 hypervariable regions of the 18S rRNA gene and the seawater filtration strategy, strongly shapes recovered community composition, the researchers deliberately analyzed separate subdatasets defined by consistent methods rather than pooling everything together. The clustering, applied independently to three subdatasets, each explained between 75 and 78 percent of total variance and produced community groupings that aligned with four major oceanic biomes: polar, subpolar to temperate, temperate to subtropical, and subtropical to tropical.

Those biome assignments were far from arbitrary. Principal component ordination and temperature-salinity-nitrate diagrams showed that the machine learning clusters ordered themselves consistently along environmental gradients of temperature, salinity, and nitrate concentration, with statistical tests confirming significant differences among clusters. Polar and subpolar communities were associated with the coldest waters and highest nitrate levels, while temperate, subtropical, and tropical communities corresponded with warmer, nutrient-poor conditions. Salinity played a comparatively weaker structural role, likely because it varies over a relatively narrow range in marine waters. The resulting biogeography matched classical oceanographic regions described in earlier plankton studies, lending confidence to the approach.

Within this framework, each mixoplankton functional type revealed its own ecological signature. Constitutive mixoplankton were broadly distributed across all biomes and showed distributional patterns closely paralleling those of non-diatom phytoplankton, suggesting either functional overlap or shared resource use between the two groups. Generalized additive models, which can capture non-linear relationships, showed that constitutive mixoplankton reached high relative abundances across a wide temperature span from near zero to 30 degrees Celsius, typical oceanic salinities, and low nitrate concentrations, consistent with the idea that mixotrophy confers a competitive advantage when dissolved nutrients are scarce. Endosymbiotic specialists, by contrast, were restricted to warmer subpolar through tropical waters and were largely absent from polar regions, with more than 88 percent of their sequence variants in one subdataset belonging to Collodaria, radiolarian colonies characteristic of oligotrophic open oceans.

The remaining two mixotypes were scarcer but ecologically revealing. Generalist non-constitutive mixoplankton, the least abundant group, consistently co-occurred with diatoms and extended into nitrate-rich regimes of 20 to 30 micromolar, echoing their dependence on frequent ingestion of phototrophic prey that flourish in productive waters; they were also detected in upwelling zones such as the equatorial Pacific and the Agulhas Current. Plastidic specialists spanned all biomes but were sparse, and in this study appeared in lower-nutrient conditions than previously reported, a shift the authors attribute to seasonal sampling differences and the capacity of retained plastids to sustain photosynthesis across varying nutrient regimes. Diatoms themselves, the only protists confidently confirmed as strictly phototrophic, were predominantly tied to cold, nitrate-rich waters, while protozooplankton and parasites displayed trends generally inverse to those of the mixoplankton, hinting at partitioned consumer niches and host-driven distributions.

The analysis also exposed how profoundly methodological choices shape what scientists see. Mixoplankton richness and relative abundance were, respectively, threefold and sixfold higher in the V9 dataset than in the V4 dataset, largely because the Tara Oceans V9 data captured radiolarians whose exceptionally high rRNA gene copy numbers are differentially amplified by the two marker regions. Comparisons of samples sequenced with both markers showed roughly 60 percent species overlap and significantly correlated abundances, yet one endosymbiotic radiolarian, Collozoum amoeboides, appeared three orders of magnitude more abundant in V9 than in V4. Filtration strategy added further complications, since fragile cells can be disrupted during size fractionation while unfractionated samples can mask rarer groups. The authors stress that these discrepancies do not undermine the conclusions but underscore the need for careful, method-aware interpretation.

By placing mixoplankton within the full context of marine protistan communities at a global scale, the study delivers the first community-level assessment of mixoplankton biogeography relative to co-occurring functional types, and it establishes an empirical foundation for incorporating these organisms into predictive models of marine ecosystem dynamics. The researchers argue that future work should prioritize targeted detection of the underrepresented generalist and plastidic specialist types, whose sparse detection partly reflects their small numbers of known species and the fragility of their cells, and should embrace emerging transcriptomic machine learning methods that can infer trophic mode from gene expression in field communities. As oceans warm and nutrient cycles shift, knowing which mixoplankton strategies dominate where, and under what environmental conditions, may prove essential for forecasting how marine food webs and biogeochemical cycles will respond.

The recognition of mixoplankton as a distinct ecological category represents a relatively recent shift in plankton science. For much of the twentieth century, marine protists were sorted into a simple dichotomy of phytoplankton and zooplankton, an arrangement that implicitly assumed photosynthesis and phagotrophy were mutually exclusive trophic modes. Observations of planktonic ciliates carrying algal plastids and dinoflagellates consuming prey date back more than a century, but only with the development of trait-based frameworks and curated databases has the full diversity of these strategies become systematically catalogued.

The ecological stakes of this reclassification are considerable. Because mixoplankton can acquire nutrients through both dissolved uptake and prey ingestion, they occupy a flexible position in microbial food webs, capable of acting as primary producers when inorganic nutrients are scarce and as grazers when prey are abundant. This dual capacity influences how carbon and nitrogen move through planktonic communities, and models that omit mixotrophy risk misallocating energy flow and nutrient recycling pathways.

The global niche patterns documented in the study also carry implications for a changing ocean. As surface waters warm and stratification intensifies, nutrient supply to the euphotic zone is expected to decline in many regions, conditions that favor organisms able to supplement photosynthesis with feeding. The observed affinity of constitutive mixoplankton for warm, oligotrophic waters, and of endosymbiotic specialists for tropical and subtropical biomes, suggests that these groups may expand as such conditions become more widespread, potentially reshaping community composition and the efficiency of biological carbon export.

Equally important is the methodological legacy of the work. By demonstrating that marker gene choice and sample processing measurably alter perceived mixoplankton abundance, the analysis provides a cautionary benchmark for future metabarcoding surveys and underscores the value of standardized, method-aware databases for tracking marine biodiversity over time.

Subject of Research: Environmental structuring of mixoplankton functional types within marine protist communities: a global analysis

Article Title: Environmental structuring of mixoplankton functional types within marine protist communities: a global analysis

Article References: Larsson, M. E., Leles, S. G., Mitra, A., Faure, E., Vaulot, D., & Santoferrera, L. (2026). Environmental structuring of mixoplankton functional types within marine protist communities: a global analysis. Ocean Microbiology, 2(1), Article 1. https://doi.org/10.1186/s44375-026-00007-3

Image Credits: AI Generated

DOI: 10.1186/s44375-026-00007-3

Keywords: Environmental, structuring, mixoplankton, functional, types, within, marine, protist, communities, global, analysis, scientific research