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Felsky D, Cannitelli A, Pipitone J. Whole Person Modeling: a transdisciplinary approach to mental health research. DISCOVER MENTAL HEALTH 2023; 3:16. [PMID: 37638348 PMCID: PMC10449734 DOI: 10.1007/s44192-023-00041-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/10/2023] [Indexed: 08/29/2023]
Abstract
The growing global burden of mental illness has prompted calls for innovative research strategies. Theoretical models of mental health include complex contributions of biological, psychosocial, experiential, and other environmental influences. Accordingly, neuropsychiatric research has self-organized into largely isolated disciplines working to decode each individual contribution. However, research directly modeling objective biological measurements in combination with cognitive, psychological, demographic, or other environmental measurements is only now beginning to proliferate. This review aims to (1) to describe the landscape of modern mental health research and current movement towards integrative study, (2) to provide a concrete framework for quantitative integrative research, which we call Whole Person Modeling, (3) to explore existing and emerging techniques and methods used in Whole Person Modeling, and (4) to discuss our observations about the scarcity, potential value, and untested aspects of highly transdisciplinary research in general. Whole Person Modeling studies have the potential to provide a better understanding of multilevel phenomena, deliver more accurate diagnostic and prognostic tests to aid in clinical decision making, and test long standing theoretical models of mental illness. Some current barriers to progress include challenges with interdisciplinary communication and collaboration, systemic cultural barriers to transdisciplinary career paths, technical challenges in model specification, bias, and data harmonization, and gaps in transdisciplinary educational programs. We hope to ease anxiety in the field surrounding the often mysterious and intimidating world of transdisciplinary, data-driven mental health research and provide a useful orientation for students or highly specialized researchers who are new to this area.
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Affiliation(s)
- Daniel Felsky
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8 Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Rotman Research Institute, Baycrest Hospital, Toronto, ON Canada
- Faculty of Medicine, McMaster University, Hamilton, ON Canada
| | - Alyssa Cannitelli
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8 Canada
- Faculty of Medicine, McMaster University, Hamilton, ON Canada
| | - Jon Pipitone
- Department of Psychiatry, Queen’s University, Kingston, ON Canada
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Zhang Y, Song H, Wang J, Xi X, Cefalo P, Wood LJ, Luo X, Wang QM. Multiplex array analysis of serum cytokines offers minimal predictive value for cognitive function in the subacute phase after stroke. Front Neurol 2022; 13:886018. [PMID: 36330425 PMCID: PMC9622930 DOI: 10.3389/fneur.2022.886018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/29/2022] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE The effects of inflammation on post-stroke cognitive function are still unclear. This study investigated the correlation between the Th17-related cytokines in peripheral blood and post-stroke cognitive function after ischemic stroke in the subacute phase. DESIGN A retrospective cohort study. SETTING Academic acute inpatient rehabilitation facility. PARTICIPANTS One hundred and fourteen patients with first ischemic stroke were categorized as the poor cognitive recovery group (n = 58) or good cognitive recovery group (n = 56) based on their cognitive MRFS efficiency. INTERVENTIONS All subjects received routine physical, occupational, and speech-language pathology therapy. MAIN OUTCOME MEASURES Serum cytokines/chemokine (IL-1 β, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-12p70, IL-13, IL-15, IL-17A, IL-17E, IL-17F, IL-21, IL-22, IL-23, IL-27, IL-28A, IL-31, IL-33, GM-CSF, IFN-γ, MIP-3 α, TNF-α, and TNF-β) levels were measured in duplicate using Human Th17 magnetic bead panel and multiplex array analysis (Luminex-200 system). The primary functional outcome was a gain in functional independence measure (FIM) cognitive subscore at discharge. The secondary outcome measures were FIM total score at discharge, length of stay in the hospital, and discharge destination. Cognitive Montebello Rehabilitation Factor Score (MRFS) and cognitive MRFS efficiency were calculated. Demographic and clinical characteristics were obtained from the medical record. RESULTS The good cognitive recovery group had an interesting trend of higher IL-13 than the poor cognitive recovery group (good cognitive recovery group 257.82 ± 268.76 vs. poor cognitive recovery group 191.67 ± 201.82, p = 0.049, unit: pg/ml). However, Pearson's correlation analysis showed no significant correlation between cytokine levels and gain of cognition, cognitive MRFS, or cognitive MRFS efficiency. Receiver operating characteristic (ROC) analysis of cytokines also suggested a low accuracy of prediction as a predictor for post-stroke cognitive recovery improvement. CONCLUSION Our preliminary findings suggested that the level of serum cytokines had minimal predictive value for the recovery of cognitive function during the subacute inpatient rehabilitation after stroke.
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Affiliation(s)
- Yuling Zhang
- Stroke Biological Recovery Laboratory, Spaulding Rehabilitation Hospital, The Teaching Affiliate of Harvard Medical School, Charlestown, MA, United States
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Haixin Song
- Stroke Biological Recovery Laboratory, Spaulding Rehabilitation Hospital, The Teaching Affiliate of Harvard Medical School, Charlestown, MA, United States
- Rehabilitation Department, Sir Run Run Show Hospital, Hangzhou, China
| | - Jun Wang
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Xiao Xi
- Stroke Biological Recovery Laboratory, Spaulding Rehabilitation Hospital, The Teaching Affiliate of Harvard Medical School, Charlestown, MA, United States
- Department of Rehabilitation Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Philip Cefalo
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, The Teaching Affiliate of Harvard Medical School, Charlestown, MA, United States
| | - Lisa J. Wood
- William F. Connell School of Nursing at Boston College, Boston, MA, United States
| | - Xun Luo
- School of Medicine, Shenzhen University, Shenzhen, China
- Kerry Rehabilitation Medicine Research Institute, Shenzhen, China
| | - Qing Mei Wang
- Stroke Biological Recovery Laboratory, Spaulding Rehabilitation Hospital, The Teaching Affiliate of Harvard Medical School, Charlestown, MA, United States
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, The Teaching Affiliate of Harvard Medical School, Charlestown, MA, United States
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Tiwari S, Qi L, Wong J, Han Z. Association of peripheral manifestation of brain-derived neurotrophic factor with depression: A meta-analysis. Brain Behav 2022; 12:e32581. [PMID: 35510613 PMCID: PMC9226806 DOI: 10.1002/brb3.2581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 03/03/2022] [Accepted: 03/26/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The relationship between brain-derived neurotrophic factor (BDNF) and depression is a hot topic in research as several results of preclinical and clinical studies have shown controversial results. Our meta-analysis aims to evaluate and update the current status of peripheral BDNF with depression. METHODS We performed a meta-analysis by comprehensively searching PubMed and Web of Science for English-language literature from inception to 1st of June 2020. The search terms included brain-derived neurotrophic factor or BDNF in combination with depression, without year restriction. Using STATA software, data were pooled using a random-effects model. RESULTS In our literature search, 24 studies involving 1130 depressed patients and 1378 healthy individuals met our inclusion criteria. The results of our meta-analysis showed that the peripheral levels of BDNF levels significantly decreased in depression than nondepressed healthy controls (SMD = -0.89, 95% CI = -1.41, -0.38, p < .0001); however, the significant heterogeneity among studies (Q = 740.91, I2 = 96.8; p < .001) was discovered. Trim-and-fill estimations for the adjustment of publication bias indicated that publication bias had no impact on our results. Our sub-group analysis showed that a history of depression and alcohol consumption had an effect on the level of BDNF. In addition, age and gender did not affect the heterogeneity of BDNF in the meta-analysis. CONCLUSIONS Although decreased peripheral expression of BDNF certainly presents a risk of depression, we cannot find a definite relationship between the peripheral level of BDNF with depression to use BDNF as a reliable biomarker to assess the depression in clinical practice. We propose that future research should consider all the factors affecting BDNF and assess the level of proBDNF and mBDNF separately while evaluating the patients with depression objectively.
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Affiliation(s)
- Sagun Tiwari
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, Shanghai, P. R. China.,International Education College, Shanghai University of Traditional Chinese Medicine, Shanghai, P. R. China
| | - Lili Qi
- Department of Emergency Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of TCM, Shanghai, P. R. China
| | - John Wong
- School of Nursing and Department of Occupational Therapy, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Zhenxiang Han
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, Shanghai, P. R. China
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Mojtabavi H, Shaka Z, Momtazmanesh S, Ajdari A, Rezaei N. Circulating brain-derived neurotrophic factor as a potential biomarker in stroke: a systematic review and meta-analysis. J Transl Med 2022; 20:126. [PMID: 35287688 PMCID: PMC8919648 DOI: 10.1186/s12967-022-03312-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/17/2022] [Indexed: 01/19/2023] Open
Abstract
Background Stroke, an acute cerebrovascular event, is a leading cause of disability, placing a significant psycho-socioeconomic burden worldwide. The adaptation and reorganization process following any neuronal damage is regarded as neuroplasticity. Among many factors believed to attribute to this process, Brain-derived Neurotrophic Factor (BDNF) is a neurotrophin coordinating neuroplasticity after various neurological disorders such as stroke. Methods We conducted a systematic search in the main electronic medical databases in January 2021. Primarily we want to compare BDNF levels between patients with stroke and healthy controls (HC). Additional aims included investigation of (1) longitudinal changes in the BDNF levels post-stroke, (2) effects of physical training, (3) repeated transcranial magnetic stimulation (rTMS), and presence of depression on BDNF levels in patients with stroke. Results Among 6243 reviewed records from PubMed, Web of Science, and Scopus, 62 studies were eligible for inclusion in our systematic review. Subjects with stroke, n = 1856, showed lower BDNF levels compared to HC, n = 1191 (SMD [95%CI] = − 1.04 [− 1.49 to − 0.58]). No significant difference was detected in the level of BDNF through time points past stroke. BDNF levels were lower in the patients with depression compared to non-depressed subjects (SMD [95%CI] = − 0.60 [− 1.10 to − 0.10]). Physical training had an immediate positive effect on the BDNF levels and not statistically significant effect in the long term; SMD [95%CI] = 0.49 [0.09 to 0.88]) and SMD [95%CI] = 0.02 [− 0.43 to 0.47]). Lastly, rTMS showed no effect on the level of BDNF with 0.00 SMD. Conclusions Our study confirms that stroke significantly decreases the level of BDNF in various domains such as cognition, affect, and motor function. As BDNF is the major representative of neuroplasticity within nervous system, it is believed that stroke has a significant impact on the CNS regeneration, which is permanent if left untreated. This effect is intensified with coexisting conditions such as depression which further decrease the BDNF level but the net impact yet needs to be discovered. We also conclude that exercise and some interventions such as different medications could effectively reverse the damage but further studies are crucial to reach the exact modality and dosage for their optimal effect. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03312-y.
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Zhang C, Wang X, Zhu Q, Mei Y, Zhang Z, Xu H. Decreased Serum Brain-Derived Neurotrophic Factor in Poststroke Depression: A Systematic Review and Meta-Analysis. Front Psychiatry 2022; 13:876557. [PMID: 35664480 PMCID: PMC9160429 DOI: 10.3389/fpsyt.2022.876557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUNDS There were conflicting results on the comparison of brain-derived neurotrophic factor (BDNF) levels between poststroke depression (PSD) patients and stroke patients without PSD among previous studies. Thus, we conducted this systemic review and meta-analysis to explore the alteration of serum BDNF levels in PSD. METHODS This study included articles from the Web of Science and PubMed databases that were published before December 2021. STATA 12.0 software was used to compute the standardized mean difference (SMD) and 95% confidence interval (CI) regarding the comparison of serum BDNF in PSD and stroke patients without PSD. RESULTS We collected the mean value and standard deviation (SD) of serum BDNF in PSD and stroke patients without PSD from six studies (PSD: n = 268, stroke patients without PSD: n = 425). The present meta-analysis showed decreased serum BDNF level in patients with PSD, compared to stroke patients without PSD with a random-effects model (mean value of BDNF level [PSD vs. stroke patients without PSD]: 14.106 vs. 17.995 ng/ml; SMD = -1.578; 95% CI: -2.820, -0.337; I 2 = 97.8%, p-value for Q test < 0.001). CONCLUSION Brain-derived neurotrophic factor may work as a potential biomarker to predict the risk of PSD among stroke survivors. More large-sample clinical trials exploring the alteration of serum BDNF levels in PSD among stroke patients need to be conducted to verify this result.
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Affiliation(s)
- Chunhui Zhang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Xuefang Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Qinghua Zhu
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Yongxia Mei
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Zhenxiang Zhang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Hui Xu
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
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Shan D, Zheng Y, Froud K. Brain-Derived Neurotrophic Factor as a Clinical Biomarker in Predicting the Development of Post-Stroke Depression: A Review of Evidence. Cureus 2021; 13:e15662. [PMID: 34141514 PMCID: PMC8204918 DOI: 10.7759/cureus.15662] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Studying the relationship between brain-derived neurotrophic factor (BDNF) and post-stroke depression (PSD) may help determine the potential for depression in stroke patients at the earliest stage possible. Current research has identified changes in BDNF levels in PSD patients. Thus, this article was intended as a review of evidence with respect to changes in the expression of BDNF in patients with PSD by integrating extant findings. We conducted a search in the electronic databases PubMed, EMBASE, and PsycINFO (all records from January 1, 2000, through October 20, 2020) using keywords: “brain-derived neurotrophic factor OR BDNF,” “post-stroke depression OR PSD,” “expression level,” “association,” and “relationship.” Returned articles were considered for inclusion in this review if they were empirical studies investigating the association between BDNF expression and PSD. Seven original papers were selected for review and revealed inconsistent findings. Five out of seven studies reported a significant decrease in BDNF levels in PSD patients at a certain stage (most likely the early stage) of stroke after admission, whereas the other two showed contrasting findings. Overall, this review reveals associations between changes in serum BDNF levels and depression following stroke. Whether serum BDNF levels, especially in the early phase of stroke, can be a potentially effective biomarker for predicting the risk of subsequent PSD development is still open to debate.
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Affiliation(s)
- Dan Shan
- Department of Biobehavioral Science, Teachers College, Columbia University, New York, USA
| | - YuanDian Zheng
- Department of Biobehavioral Science, Teachers College, Columbia University, New York, USA.,College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Karen Froud
- Department of Biobehavioral Science, Teachers College, Columbia University, New York, USA
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Dong H, Qin YQ, Sun YC, Yao HJ, Cheng XK, Yu Y, Lu SS. Electroacupuncture Ameliorates Depressive-Like Behaviors in Poststroke Rats via Activating the tPA/BDNF/TrkB Pathway. Neuropsychiatr Dis Treat 2021; 17:1057-1067. [PMID: 33880028 PMCID: PMC8053498 DOI: 10.2147/ndt.s298540] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/22/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Electroacupuncture (EA) is a form of physical therapy that has been widely used in clinical practice in China. Post-stroke depression (PSD) is the most common neuropsychiatric complication after stroke. EA has been shown to have beneficial effects on PSD patients. However, the potential mechanism underlying the protective effects of EA on PSD remains unclear. Here, we investigated whether tissue plasminogen activator (tPA)/brain-derived neurotrophic factor (BDNF)/tyrosine kinase receptor B (TrkB) signaling pathway participates in the therapeutic effects of EA in a rat PSD model. METHODS Experimental PSD was induced by combining middle cerebral artery occlusion (MCAO) with chronic unpredictable mild stimulation (CUMS) in adult male rats. Bodyweight gain, neurological score, sucrose preference, and open field test were determined at 0, 7, 14, and 35 days after completing MCAO. The protein expressions of tPA, precursor BDNF (proBDNF), mature BDNF (mBDNF), and TrkB were measured by immunofluorescence and Western blot analysis. The tPA inhibitor plasminogen inhibitor-1 (PAI-1) was used to explore whether tPA plays a crucial role in the protective effects of EA on PSD. RESULTS Compared with the sham rats, the PSD rats showed decreased bodyweight, deteriorated neurological score, and significant depressive-like behaviors. EA remarkably reversed bodyweight loss, neurological deficit, and depressive-like behaviors in PSD rats. Immunofluorescence staining and Western blot analysis showed that PSD-induced decreased expression of tPA, mBDNF, and TrkB were prevented by EA. Furthermore, we found that the effects of EA against PSD-induced depressive-like behaviors were abolished by PAI-1, the specific inhibitor of tPA. CONCLUSION Our results suggest that the improvement in depressive-like behaviors induced by EA is likely achieved via activation of the tPA/BDNF/TrkB pathway.
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Affiliation(s)
- Hao Dong
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, China Rehabilitation Science Institute, Beijing, People's Republic of China
| | - Yan-Qiang Qin
- Treatment Center of TCM, Beijing Bo'ai Hospital, China Rehabilitation Research Center, China Rehabilitation Science Institute, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Ying-Chun Sun
- Treatment Center of TCM, Beijing Bo'ai Hospital, China Rehabilitation Research Center, China Rehabilitation Science Institute, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Hai-Jiang Yao
- Treatment Center of TCM, Beijing Bo'ai Hospital, China Rehabilitation Research Center, China Rehabilitation Science Institute, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Xian-Kuan Cheng
- Treatment Center of TCM, Beijing Bo'ai Hospital, China Rehabilitation Research Center, China Rehabilitation Science Institute, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Yan Yu
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, China Rehabilitation Science Institute, Beijing, People's Republic of China
| | - Shou-Si Lu
- Beijing Bo'ai Hospital, China Rehabilitation Research Center, China Rehabilitation Science Institute, Beijing, People's Republic of China
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Rhea EM, Logsdon AF, Banks WA, Erickson ME. Intranasal Delivery: Effects on the Neuroimmune Axes and Treatment of Neuroinflammation. Pharmaceutics 2020; 12:pharmaceutics12111120. [PMID: 33233734 PMCID: PMC7699866 DOI: 10.3390/pharmaceutics12111120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 02/02/2023] Open
Abstract
This review highlights the pre-clinical and clinical work performed to use intranasal delivery of various compounds from growth factors to stem cells to reduce neuroimmune interactions. We introduce the concept of intranasal (IN) delivery and the variations of this delivery method based on the model used (i.e., rodents, non-human primates, and humans). We summarize the literature available on IN delivery of growth factors, vitamins and metabolites, cytokines, immunosuppressants, exosomes, and lastly stem cells. We focus on the improvement of neuroimmune interactions, such as the activation of resident central nervous system (CNS) immune cells, expression or release of cytokines, and detrimental effects of signaling processes. We highlight common diseases that are linked to dysregulations in neuroimmune interactions, such as Alzheimer's disease, Parkinson's disease, stroke, multiple sclerosis, and traumatic brain injury.
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Affiliation(s)
- Elizabeth M. Rhea
- Geriatrics Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (A.F.L.); (W.A.B.); (M.E.E.)
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
- Correspondence: ; Tel.: +1-206-764-2938
| | - Aric F. Logsdon
- Geriatrics Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (A.F.L.); (W.A.B.); (M.E.E.)
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - William A. Banks
- Geriatrics Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (A.F.L.); (W.A.B.); (M.E.E.)
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Michelle E. Erickson
- Geriatrics Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA; (A.F.L.); (W.A.B.); (M.E.E.)
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
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