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Schläpfer S, Astakhov G, Pawel S, Eicher M, Kowatsch T, Held L, Witt CM, Barth J. Effects of app-based relaxation techniques on perceived momentary relaxation: Observational data analysis in people with cancer. J Psychosom Res 2024; 184:111864. [PMID: 39067182 DOI: 10.1016/j.jpsychores.2024.111864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 07/02/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE To examine the effects of six relaxation techniques on perceived momentary relaxation and a possible association of relaxation effects with time and practice experience in people with cancer. METHODS We used data from participants with cancer in a larger study practicing app-based relaxation techniques over 10 weeks, assessed momentary relaxation before and after every third relaxation practice, and analyzed momentary relaxation changes with a linear mixed-effects model. RESULTS The sample included 611 before-after observations from 91 participants (70 females (76.9%)) with a mean age of 55.43 years (SD 10.88). We found moderate evidence for variations in momentary relaxation changes across different techniques (P = .026), with short meditation, mindfulness meditation, guided imagery, and progressive muscle relaxation more frequently observed and leading to more relaxation than body scan and walking meditation. Furthermore, we found moderate evidence for increasing momentary relaxation changes over time (P = .046), but no evidence for an association between momentary relaxation and the number of previous observations (proxy for practice experience; P = .47). CONCLUSION We compared six app-based relaxation techniques in a real-life setting of people with cancer. The observed variations in perceived momentary relaxation appear to correspond with the popularity of the techniques used: The most popular relaxation techniques were the most effective and the least popular were the least effective. The effects increased over time, likely caused by dropout of individuals who gained no immediate benefit. Our findings open an interesting avenue for future research to better understand which relaxation techniques work best for whom in which situations. TRIAL REGISTRATION DRKS00027546; https://drks.de/search/en/trial/DRKS00027546.
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Affiliation(s)
- Sonja Schläpfer
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
| | - George Astakhov
- Epidemiology, Biostatistics and Prevention Institute (EBPI), Center for Reproducible Science (CRS), University of Zurich, Zurich, Switzerland
| | - Samuel Pawel
- Epidemiology, Biostatistics and Prevention Institute (EBPI), Center for Reproducible Science (CRS), University of Zurich, Zurich, Switzerland
| | - Manuela Eicher
- IUFRS Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland; Department of Oncology, CHUV, Lausanne, Switzerland
| | - Tobias Kowatsch
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland; School of Medicine, University of St. Gallen, St. Gallen, Switzerland; Centre for Digital Health Interventions, Department of Management, Technology, and Economics at ETH Zurich, Zurich, Switzerland
| | - Leonhard Held
- Epidemiology, Biostatistics and Prevention Institute (EBPI), Center for Reproducible Science (CRS), University of Zurich, Zurich, Switzerland
| | - Claudia M Witt
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jürgen Barth
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Jun X, Feng L, Fangyun W, Xuexing W, Linlin L, Zhihui L, Zhijin L. Development and validation of the head and neck cancer psychosocial distress scale (HNCPDS) to identify patients at high risk for psychological problems : a multicenter study. Sci Rep 2024; 14:18591. [PMID: 39127748 PMCID: PMC11316735 DOI: 10.1038/s41598-024-67719-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 07/15/2024] [Indexed: 08/12/2024] Open
Abstract
To develop the Head and Neck Cancer Psychosocial Distress Scale (HNCPDS) with the aim of identifying high-risk individuals for psychosocial distress among patients, and to assess its reliability, validity and applicability. Using the classical test theory, a total of 435 head and neck cancer patients from six tertiary hospitals in China were recruited for developing the HNCPDS. Delphi expert consultation and item analysis were used to improve the content validity of the preliminary HNCPDS. Factor analysis (FA) and Structural equation modeling (SEM) were used to test the structural validity of HNCPDS. Cronbach's alpha coefficient, Spearman-Brown coefficient and Intra-class correlation coefficient (ICC) were used to test the internal consistency and retest reliability of HNCPDS. Multiple stepped-linear regression was used to analyze the risk factors of psychological disorder, and Pearson correlation coefficient was used to analyze the correlation between psychosocial distress and quality of life (QOL). The HNCPDS consisted of 14 items, which were divided into 3 subscales: 3 items for cancer discrimination, 5 items for anxiety and depression, and 6 items for social phobia. The HNCPDS had good validity [KMO coefficient was 0.947, Bartlett's test was 5027.496 (P < 0.001), Cumulative variance contribution rate was 75.416%, and all factor loadings were greater than 0.55], reliability (Cronbach's alpha coefficient was 0.954, Spearman-Brown coefficient was 0.955, test-retest reliability was 0.845) and acceptability [average completion time (14.31 ± 2.354 min) and effective completion rate of 90.63%]. Financial burden, sex, age and personality were found to be independent risk factors for HNCPDS (P < 0.05), and patients with higher HNCPDS scores reported a lower QOL (P < 0.01). The HNCPDS is effective and reliable in early identification and assessment of the level of psychosocial distress in patients with head and neck cancer, which can provide an effective basis for health education, psychological counseling, and social support in the future.
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Affiliation(s)
- Xu Jun
- Department of Oncology, The Third Affiliated Hospital, Jiangxi Medical College, Nanchang University-The First Hospital of Nanchang, No.128, Xiangshan North Road, Donghu District, Nanchang, 330008, Jiangxi, People's Republic of China
| | - Li Feng
- Department of Oncology, Pingxiang People's Hospital, Pingxiang, Jiangxi, People's Republic of China
| | - Wan Fangyun
- Department of Oncology, The Third Affiliated Hospital, Jiangxi Medical College, Nanchang University-The First Hospital of Nanchang, No.128, Xiangshan North Road, Donghu District, Nanchang, 330008, Jiangxi, People's Republic of China
| | - Wang Xuexing
- Department of Oncology, Anning First People's Hospital, Kunming, Yunnan, People's Republic of China
| | - Luan Linlin
- Department of Anesthesia Surgery II, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, People's Republic of China
| | - Lu Zhihui
- Department of Oncology, The Third Affiliated Hospital, Jiangxi Medical College, Nanchang University-The First Hospital of Nanchang, No.128, Xiangshan North Road, Donghu District, Nanchang, 330008, Jiangxi, People's Republic of China.
- Department of Oncology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, NO.17, Yongwaizheng Street, Donghu District, Nanchang, 330000, Jiangxi, People's Republic of China.
| | - Liu Zhijin
- Department of Oncology, The Third Affiliated Hospital, Jiangxi Medical College, Nanchang University-The First Hospital of Nanchang, No.128, Xiangshan North Road, Donghu District, Nanchang, 330008, Jiangxi, People's Republic of China.
- Department of Geriatric Oncology, The Third Affiliated Hospital of Kunming Medical University-Yunnan Cancer Hospital, Kunming, Yunnan, People's Republic of China.
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Gomes M, Silva ER, Salgado J. Focusing with colorectal cancer patients: a pilot study of a brief online group intervention. Front Psychol 2024; 15:1339823. [PMID: 39176044 PMCID: PMC11339957 DOI: 10.3389/fpsyg.2024.1339823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 07/22/2024] [Indexed: 08/24/2024] Open
Abstract
Introduction Focusing-Oriented Psychotherapy has had a long history and influence on the field of psychotherapy. By "clearing a space" and "focusing," individuals can enhance their emotional awareness and improve their ability to self-regulate. These tasks are particularly relevant in the context of Psycho-Oncology, although the research on their potential benefits for cancer patients is limited. Furthermore, the application of these tasks in a group or online setting has not been thoroughly explored. Methods This study aimed to examine the effectiveness of a two-session online intervention based on Focusing for cancer-diagnosed participants and its impact on their mental health and wellbeing. The study involved three participants with a diagnosis of colorectal cancer who were undergoing palliative treatment. We used both qualitative and quantitative methods. PFC-2 was used to assess participants' accomplishment of the task; FMS was used to assess the change in the focusing attitude, while CORE-OM, and PWBS-RV were used as mental health distress and psychological wellbeing measures; participant feedback was collected through questionnaires and a semi-structured interview. Results The results suggest that the tasks led to greater self-awareness, heightened self-reflection, and a sense of relief for the participants. Discussion These findings suggest that the group intervention protocol based on online Focusing sessions is potentially useful for broader applications.
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Affiliation(s)
- Marta Gomes
- Department of Social and Behavioural Sciences, University of Maia, Maia, Portugal
- Center for Psychology, University of Porto, Porto, Portugal
| | - Eunice R. Silva
- Portuguese Institute of Oncology of Porto Francisco Gentil, EPE, Porto, Portugal
| | - João Salgado
- Department of Social and Behavioural Sciences, University of Maia, Maia, Portugal
- Center for Psychology, University of Porto, Porto, Portugal
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Schläpfer S, Schneider F, Santhanam P, Eicher M, Kowatsch T, Witt CM, Barth J. Engagement With a Relaxation and Mindfulness Mobile App Among People With Cancer: Exploratory Analysis of Use Data and Self-Reports From a Randomized Controlled Trial. JMIR Cancer 2024; 10:e52386. [PMID: 38819907 PMCID: PMC11179041 DOI: 10.2196/52386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/01/2024] [Accepted: 04/14/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Mobile health (mHealth) apps offer unique opportunities to support self-care and behavior change, but poor user engagement limits their effectiveness. This is particularly true for fully automated mHealth apps without any human support. Human support in mHealth apps is associated with better engagement but at the cost of reduced scalability. OBJECTIVE This work aimed to (1) describe the theory-informed development of a fully automated relaxation and mindfulness app to reduce distress in people with cancer (CanRelax app 2.0), (2) describe engagement with the app on multiple levels within a fully automated randomized controlled trial over 10 weeks, and (3) examine whether engagement was related to user characteristics. METHODS The CanRelax app 2.0 was developed in iterative processes involving input from people with cancer and relevant experts. The app includes evidence-based relaxation exercises, personalized weekly coaching sessions with a rule-based conversational agent, 39 self-enactable behavior change techniques, a self-monitoring dashboard with gamification elements, highly tailored reminder notifications, an educational video clip, and personalized in-app letters. For the larger study, German-speaking adults diagnosed with cancer within the last 5 years were recruited via the web in Switzerland, Austria, and Germany. Engagement was analyzed in a sample of 100 study participants with multiple measures on a micro level (completed coaching sessions, relaxation exercises practiced with the app, and feedback on the app) and a macro level (relaxation exercises practiced without the app and self-efficacy toward self-set weekly relaxation goals). RESULTS In week 10, a total of 62% (62/100) of the participants were actively using the CanRelax app 2.0. No associations were identified between engagement and level of distress at baseline, sex assigned at birth, educational attainment, or age. At the micro level, 71.88% (3520/4897) of all relaxation exercises and 714 coaching sessions were completed in the app, and all participants who provided feedback (52/100, 52%) expressed positive app experiences. At the macro level, 28.12% (1377/4897) of relaxation exercises were completed without the app, and participants' self-efficacy remained stable at a high level. At the same time, participants raised their weekly relaxation goals, which indicates a potential relative increase in self-efficacy. CONCLUSIONS The CanRelax app 2.0 achieved promising engagement even though it provided no human support. Fully automated social components might have compensated for the lack of human involvement and should be investigated further. More than one-quarter (1377/4897, 28.12%) of all relaxation exercises were practiced without the app, highlighting the importance of assessing engagement on multiple levels.
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Affiliation(s)
- Sonja Schläpfer
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Fabian Schneider
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
| | - Prabhakaran Santhanam
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
| | - Manuela Eicher
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland
- Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Tobias Kowatsch
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
- School of Medicine, University of St.Gallen, St.Gallen, Switzerland
| | - Claudia M Witt
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jürgen Barth
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Brunet J, Hussien J, Pitman A, Wurz A, Conte E, Polskaia N, Seely D. Yoga Therapy as an Intervention to Improve Patient-Reported Outcomes Among Adults After Treatment for Cancer: Preliminary Findings From a Trial Using Single-Subject Experimental Design. Integr Cancer Ther 2024; 23:15347354241233517. [PMID: 38385326 PMCID: PMC10893844 DOI: 10.1177/15347354241233517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/23/2024] [Accepted: 02/02/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Cancer is a chronic condition associated with a substantial symptom burden, which can impair recovery after treatment. Investigating interventions with potential to improve self-reported disease and/or treatment effects-known as patient-reported outcomes (PROs)-is paramount to inform cancer care. The objective of this study was to evaluate the effects of a yoga therapy (YT) intervention on key PROs (ie, cancer-related fatigue, anxiety, cognitive function, depression, stress, quality of life [QoL]) among adults after treatment for cancer. METHODS Data from 20 adults (Mage = 55.74 years, 85% female; Mtime since diagnosis = 2.83 years) who had completed treatment for cancer were analyzed for this study. In this single-subject exploratory experimental study, the YT intervention comprised a 1:1 YT session (ie, 1 participant with 1 yoga therapist) followed by 6 weekly small (ie, 2-3 participants) group YT sessions. Group sessions were facilitated by the same yoga therapist who delivered participants' 1:1 session to ensure an in-depth personalized approach. PROs were assessed before (ie, pre-intervention) and after the 1:1 YT session (ie, during the intervention), as well as after the last group YT session (ie, post-intervention). Hierarchical linear modeling was used to analyze the data. RESULTS Participants showed improvements in cancer-related fatigue, state anxiety, trait anxiety, perceived cognitive impairments, impacts of perceived cognitive impairments on QoL, and 1 dimension of QoL (ie, functional wellbeing) over time. Notably, cancer-related fatigue and state anxiety increased immediately after the 1:1 session, but showed greater improvements over time afterward (ie, during the intervention phase). No changes were observed for the remaining PROs. CONCLUSION Although results require confirmation in future trials, this study highlights the importance of continuing to investigate YT as an intervention to enhance important PROs (ie, cancer-related fatigue and state anxiety) after treatment for cancer. More research is needed to identify additional beneficial effects and factors that influence participants' responses to 1:1 and group YT (ie, moderators and mediators). REGISTRATION NUMBER ISRCTN64763228. DATE OF REGISTRATION December 12, 2021. This trial was registered retrospectively. URL OF TRIAL REGISTRY RECORD https://www.isrctn.com/ISRCTN64763228. PUBLISHED PROTOCOL Brunet, J., Wurz, A., Hussien, J., Pitman, A., Conte, E., Ennis, J. K., . . . & Seely, D. (2022). Exploring the Effects of Yoga Therapy on Heart Rate Variability and Patient-Reported Outcomes After Cancer Treatment: A Study Protocol. Integrative Cancer Therapies, 21, 15347354221075576.
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Affiliation(s)
- Jennifer Brunet
- University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Hôpital Montfort, Ottawa, ON, Canada
| | | | - Anne Pitman
- Centre for Health Innovation, Ottawa, ON, Canada
| | - Amanda Wurz
- University of the Fraser Valley, Chilliwack, BC, Canada
| | - Ellen Conte
- Centre for Health Innovation, Ottawa, ON, Canada
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | | | - Dugald Seely
- University of Ottawa, Ottawa, ON, Canada
- Centre for Health Innovation, Ottawa, ON, Canada
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
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Antoni MH, Moreno PI, Penedo FJ. Stress Management Interventions to Facilitate Psychological and Physiological Adaptation and Optimal Health Outcomes in Cancer Patients and Survivors. Annu Rev Psychol 2023; 74:423-455. [PMID: 35961041 PMCID: PMC10358426 DOI: 10.1146/annurev-psych-030122-124119] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Cancer diagnosis and treatment constitute profoundly stressful experiences involving unique and common challenges that generate uncertainty, fear, and emotional distress. Individuals with cancer must cope with multiple stressors, from the point of diagnosis through surgical and adjuvant treatments and into survivorship, that require substantial psychological and physiological adaptation. This can take a toll on quality of life and well-being and may also promote cellular and molecular changes that can exacerbate physical symptoms and facilitate tumor growth and metastasis, thereby contributing to negative long-term health outcomes. Since modifying responses tostressors might improve psychological and physiological adaptation, quality of life, and clinical health outcomes, several randomized controlled trials have tested interventions that aim to facilitate stress management. We review evidence for the effects of stress management interventions on psychological and physiological adaptation and health outcomes in cancer patients and survivors and summarize emerging research in the field to address unanswered questions.
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Affiliation(s)
- Michael H Antoni
- Department of Psychology, University of Miami, Coral Gables, Florida, USA;
- Cancer Control Research Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Patricia I Moreno
- Cancer Control Research Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Public Health Sciences, University of Miami School of Medicine, Miami, Florida, USA
| | - Frank J Penedo
- Department of Psychology, University of Miami, Coral Gables, Florida, USA;
- Cancer Control Research Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Medicine, University of Miami School of Medicine, Miami, Florida, USA
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Su K, Din ZU, Cui B, Peng F, Zhou Y, Wang C, Zhang X, Lu J, Luo H, He B, Kelley KW, Liu Q. A broken circadian clock: The emerging neuro-immune link connecting depression to cancer. Brain Behav Immun Health 2022; 26:100533. [PMID: 36281466 PMCID: PMC9587523 DOI: 10.1016/j.bbih.2022.100533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/26/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022] Open
Abstract
Circadian clocks orchestrate daily rhythms in many organisms and are essential for optimal health. Circadian rhythm disrupting events, such as jet-lag, shift-work, night-light exposure and clock gene alterations, give rise to pathologic conditions that include cancer and clinical depression. This review systemically describes the fundamental mechanisms of circadian clocks and the interacting relationships among a broken circadian clock, cancer and depression. We propose that this broken clock is an emerging link that connects depression and cancer development. Importantly, broken circadian clocks, cancer and depression form a vicious feedback loop that threatens systemic fitness. Arresting this harmful loop by restoring normal circadian rhythms is a potential therapeutic strategy for treating both cancer and depression.
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Affiliation(s)
- Keyu Su
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Zaheer Ud Din
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Bai Cui
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China,State Key Laboratory of Oncology in South China, Cancer Center, Sun Yat-sen University, 651 Dongfeng East Road, Guangzhou, Guangdong Province, 510060, China,Corresponding author. Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China.
| | - Fei Peng
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Yuzhao Zhou
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Cenxin Wang
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Xiaoyu Zhang
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Jinxin Lu
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Huandong Luo
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Bin He
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China
| | - Keith W. Kelley
- Department of Animal Sciences, College of ACES, University of Illinois at Urbana-Champaign, 212 Edward R. Madigan Laboratory, 1201 West Gregory Drive, Urbana, Il, 61801, USA
| | - Quentin Liu
- Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China,State Key Laboratory of Oncology in South China, Cancer Center, Sun Yat-sen University, 651 Dongfeng East Road, Guangzhou, Guangdong Province, 510060, China,Corresponding author. Institute of Cancer Stem Cell, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116044, China.
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