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Sun YM, Wang ZY, Liang YY, Hao CW, Shi CH. Digital biomarkers for precision diagnosis and monitoring in Parkinson's disease. NPJ Digit Med 2024; 7:218. [PMID: 39169258 PMCID: PMC11339454 DOI: 10.1038/s41746-024-01217-2] [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: 04/02/2024] [Accepted: 08/07/2024] [Indexed: 08/23/2024] Open
Abstract
Parkinson's disease (PD) is a multifactorial neurodegenerative disorder with high prevalence among the elderly, primarily manifested by progressive decline in motor function. The aging global demographic and increased life expectancy have led to a rapid surge in PD cases, imposing a significant societal burden. PD along with other neurodegenerative diseases has garnered increasing attention from the scientific community. In PD, motor symptoms are recognized when approximately 60% of dopaminergic neurons have been damaged. The irreversible feature of PD and benefits of early intervention underscore the importance of disease onset prediction and prompt diagnosis. The advent of digital health technology in recent years has elevated the role of digital biomarkers in precisely and sensitively detecting early PD clinical symptoms, evaluating treatment effectiveness, and guiding clinical medication, focusing especially on motor function, responsiveness and sleep quality assessments. This review examines prevalent digital biomarkers for PD and highlights the latest advancements.
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Affiliation(s)
- Yue-Meng Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Zhi-Yun Wang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Yuan-Yuan Liang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Chen-Wei Hao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Chang-He Shi
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, 450000, Henan, China.
- Henan Key Laboratory of Cerebrovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, 450000, Henan, China.
- Institute of Neuroscience, Zhengzhou University, Zhengzhou, 450000, Henan, China.
- NHC Key Laboratory of Prevention and treatment of Cerebrovascular Diseases, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, 450000, Henan, China.
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2
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Ahmed MA, Krishna R, Rayad N, Albusaysi S, Mitra A, Shang E, Hon YY, AbuAsal B, Bakhaidar R, Roman YM, Bhattacharya I, Cloyd J, Patel M, Kartha RV, Younis IR. Getting the Dose Right in Drug Development for Rare Diseases: Barriers and Enablers. Clin Pharmacol Ther 2024. [PMID: 39148459 DOI: 10.1002/cpt.3407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/23/2024] [Indexed: 08/17/2024]
Abstract
In the relentless pursuit of optimizing drug development, the intricate process of determining the ideal dosage unfolds. This involves "dose-finding" studies, crucial for providing insights into subsequent registration trials. However, the challenges intensify when tackling rare diseases. The complexity arises from poorly understood pathophysiologies, scarcity of appropriate animal models, and limited natural history understanding. The inherent heterogeneity, coupled with challenges in defining clinical end points, poses substantial challenges, hindering the utility of available data. The small affected population, low disease awareness, and restricted healthcare access compound the difficulty in conducting dose-finding studies. This white paper delves into critical dose selection aspects, focusing on key therapeutic areas, such as oncology, neurology, hepatology, metabolic rare diseases. It also explores dose selection challenges posed by pediatric rare diseases as well as novel modalities, including enzyme replacement therapies, cell and gene therapies, and oligonucleotides. Several examples emphasize the pivotal role of clinical pharmacology in navigating the complexities associated with these diseases and emerging treatment modalities.
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Affiliation(s)
- Mariam A Ahmed
- Quantitative Clinical Pharmacology, Takeda Development Center, Cambridge, Massachusetts, USA
| | - Rajesh Krishna
- Certara Drug Development Solutions, Certara USA, Inc., Princeton, New Jersey, USA
| | - Noha Rayad
- Parexel International (MA) Corporation, Mississauga, Ontario, Canada
- Clinical Pharmacology and Safety Sciences, Alexion, AstraZeneca Rare Disease, Mississauga, ON, Canada
| | - Salwa Albusaysi
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Amitava Mitra
- Clinical Pharmacology, Kura Oncology Inc, Boston, Massachusetts, USA
| | - Elizabeth Shang
- Global Regulatory Affairs and Clinical Safety, Merck &Co., Inc., Rahway, New Jersey, USA
| | - Yuen Yi Hon
- Divsion of Rare Diseases and Medical Genetics, Office of Rare Diseases, Pediatrics, Urologic and Reproductive Medicine, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bilal AbuAsal
- Division of Translational and Precision Medicine, Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Rana Bakhaidar
- Department of Pharmaceutics, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Youssef M Roman
- Division of Translational and Precision Medicine, Office of Clinical Pharmacology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Indranil Bhattacharya
- Quantitative Clinical Pharmacology, Takeda Development Center, Cambridge, Massachusetts, USA
| | - James Cloyd
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Munjal Patel
- Quantitative Clinical Pharmacology, Takeda Development Center, Cambridge, Massachusetts, USA
| | - Reena V Kartha
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Islam R Younis
- Quantitative Pharmacology and Pharmacometrics, Merck & Co., Inc., Rahway, New Jersey, USA
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Ilg W, Milne S, Schmitz-Hübsch T, Alcock L, Beichert L, Bertini E, Mohamed Ibrahim N, Dawes H, Gomez CM, Hanagasi H, Kinnunen KM, Minnerop M, Németh AH, Newman J, Ng YS, Rentz C, Samanci B, Shah VV, Summa S, Vasco G, McNames J, Horak FB. Quantitative Gait and Balance Outcomes for Ataxia Trials: Consensus Recommendations by the Ataxia Global Initiative Working Group on Digital-Motor Biomarkers. CEREBELLUM (LONDON, ENGLAND) 2024; 23:1566-1592. [PMID: 37955812 PMCID: PMC11269489 DOI: 10.1007/s12311-023-01625-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/14/2023]
Abstract
With disease-modifying drugs on the horizon for degenerative ataxias, ecologically valid, finely granulated, digital health measures are highly warranted to augment clinical and patient-reported outcome measures. Gait and balance disturbances most often present as the first signs of degenerative cerebellar ataxia and are the most reported disabling features in disease progression. Thus, digital gait and balance measures constitute promising and relevant performance outcomes for clinical trials.This narrative review with embedded consensus will describe evidence for the sensitivity of digital gait and balance measures for evaluating ataxia severity and progression, propose a consensus protocol for establishing gait and balance metrics in natural history studies and clinical trials, and discuss relevant issues for their use as performance outcomes.
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Affiliation(s)
- Winfried Ilg
- Section Computational Sensomotorics, Hertie Institute for Clinical Brain Research, Otfried-Müller-Straße 25, 72076, Tübingen, Germany.
- Centre for Integrative Neuroscience (CIN), Tübingen, Germany.
| | - Sarah Milne
- Bruce Lefroy Centre for Genetic Health Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, Melbourne University, Melbourne, VIC, Australia
- Physiotherapy Department, Monash Health, Clayton, VIC, Australia
- School of Primary and Allied Health Care, Monash University, Frankston, VIC, Australia
| | - Tanja Schmitz-Hübsch
- Experimental and Clinical Research Center, a cooperation of Max-Delbrueck Center for Molecular Medicine and Charité, Universitätsmedizin Berlin, Berlin, Germany
- Neuroscience Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lisa Alcock
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Lukas Beichert
- Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Enrico Bertini
- Research Unit of Neuromuscular and Neurodegenerative Disorders, Bambino Gesu' Children's Research Hospital, IRCCS, Rome, Italy
| | | | - Helen Dawes
- NIHR Exeter BRC, College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Hasmet Hanagasi
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Martina Minnerop
- Institute of Neuroscience and Medicine (INM-1)), Research Centre Juelich, Juelich, Germany
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty & University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Center for Movement Disorders and Neuromodulation, Medical Faculty & University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrea H Németh
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Jane Newman
- NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
| | - Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
| | - Clara Rentz
- Institute of Neuroscience and Medicine (INM-1)), Research Centre Juelich, Juelich, Germany
| | - Bedia Samanci
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Vrutangkumar V Shah
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- APDM Precision Motion, Clario, Portland, OR, USA
| | - Susanna Summa
- Movement Analysis and Robotics Laboratory (MARLab), Neurorehabilitation Unit, Neurological Science and Neurorehabilitation Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Gessica Vasco
- Movement Analysis and Robotics Laboratory (MARLab), Neurorehabilitation Unit, Neurological Science and Neurorehabilitation Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - James McNames
- APDM Precision Motion, Clario, Portland, OR, USA
- Department of Electrical and Computer Engineering, Portland State University, Portland, OR, USA
| | - Fay B Horak
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- APDM Precision Motion, Clario, Portland, OR, USA
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McGagh D, Song K, Yuan H, Creagh AP, Fenton S, Ng WF, Goldsack JC, Dixon WG, Doherty A, Coates LC. Digital health technologies to strengthen patient-centred outcome assessment in clinical trials in inflammatory arthritis. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00186-3. [PMID: 39089297 DOI: 10.1016/s2665-9913(24)00186-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/22/2024] [Accepted: 06/18/2024] [Indexed: 08/03/2024]
Abstract
Common to all inflammatory arthritides, namely rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and juvenile idiopathic arthritis, is a potential for reduced mobility that manifests through joint pain, swelling, stiffness, and ultimately joint damage. Across these conditions, consensus has been reached on the need to capture outcomes related to mobility, such as functional capacity and physical activity, as core domains in randomised controlled trials. Existing endpoints within these core domains rely wholly on self-reported questionnaires that capture patients' perceptions of their symptoms and activities. These questionnaires are subjective, inherently vulnerable to recall bias, and do not capture the granularity of fluctuations over time. Several early adopters have integrated sensor-based digital health technology (DHT)-derived endpoints to measure physical function and activity in randomised controlled trials for conditions including Parkinson's disease, Duchenne's muscular dystrophy, chronic obstructive pulmonary disease, and heart failure. Despite these applications, there have been no sensor-based DHT-derived endpoints in clinical trials recruiting patients with inflammatory arthritis. Borrowing from case studies across medicine, we outline the opportunities and challenges in developing novel sensor-based DHT-derived endpoints that capture the symptoms and disease manifestations most relevant to patients with inflammatory arthritis.
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Affiliation(s)
- Dylan McGagh
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Big Data Institute, University of Oxford, Oxford, UK; Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Kaiyang Song
- Oxford Medical School, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Hang Yuan
- Big Data Institute, University of Oxford, Oxford, UK; Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew P Creagh
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Sally Fenton
- School of Sport, Exercise, and Rehabilitation Science, University of Birmingham, Birmingham, UK; National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
| | - Wan-Fai Ng
- Health Research Board Clinical Research Facility, University College Cork, Cork, Ireland; Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK; NIHR Newcastle Biomedical Research Centre and NIHR Newcastle Clinical Research Facility, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - William G Dixon
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, UK
| | - Aiden Doherty
- Big Data Institute, University of Oxford, Oxford, UK; Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Leyens L, Batchelor J, De Beuckelaer E, Langel K, Hartog B. Unlocking the full potential of digital endpoints for decision making: a novel modular evidence concept enabling re-use and advancing collaboration. Expert Rev Pharmacoecon Outcomes Res 2024; 24:731-741. [PMID: 38747565 DOI: 10.1080/14737167.2024.2334347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 03/20/2024] [Indexed: 06/17/2024]
Abstract
INTRODUCTION Over the last decade increasing examples indicate opportunities to measure patient functioning and its relevance for clinical and regulatory decision making via endpoints collected through digital health technologies. More recently, we have seen such measures support primary study endpoints and enable smaller trials. The field is advancing fast: validation requirements have been proposed in the literature and regulators are releasing new guidances to review these endpoints. Pharmaceutical companies are embracing collaborations to develop them and working with academia and patient organizations in their development. However, the road to validation and regulatory acceptance is lengthy. The full value of digital endpoints cannot be unlocked until better collaboration and modular evidence frameworks are developed enabling re-use of evidence and repurposing of digital endpoints. AREAS COVERED This paper proposes a solution by presenting a novel modular evidence framework -the Digital Evidence Ecosystem and Protocols (DEEP)- enabling repurposing of measurement solutions, re-use of evidence, application of standards and also facilitates collaboration with health technology assessment bodies. EXPERT OPINION The integration of digital endpoints in healthcare, essential for personalized and remote care, requires harmonization and transparency. The proposed novel stack model offers a modular approach, fostering collaboration and expediting the adoption in patient care.
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Affiliation(s)
- Lada Leyens
- Regulatory Science, DEEP Measures Oy, Helsinki, Finland
- Product Development Regulatory, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | | | - Kai Langel
- Regulatory, Janssen Cilag S.A, Madrid, Spain
| | - Bert Hartog
- Clinical Operations and Innovation, Janssen-Cilag B.V, DS Breda, The Netherlands
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Sharma M, Mishra RK, Hall AJ, Casado J, Cole R, Nunes AS, Barchard G, Vaziri A, Pantelyat A, Wills AM. Remote at-home wearable-based gait assessments in Progressive Supranuclear Palsy compared to Parkinson's Disease. BMC Neurol 2023; 23:434. [PMID: 38082255 PMCID: PMC10712191 DOI: 10.1186/s12883-023-03466-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Wearable sensors can differentiate Progressive Supranuclear Palsy (PSP) from Parkinson's Disease (PD) in laboratory settings but have not been tested in remote settings. OBJECTIVES To compare gait and balance in PSP and PD remotely using wearable-based assessments. METHODS Participants with probable PSP or probable/clinically established PD with reliable caregivers, still able to ambulate 10 feet unassisted, were recruited, enrolled, and consented remotely and instructed by video conference to operate a study-specific tablet solution (BioDigit Home ™) and to wear three inertial sensors (LEGSys™, BioSensics LLC, Newton, MA USA) while performing the Timed Up and Go, 5 × sit-to-stand, and 2-min walk tests. PSPRS and MDS-UPDRS scores were collected virtually or during routine clinical visits. RESULTS Between November, 2021- November, 2022, 27 participants were screened of whom 3 were excluded because of technological difficulties. Eleven PSP and 12 PD participants enrolled, of whom 10 from each group had complete analyzable data. Demographics were well-matched (PSP mean age = 67.6 ± 1.3 years, 40% female; PD mean age = 70.3 ± 1.8 years, 40% female) while disease duration was significantly shorter in PSP (PSP 14 ± 3.5 months vs PD 87.9 ± 16.9 months). Gait parameters showed significant group differences with effect sizes ranging from d = 1.0 to 2.27. Gait speed was significantly slower in PSP: 0.45 ± 0.06 m/s vs. 0.79 ± 0.06 m/s in PD (d = 1.78, p < 0.001). CONCLUSION Our study demonstrates the feasibility of measuring gait in PSP and PD remotely using wearable sensors. The study provides insight into digital biomarkers for both neurodegenerative diseases. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04753320, first posted Febuary 15, 2021.
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Affiliation(s)
- Mansi Sharma
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Wang ACC Rm 715, 55 Fruit St. , Boston, MA, 02114, USA
| | | | - Anna J Hall
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 6-181C, Baltimore, MD, 21287, USA
| | - Jose Casado
- BioSensics LLC, 57 Chapel St, Suite 200, Newton, MA, 02458, USA
| | - Rylee Cole
- BioSensics LLC, 57 Chapel St, Suite 200, Newton, MA, 02458, USA
| | - Adonay S Nunes
- BioSensics LLC, 57 Chapel St, Suite 200, Newton, MA, 02458, USA
| | | | - Ashkan Vaziri
- BioSensics LLC, 57 Chapel St, Suite 200, Newton, MA, 02458, USA
| | - Alexander Pantelyat
- Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 6-181C, Baltimore, MD, 21287, USA
| | - Anne-Marie Wills
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Wang ACC Rm 715, 55 Fruit St. , Boston, MA, 02114, USA.
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Chopra H, Annu, Shin DK, Munjal K, Priyanka, Dhama K, Emran TB. Revolutionizing clinical trials: the role of AI in accelerating medical breakthroughs. Int J Surg 2023; 109:4211-4220. [PMID: 38259001 PMCID: PMC10720846 DOI: 10.1097/js9.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/13/2023] [Indexed: 01/24/2024]
Abstract
Clinical trials are the essential assessment for safe, reliable, and effective drug development. Data-related limitations, extensive manual efforts, remote patient monitoring, and the complexity of traditional clinical trials on patients drive the application of Artificial Intelligence (AI) in medical and healthcare organisations. For expeditious and streamlined clinical trials, a personalised AI solution is the best utilisation. AI provides broad utility options through structured, standardised, and digitally driven elements in medical research. The clinical trials are a time-consuming process with patient recruitment, enrolment, frequent monitoring, and medical adherence and retention. With an AI-powered tool, the automated data can be generated and managed for the trial lifecycle with all the records of the medical history of the patient as patient-centric AI. AI can intelligently interpret the data, feed downstream systems, and automatically fill out the required analysis report. This article explains how AI has revolutionised innovative ways of collecting data, biosimulation, and early disease diagnosis for clinical trials and overcomes the challenges more precisely through cost and time reduction, improved efficiency, and improved drug development research with less need for rework. The future implications of AI to accelerate clinical trials are important in medical research because of its fast output and overall utility.
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Affiliation(s)
- Hitesh Chopra
- Department of Biosciences, Saveetha School of Engineering, Saveetha Institute of Medical and Technical Sciences, Chennai - 602105, Tamil Nadu, India
| | - Annu
- Thin Film and Materials Laboratory, School of Mechanical Engineering, Yeungnam University, Gyeongsan 38541, Republic of Korea
| | - Dong K. Shin
- Thin Film and Materials Laboratory, School of Mechanical Engineering, Yeungnam University, Gyeongsan 38541, Republic of Korea
| | - Kavita Munjal
- Department of Pharmacy, Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh 201303, India
| | - Priyanka
- Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University (GADVASU), Rampura Phul, Bathinda, Punjab
| | - Kuldeep Dhama
- Indian Veterinary Research Institute (IVRI), Izatnagar, Bareilly, Uttar Pradesh
| | - Talha B. Emran
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International niversity, Dhaka, Bangladesh
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Sedlakova J, Daniore P, Horn Wintsch A, Wolf M, Stanikic M, Haag C, Sieber C, Schneider G, Staub K, Alois Ettlin D, Grübner O, Rinaldi F, von Wyl V. Challenges and best practices for digital unstructured data enrichment in health research: A systematic narrative review. PLOS DIGITAL HEALTH 2023; 2:e0000347. [PMID: 37819910 PMCID: PMC10566734 DOI: 10.1371/journal.pdig.0000347] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/14/2023] [Indexed: 10/13/2023]
Abstract
Digital data play an increasingly important role in advancing health research and care. However, most digital data in healthcare are in an unstructured and often not readily accessible format for research. Unstructured data are often found in a format that lacks standardization and needs significant preprocessing and feature extraction efforts. This poses challenges when combining such data with other data sources to enhance the existing knowledge base, which we refer to as digital unstructured data enrichment. Overcoming these methodological challenges requires significant resources and may limit the ability to fully leverage their potential for advancing health research and, ultimately, prevention, and patient care delivery. While prevalent challenges associated with unstructured data use in health research are widely reported across literature, a comprehensive interdisciplinary summary of such challenges and possible solutions to facilitate their use in combination with structured data sources is missing. In this study, we report findings from a systematic narrative review on the seven most prevalent challenge areas connected with the digital unstructured data enrichment in the fields of cardiology, neurology and mental health, along with possible solutions to address these challenges. Based on these findings, we developed a checklist that follows the standard data flow in health research studies. This checklist aims to provide initial systematic guidance to inform early planning and feasibility assessments for health research studies aiming combining unstructured data with existing data sources. Overall, the generality of reported unstructured data enrichment methods in the studies included in this review call for more systematic reporting of such methods to achieve greater reproducibility in future studies.
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Affiliation(s)
- Jana Sedlakova
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Paola Daniore
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
| | - Andrea Horn Wintsch
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Center for Gerontology, University of Zurich, Zurich, Switzerland
- CoupleSense: Health and Interpersonal Emotion Regulation Group, University Research Priority Program (URPP) Dynamics of Healthy Aging, University of Zurich, Zurich, Switzerland
| | - Markus Wolf
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Mina Stanikic
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Christina Haag
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Chloé Sieber
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Gerold Schneider
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Department of Computational Linguistics, University of Zurich, Zurich, Switzerland
| | - Kaspar Staub
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Institute of Evolutionary Medicine, University of Zurich, Zurich, Switzerland
| | - Dominik Alois Ettlin
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Center of Dental Medicine, University of Zurich, Zurich, Switzerland
| | - Oliver Grübner
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Department of Geography, University of Zurich, Zurich, Switzerland
| | - Fabio Rinaldi
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Dalle Molle Institute for Artificial Intelligence (IDSIA), Switzerland
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
- Fondazione Bruno Kessler, Trento, Italy
- Swiss Institute of Bioinformatics, Switzerland
| | - Viktor von Wyl
- Digital Society Initiative, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Stephenson D, Belfiore-Oshan R, Karten Y, Keavney J, Kwok DK, Martinez T, Montminy J, Müller MLTM, Romero K, Sivakumaran S. Transforming Drug Development for Neurological Disorders: Proceedings from a Multidisease Area Workshop. Neurotherapeutics 2023; 20:1682-1691. [PMID: 37823970 PMCID: PMC10684834 DOI: 10.1007/s13311-023-01440-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] [Accepted: 09/06/2023] [Indexed: 10/13/2023] Open
Abstract
Neurological disorders represent some of the most challenging therapeutic areas for successful drug approvals. The escalating global burden of death and disability for such diseases represents a significant worldwide public health challenge, and the rate of failure of new therapies for chronic progressive disorders of the nervous system is higher relative to other non-neurological conditions. However, progress is emerging rapidly in advancing the drug development landscape in both rare and common neurodegenerative diseases. In October 2022, the Critical Path Institute (C-Path) and the US Food and Drug Administration (FDA) organized a Neuroscience Annual Workshop convening representatives from the drug development industry, academia, the patient community, government agencies, and regulatory agencies regarding the future development of tools and therapies for neurological disorders. This workshop focused on five chronic progressive diseases: Alzheimer's disease, Parkinson's disease, Huntington's disease, Duchenne muscular dystrophy, and inherited ataxias. This special conference report reviews the key points discussed during the three-day dynamic workshop, including shared learnings, and recommendations that promise to catalyze future advancement of novel therapies and drug development tools.
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Khanna A, Jones G. Toward Personalized Medicine Approaches for Parkinson Disease Using Digital Technologies. JMIR Form Res 2023; 7:e47486. [PMID: 37756050 PMCID: PMC10568402 DOI: 10.2196/47486] [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: 03/21/2023] [Revised: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 09/28/2023] Open
Abstract
Parkinson disease (PD) is a complex neurodegenerative disorder that afflicts over 10 million people worldwide, resulting in debilitating motor and cognitive impairment. In the United States alone (with approximately 1 million cases), the economic burden for treating and caring for persons with PD exceeds US $50 billion and myriad therapeutic approaches are under development, including both symptomatic- and disease-modifying agents. The challenges presented in addressing PD are compounded by observations that numerous, statistically distinct patient phenotypes present with a wide variety of motor and nonmotor symptomatic profiles, varying responses to current standard-of-care symptom-alleviating medications (L-DOPA and dopaminergic agonists), and different disease trajectories. The existence of these differing phenotypes highlights the opportunities in personalized approaches to symptom management and disease control. The prodromal period of PD can span across several decades, allowing the potential to leverage the unique array of composite symptoms presented to trigger early interventions. This may be especially beneficial as disease progression in PD (alongside Alzheimer disease and Huntington disease) may be influenced by biological processes such as oxidative stress, offering the potential for individual lifestyle factors to be tailored to delay disease onset. In this viewpoint, we offer potential scenarios where emerging diagnostic and monitoring strategies might be tailored to the individual patient under the tenets of P4 medicine (predict, prevent, personalize, and participate). These approaches may be especially relevant as the causative factors and biochemical pathways responsible for the observed neurodegeneration in patients with PD remain areas of fluid debate. The numerous observational patient cohorts established globally offer an excellent opportunity to test and refine approaches to detect, characterize, control, modify the course, and ultimately stop progression of this debilitating disease. Such approaches may also help development of parallel interventive strategies in other diseases such as Alzheimer disease and Huntington disease, which share common traits and etiologies with PD. In this overview, we highlight near-term opportunities to apply P4 medicine principles for patients with PD and introduce the concept of composite orthogonal patient monitoring.
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Affiliation(s)
- Amit Khanna
- Neuroscience Global Drug Development, Novartis Pharma AG, Basel, Switzerland
| | - Graham Jones
- GDD Connected Health and Innovation Group, Novartis Pharmaceuticals, East Hanover, NJ, United States
- Clinical and Translational Science Institute, Tufts University Medical Center, Boston, MA, United States
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11
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Burton J, Abuasal B, Bachhav S, Connarn J, Cosman J, Gupta N, Jing J, Kim S, Long T, Terranova N, Venkatakrishnan K, Wang J, Liu Q. Future Opportunities in Drug Development: American Society for Clinical Pharmacology and Therapeutics Pharmacometrics and Pharmacokinetics Community Vision. Clin Pharmacol Ther 2023; 114:507-510. [PMID: 37303106 DOI: 10.1002/cpt.2955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/10/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Jackson Burton
- Clinical Pharmacology and Pharmacometrics, Biogen Inc., Cambridge, Massachusetts, USA
| | - Bilal Abuasal
- Office of Clinical Pharmacology, Office of Translational Sciences, CDER, FDA, Silver Spring, Maryland, USA
| | - Sagar Bachhav
- Clinical Pharmacology, AbbVie Inc., North Chicago, Illinois, USA
| | - Jamie Connarn
- Clinical Pharmacology, Modeling and Simulation, Amgen Inc., South San Francisco, California, USA
| | - Josh Cosman
- Digital Sciences, Abbvie, Inc., North Chicago, Illinois, USA
| | - Neeraj Gupta
- Quantitative Clinical Pharmacology, Takeda Development Center Americas, Inc. (TDCA), Lexington, Massachusetts, USA
| | - Jing Jing
- Clinical Pharmacology, Genentech, Inc., South San Francisco, California, USA
| | - Sarah Kim
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Tao Long
- Quantitative Clinical Pharmacology, Takeda Development Center Americas, Inc. (TDCA), Lexington, Massachusetts, USA
| | - Nadia Terranova
- Merck Institute for Pharmacometrics, Lausanne, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany
| | | | - Jian Wang
- Oncology Regulatory Science Strategy & Excellence, AstraZeneca, Wilmington, Delaware, USA
| | - Qi Liu
- Office of Clinical Pharmacology, Office of Translational Sciences, CDER, FDA, Silver Spring, Maryland, USA
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12
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Tam W, Alajlani M, Abd-Alrazaq A. An Exploration of Wearable Device Features Used in UK Hospital Parkinson Disease Care: Scoping Review. J Med Internet Res 2023; 25:e42950. [PMID: 37594791 PMCID: PMC10474516 DOI: 10.2196/42950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 03/13/2023] [Accepted: 04/14/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The prevalence of Parkinson disease (PD) is becoming an increasing concern owing to the aging population in the United Kingdom. Wearable devices have the potential to improve the clinical care of patients with PD while reducing health care costs. Consequently, exploring the features of these wearable devices is important to identify the limitations and further areas of investigation of how wearable devices are currently used in clinical care in the United Kingdom. OBJECTIVE In this scoping review, we aimed to explore the features of wearable devices used for PD in hospitals in the United Kingdom. METHODS A scoping review of the current research was undertaken and reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The literature search was undertaken on June 6, 2022, and publications were obtained from MEDLINE or PubMed, Embase, and the Cochrane Library. Eligible publications were initially screened by their titles and abstracts. Publications that passed the initial screening underwent a full review. The study characteristics were extracted from the final publications, and the evidence was synthesized using a narrative approach. Any queries were reviewed by the first and second authors. RESULTS Of the 4543 publications identified, 39 (0.86%) publications underwent a full review, and 20 (0.44%) publications were included in the scoping review. Most studies (11/20, 55%) were conducted at the Newcastle upon Tyne Hospitals NHS Foundation Trust, with sample sizes ranging from 10 to 418. Most study participants were male individuals with a mean age ranging from 57.7 to 78.0 years. The AX3 was the most popular device brand used, and it was commercially manufactured by Axivity. Common wearable device types included body-worn sensors, inertial measurement units, and smartwatches that used accelerometers and gyroscopes to measure the clinical features of PD. Most wearable device primary measures involved the measured gait, bradykinesia, and dyskinesia. The most common wearable device placements were the lumbar region, head, and wrist. Furthermore, 65% (13/20) of the studies used artificial intelligence or machine learning to support PD data analysis. CONCLUSIONS This study demonstrated that wearable devices could help provide a more detailed analysis of PD symptoms during the assessment phase and personalize treatment. Using machine learning, wearable devices could differentiate PD from other neurodegenerative diseases. The identified evidence gaps include the lack of analysis of wearable device cybersecurity and data management. The lack of cost-effectiveness analysis and large-scale participation in studies resulted in uncertainty regarding the feasibility of the widespread use of wearable devices. The uncertainty around the identified research gaps was further exacerbated by the lack of medical regulation of wearable devices for PD, particularly in the United Kingdom where regulations were changing due to the political landscape.
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Affiliation(s)
- William Tam
- Insitute of Digital Healthcare, Warwick Manufacturing Group, University of Warwick, Coventry, United Kingdom
| | - Mohannad Alajlani
- Insitute of Digital Healthcare, Warwick Manufacturing Group, University of Warwick, Coventry, United Kingdom
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Bertha A, Alaj R, Bousnina I, Doyle MK, Friend D, Kalamegham R, Oliva L, Knezevic I, Kramer F, Podhaisky HP, Reimann S. Incorporating digitally derived endpoints within clinical development programs by leveraging prior work. NPJ Digit Med 2023; 6:139. [PMID: 37563201 PMCID: PMC10415378 DOI: 10.1038/s41746-023-00886-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Affiliation(s)
- Amy Bertha
- Bayer, 801 Pennsylvania Ave NW, Washington, DC, 20004, USA.
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14
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Izmailova ES, AbuAsal B, Hassan HE, Saha A, Stephenson D. Digital technologies: Innovations that transform the face of drug development. Clin Transl Sci 2023; 16:1323-1330. [PMID: 37157935 PMCID: PMC10432869 DOI: 10.1111/cts.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/14/2023] [Accepted: 04/13/2023] [Indexed: 05/10/2023] Open
Abstract
Recently, digital health technologies (DHTs) and digital biomarkers have gained a lot of traction in clinical investigations, motivating sponsors, investigators, and regulators to discuss and implement integrated approaches for deploying DHTs. These new tools present new and unique challenges for optimal technology integration in clinical trial processes, including operational, ethical, and regulatory issues. In this paper, we gathered different perspectives to discuss challenges and perspectives from three different stakeholders: industry, US regulators, and a public-private partnership consortium. The complexities of DHT implementation, which include regulatory definitions, defining the scope of validation experiments, and the need for partnerships between BioPharma and the technology sectors, are highlighted. Most of these challenges are related to translation of DHT-derived measures into endpoints that are meaningful to clinicians and patients, participant safety, training, and retention and privacy of data. The example of the Wearable Assessments in the Clinic and Home in PD (WATCH-PD) study is discussed as an example that demonstrated the advantages of pre-competitive collaborations, which include early regulatory feedback, data sharing, and multistakeholder alignment. Future advances in DHTs are expected to spur device-agnostic measured development and incorporate patient reported outcomes in drug development. More efforts are needed to define validation experiments for a defined context of use, incentivize data sharing and development of data standards. Multistakeholder collaborations via precompetitive consortia will help facilitate broad acceptance of DHT-enabled measures in drug development.
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Affiliation(s)
| | - Bilal AbuAsal
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug AdministrationSilver SpringMarylandUSA
| | - Hazem E. Hassan
- Department of Pharmaceutical SciencesUniversity of MarylandMarylandBaltimoreUSA
| | - Anindita Saha
- Digital Health Center of Excellence, Center for Devices and Radiological Health, US Food and Drug AdministrationSilver SpringMarylandUSA
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15
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Izmailova ES, Demanuele C, McCarthy M. Digital health technology derived measures: Biomarkers or clinical outcome assessments? Clin Transl Sci 2023; 16:1113-1120. [PMID: 37118983 PMCID: PMC10339690 DOI: 10.1111/cts.13529] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/22/2023] [Accepted: 03/25/2023] [Indexed: 04/30/2023] Open
Abstract
Digital health technologies (DHTs) present unique opportunities for clinical evidence generation but pose certain challenges. These challenges stem, in part, from existing definitions of drug development tools, which were not created with DHT-derived measures in mind. DHT-derived measures can be leveraged as either clinical outcome assessments (COAs) or as biomarkers since they share properties with both categories of drug development tools. Examples from the literature indicate a variety of applications for DHT-derived data, including capturing disease physiology, symptom tracking, or response to therapies. The distinction between the categorization of DHT-derived measures as COAs or as biomarkers can be very fine, with terminology variability among regulatory authorities. This has significant implications for integration of DHT-derived measures in clinical trials, leading to confusion regarding the evidence required to support these tools' use in drug development. There is a need to amend definitions and create clear evidentiary requirements to support broad adoption of these new and innovative tools. The biopharma industry, the technology sector, consulting businesses, academic researchers, and regulators need a dialogue via multi-stakeholder collaborations to clarify questions around DHT-derived measures, to unify definitions, and to create the foundations for evidentiary package requirements, providing a path forward to predictable results.
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16
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Colloud S, Metcalfe T, Askin S, Belachew S, Ammann J, Bos E, Kilchenmann T, Strijbos P, Eggenspieler D, Servais L, Garay C, Konstantakopoulos A, Ritzhaupt A, Vetter T, Vincenzi C, Cerreta F. Evolving regulatory perspectives on digital health technologies for medicinal product development. NPJ Digit Med 2023; 6:56. [PMID: 36991116 DOI: 10.1038/s41746-023-00790-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/05/2023] [Indexed: 03/31/2023] Open
Abstract
Digital health technology tools (DHTTs) present real opportunities for accelerating innovation, improving patient care, reducing clinical trial duration and minimising risk in medicines development. This review is comprised of four case studies of DHTTs used throughout the lifecycle of medicinal products, starting from their development. These cases illustrate how the regulatory requirements of DHTTs used in medicines development are based on two European regulatory frameworks (medical device and the medicinal product regulations) and highlight the need for increased collaboration between various stakeholders, including regulators (medicines regulators and device bodies), pharmaceutical sponsors, manufacturers of devices and software, and academia. As illustrated in the examples, the complexity of the interactions is further increased by unique challenges related to DHTTs. These case studies are the main examples of DHTTs with a regulatory assessment thus far, providing an insight into the applicable current regulatory approach; they were selected by a group of authors, including regulatory specialists from pharmaceutical sponsors, technology experts, academic researchers and employees of the European Medicines Agency. For each case study, the challenges faced by sponsors and proposed potential solutions are discussed, and the benefit of a structured interaction among the different stakeholders is also highlighted.
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Affiliation(s)
| | | | | | | | | | - Ernst Bos
- F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | | | | | | | - Laurent Servais
- Muscular Dystrophy UK Oxford Neuromuscular Centre, Department of Paediatrics, University of Oxford, Oxford, UK
- Division of Child Neurology, Centre de Références des Maladies Neuromusculaires, Department of Paediatrics, University Hospital Liège and University of Liège, Liège, Belgium
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17
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Izmailova ES, Maguire RP, McCarthy TJ, Müller MLTM, Murphy P, Stephenson D. Empowering drug development: Leveraging insights from imaging technologies to enable the advancement of digital health technologies. Clin Transl Sci 2023; 16:383-397. [PMID: 36382716 PMCID: PMC10014695 DOI: 10.1111/cts.13461] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/27/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
The US Food and Drug Administration (FDA) has publicly recognized the importance of improving drug development efficiency, deeming translational biomarkers a top priority. The use of imaging biomarkers has been associated with increased rates of drug approvals. An appropriate level of validation provides a pragmatic way to choose and implement these biomarkers. Standardizing imaging modality selection, data acquisition protocols, and image analysis (in ways that are agnostic to equipment and algorithms) have been key to imaging biomarker deployment. The best known examples come from studies done via precompetitive collaboration efforts, which enable input from multiple stakeholders and data sharing. Digital health technologies (DHTs) provide an opportunity to measure meaningful aspects of patient health, including patient function, for extended periods of time outside of the hospital walls, with objective, sensor-based measures. We identified the areas where learnings from the imaging biomarker field can accelerate the adoption and widespread use of DHTs to develop novel treatments. As with imaging, technical validation parameters and performance acceptance thresholds need to be established. Approaches amenable to multiple hardware options and data processing algorithms can be enabled by sharing DHT data and by cross-validating algorithms. Data standardization and creation of shared databases will be vital. Pre-competitive consortia (public-private partnerships and professional societies that bring together all stakeholders, including patient organizations, industry, academic experts, and regulators) will advance the regulatory maturity of DHTs in clinical trials.
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18
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Müller MLTM, Stephenson DT. Leveraging the regulatory framework to facilitate drug development in Parkinson's disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 193:347-360. [PMID: 36803822 DOI: 10.1016/b978-0-323-85555-6.00015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
There is an exigent need for disease-modifying and symptomatic treatment approaches for Parkinson's disease. A better understanding of Parkinson's disease pathophysiology and new insights in genetics has opened exciting new venues for pharmacological treatment targets. There are, however, many challenges on the path from discovery to drug approval. These challenges revolve around appropriate endpoint selection, the lack of accurate biomarkers, challenges with diagnostic accuracy, and other challenges commonly encountered by drug developers. The regulatory health authorities, however, have provided tools to provide guidance for drug development and to assist with these challenges. The main goal of the Critical Path for Parkinson's Consortium, a nonprofit public-private partnership part of the Critical Path Institute, is to advance these so-called drug development tools for Parkinson's disease trials. The focus of this chapter will be on how the health regulators' tools were successfully leveraged to facilitate drug development in Parkinson's disease and other neurodegenerative diseases.
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Affiliation(s)
- Martijn L T M Müller
- Critical Path for Parkinson's Consortium - Critical Path Institute, Tucson, AZ, United States.
| | - Diane T Stephenson
- Critical Path for Parkinson's Consortium - Critical Path Institute, Tucson, AZ, United States
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19
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Chahine LM, Simuni T. Role of novel endpoints and evaluations of response in Parkinson disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 193:325-345. [PMID: 36803820 DOI: 10.1016/b978-0-323-85555-6.00010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
With progress in our understanding of Parkinson disease (PD) and other neurodegenerative disorders, from clinical features to imaging, genetic, and molecular characterization comes the opportunity to refine and revise how we measure these diseases and what outcome measures are used as endpoints in clinical trials. While several rater-, patient-, and milestone-based outcomes for PD exist that may serve as clinical trial endpoints, there remains an unmet need for endpoints that are clinically meaningful, patient centric while also being more objective and quantitative, less susceptible to effects of symptomatic therapy (for disease-modification trials), and that can be measured over a short period and yet accurately represent longer-term outcomes. Several novel outcomes that may be used as endpoints in PD clinical trials are in development, including digital measures of signs and symptoms, as well a growing array of imaging and biospecimen biomarkers. This chapter provides an overview of the state of PD outcome measures as of 2022, including considerations for selection of clinical trial endpoints in PD, advantages and limitations of existing measures, and emerging potential novel endpoints.
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Affiliation(s)
- Lana M Chahine
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tanya Simuni
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
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20
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Zeissler ML, McFarthing K, Raphael KG, Rafaloff G, Windle R, Carroll CB. An International Multi-Stakeholder Delphi Survey Study on the Design of Disease Modifying Parkinson's Disease Trials. JOURNAL OF PARKINSON'S DISEASE 2023; 13:1343-1356. [PMID: 38007672 PMCID: PMC10741330 DOI: 10.3233/jpd-230109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Design of disease modification (DM) trials for Parkinson's disease (PD) is challenging. Successful delivery requires a shared understanding of priorities and practicalities. OBJECTIVE To seek stakeholder consensus on phase 3 trials' overall goals and structure, inclusion criteria, outcome measures, and trial delivery and understand where perspectives differ. METHODS An international expert panel comprising people with Parkinson's (PwP), care partners (CP), clinical scientists, representatives from industry, funders and regulators participated in a survey-based Delphi study. Survey items were informed by a scoping review of DM trials and PwP input. Respondents scored item agreement over 3 rounds. Scores and reasoning were summarized by participant group each round until consensus, defined as≥70% of at least 3 participant groups falling within the same 3-point region of a 9-point Likert scale. RESULTS 92/121 individuals from 13 countries (46/69 PwP, 13/18 CP, 20/20 clinical scientists, representatives from 8/8 companies, 4/5 funders, and 1/1 regulator) completed the study. Consensus was reached on 14/31 survey items: 5/8 overall goals and structure, 1/8 Eligibility criteria, 7/13 outcome measures, and 1/2 trial delivery items. Extent of stakeholder endorsement for 428 reasons for scores was collated across items. CONCLUSIONS This is the first systematic multi-stakeholder consultation generating a unique repository of perspectives on pivotal aspects of DM trial design including those of PwP and CP. The panel endorsed outcomes that holistically measure PD and the importance of inclusive trials with hybrid delivery models. Areas of disagreement will inform mitigating strategies of researchers to ensure successful delivery of future trials.
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Affiliation(s)
| | | | - Karen G. Raphael
- College of Dentistry, New York University, New York, NY, USA
- Parkinson’s Research Advocate, USA
| | | | | | - Camille B. Carroll
- Faculty of Health, University of Plymouth, Plymouth, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
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21
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Garcia-Gancedo L, Bate A. Digital biomarkers for post-licensure safety monitoring. Drug Discov Today 2022; 27:103354. [PMID: 36108916 DOI: 10.1016/j.drudis.2022.103354] [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: 04/14/2022] [Revised: 08/04/2022] [Accepted: 09/07/2022] [Indexed: 11/21/2022]
Abstract
Post-licensure safety data form the cornerstone of safety surveillance. However, such data have some limitations related to the subjectiveness of reporting and recording, primary purpose of the collected data, or heterogeneity. Routine capture of richer data would in part help mitigate these limitations, enabling earlier, more reliable safety insights. Digital health tools that remotely acquire health-related information are increasingly available and used by patients and the wider population. However, they are rarely used for pharmacovigilance purposes. Here, we review different cases that reveal the opportunities and challenges of using these technologies for enhanced safety assessment in routine healthcare delivery. We believe such approaches will advance our understanding of the safety of drugs and vaccines in the future.
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Affiliation(s)
| | - Andrew Bate
- Global Safety, GSK, Brentford, UK; Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
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22
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Connecting real-world digital mobility assessment to clinical outcomes for regulatory and clinical endorsement-the Mobilise-D study protocol. PLoS One 2022; 17:e0269615. [PMID: 36201476 PMCID: PMC9536536 DOI: 10.1371/journal.pone.0269615] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/17/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The development of optimal strategies to treat impaired mobility related to ageing and chronic disease requires better ways to detect and measure it. Digital health technology, including body worn sensors, has the potential to directly and accurately capture real-world mobility. Mobilise-D consists of 34 partners from 13 countries who are working together to jointly develop and implement a digital mobility assessment solution to demonstrate that real-world digital mobility outcomes have the potential to provide a better, safer, and quicker way to assess, monitor, and predict the efficacy of new interventions on impaired mobility. The overarching objective of the study is to establish the clinical validity of digital outcomes in patient populations impacted by mobility challenges, and to support engagement with regulatory and health technology agencies towards acceptance of digital mobility assessment in regulatory and health technology assessment decisions. METHODS/DESIGN The Mobilise-D clinical validation study is a longitudinal observational cohort study that will recruit 2400 participants from four clinical cohorts. The populations of the Innovative Medicine Initiative-Joint Undertaking represent neurodegenerative conditions (Parkinson's Disease), respiratory disease (Chronic Obstructive Pulmonary Disease), neuro-inflammatory disorder (Multiple Sclerosis), fall-related injuries, osteoporosis, sarcopenia, and frailty (Proximal Femoral Fracture). In total, 17 clinical sites in ten countries will recruit participants who will be evaluated every six months over a period of two years. A wide range of core and cohort specific outcome measures will be collected, spanning patient-reported, observer-reported, and clinician-reported outcomes as well as performance-based outcomes (physical measures and cognitive/mental measures). Daily-living mobility and physical capacity will be assessed directly using a wearable device. These four clinical cohorts were chosen to obtain generalizable clinical findings, including diverse clinical, cultural, geographical, and age representation. The disease cohorts include a broad and heterogeneous range of subject characteristics with varying chronic care needs, and represent different trajectories of mobility disability. DISCUSSION The results of Mobilise-D will provide longitudinal data on the use of digital mobility outcomes to identify, stratify, and monitor disability. This will support the development of widespread, cost-effective access to optimal clinical mobility management through personalised healthcare. Further, Mobilise-D will provide evidence-based, direct measures which can be endorsed by regulatory agencies and health technology assessment bodies to quantify the impact of disease-modifying interventions on mobility. TRIAL REGISTRATION ISRCTN12051706.
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23
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Ferrer-Mallol E, Matthews C, Stoodley M, Gaeta A, George E, Reuben E, Johnson A, Davies EH. Patient-led development of digital endpoints and the use of computer vision analysis in assessment of motor function in rare diseases. Front Pharmacol 2022; 13:916714. [PMID: 36172196 PMCID: PMC9510779 DOI: 10.3389/fphar.2022.916714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022] Open
Abstract
Digital health technologies are transforming the way health outcomes are captured and measured. Digital biomarkers may provide more objective measurements than traditional approaches as they encompass continuous and longitudinal data collection and use of automated analysis for data interpretation. In addition, the use of digital health technology allows for home-based disease assessments, which in addition to reducing patient burden from on-site hospital visits, provides a more holistic picture of how the patient feels and functions in the real world. Tools that can robustly capture drug efficacy based on disease-specific outcomes that are meaningful to patients, are going to be key to the successful development of new treatments. This is particularly important for people living with rare and chronic complex conditions, where therapeutic options are limited and need to be developed using a patient-focused approach to achieve the biggest impact. Working in partnership with patient Organisation Duchenne UK, we co-developed a video-based approach, delivered through a new mobile health platform (DMD Home), to assess motor function in patients with Duchenne muscular dystrophy (DMD), a genetic, rare, muscular disease characterized by the progressive loss of muscle function and strength. Motor function tasks were selected to reflect the “transfer stage” of the disease, when patients are no longer able to walk independently but can stand and weight-bear to transfer. This stage is important for patients and families as it represents a significant milestone in the progression of DMD but it is not routinely captured and/or scored by standard DMD clinical and physiotherapy assessments. A total of 62 videos were submitted by eight out of eleven participants who onboarded the app and were analysed with pose estimation software (OpenPose) that led to the extraction of objective, quantitative measures, including time, pattern of movement trajectory, and smoothness and symmetry of movement. Computer vision analysis of video tasks to identify voluntary or compensatory movements within the transfer stage merits further investigation. Longitudinal studies to validate DMD home as a new methodology to predict progression to the non-ambulant stage will be pursued.
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Ratitch B, Rodriguez-Chavez IR, Dabral A, Fontanari A, Vega J, Onorati F, Vandendriessche B, Morton S, Damestani Y. Considerations for Analyzing and Interpreting Data from Biometric Monitoring Technologies in Clinical Trials. Digit Biomark 2022; 6:83-97. [PMID: 36466953 PMCID: PMC9716191 DOI: 10.1159/000525897] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/31/2022] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The proliferation and increasing maturity of biometric monitoring technologies allow clinical investigators to measure the health status of trial participants in a more holistic manner, especially outside of traditional clinical settings. This includes capturing meaningful aspects of health in daily living and a more granular and objective manner compared to traditional tools in clinical settings. SUMMARY Within multidisciplinary teams, statisticians and data scientists are increasingly involved in clinical trials that incorporate digital clinical measures. They are called upon to provide input into trial planning, generation of evidence on the clinical validity of novel clinical measures, and evaluation of the adequacy of existing evidence. Analysis objectives related to demonstrating clinical validity of novel clinical measures differ from typical objectives related to demonstrating safety and efficacy of therapeutic interventions using established measures which statisticians are most familiar with. KEY MESSAGES This paper discusses key considerations for generating evidence for clinical validity through the lens of the type and intended use of a clinical measure. This paper also briefly discusses the regulatory pathways through which clinical validity evidence may be reviewed and highlights challenges that investigators may encounter while dealing with data from biometric monitoring technologies.
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Affiliation(s)
- Bohdana Ratitch
- Statistics and Data Insights, Bayer, Westmount, Québec, Canada
| | - Isaac R. Rodriguez-Chavez
- Strategy Center for Decentralized Clinical Trials and Digital Medicine, Drug Development Solutions, ICON plc, Blue Bell, Pennsylvania, USA
| | - Abhishek Dabral
- Global Development Operations, Amgen Inc., Thousand Oaks, California, USA
| | | | - Julio Vega
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Francesco Onorati
- Applied Data Science, Current Health, A Best Buy Health Company, Boston, Massachusetts, USA
| | - Benjamin Vandendriessche
- Byteflies, Antwerp, Belgium & Department of Electrical, Computer and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Stuart Morton
- Emerging Digital Medicines, Eli Lilly & Co., Indianapolis, Indiana, USA
| | - Yasaman Damestani
- Digital Medicine, Karyopharm Therapeutics, Newton, Massachusetts, USA
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25
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Stephenson D, Ollivier C, Brinton R, Barrett J. Can Innovative Trial Designs in Orphan Diseases Drive Advancement of Treatments for Common Neurological Diseases? Clin Pharmacol Ther 2022; 111:799-806. [PMID: 35034352 PMCID: PMC9305159 DOI: 10.1002/cpt.2528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022]
Abstract
Global regulatory agencies have transformed their approach to approvals in their processes for formal review of the safety and efficacy of new drugs. Opportunities for innovation have expanded because of the coronavirus disease 2019 (COVID-19) pandemic. Several regulatory-led initiatives have progressed rapidly during the past year, including patient-focused drug development, model-informed drug development, real-world evidence, and complex innovative trial designs. Collectively, these initiatives have accelerated the rate of approvals. Despite demands to focus on urgent needs imposed by the COVID-19 pandemic, the number of new drug approvals over the past year, particularly for rare diseases, has outpaced expectations. Advancing therapeutics for nervous system disorders requires adaptive strategies that align with rapid developments in the field. Three relentlessly progressive diseases, amyotrophic lateral sclerosis, Duchenne muscular dystrophy, and Parkinson's disease are in urgent need of new treatments. Herein, we propose new regulatory initiatives, including innovative trial designs and patient-focused drug development that accelerate clinical trial conduct while meeting critical regulatory requirements for therapeutic approval.
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Affiliation(s)
| | | | - Roberta Brinton
- Center for Innovation in Brain SciencesUniversity of Arizona Health SciencesTucsonArizonaUSA
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26
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Hill DL, Stephenson D, Brayanov J, Claes K, Badawy R, Sardar S, Fisher K, Lee SJ, Bannon A, Roussos G, Kangarloo T, Terebaite V, Müller MLTM, Bhatnagar R, Adams JL, Dorsey ER, Cosman J. Metadata Framework to Support Deployment of Digital Health Technologies in Clinical Trials in Parkinson's Disease. SENSORS (BASEL, SWITZERLAND) 2022; 22:2136. [PMID: 35336307 PMCID: PMC8954603 DOI: 10.3390/s22062136] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 06/14/2023]
Abstract
Sensor data from digital health technologies (DHTs) used in clinical trials provides a valuable source of information, because of the possibility to combine datasets from different studies, to combine it with other data types, and to reuse it multiple times for various purposes. To date, there exist no standards for capturing or storing DHT biosensor data applicable across modalities and disease areas, and which can also capture the clinical trial and environment-specific aspects, so-called metadata. In this perspectives paper, we propose a metadata framework that divides the DHT metadata into metadata that is independent of the therapeutic area or clinical trial design (concept of interest and context of use), and metadata that is dependent on these factors. We demonstrate how this framework can be applied to data collected with different types of DHTs deployed in the WATCH-PD clinical study of Parkinson's disease. This framework provides a means to pre-specify and therefore standardize aspects of the use of DHTs, promoting comparability of DHTs across future studies.
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Affiliation(s)
- Derek L. Hill
- Panoramic Digital Health, 38000 Grenoble, France
- Centre for Medical Imaging, University College London (UCL), London WC1E 6BT, UK
| | - Diane Stephenson
- Critical Path Institute, Tucson, AZ 85718, USA; (D.S.); (S.S.); (M.L.T.M.M.); (R.B.)
| | - Jordan Brayanov
- Takeda Development Center Americas, Inc., Deerfield, IL 60015, USA; (J.B.); (T.K.)
| | | | - Reham Badawy
- School of Computer Science, University of Birmingham, Birmingham B15 2TT, UK;
| | - Sakshi Sardar
- Critical Path Institute, Tucson, AZ 85718, USA; (D.S.); (S.S.); (M.L.T.M.M.); (R.B.)
| | | | | | | | - George Roussos
- Birkbeck College, University of London, London WC1E 7HX, UK;
| | - Tairmae Kangarloo
- Takeda Development Center Americas, Inc., Deerfield, IL 60015, USA; (J.B.); (T.K.)
| | | | | | - Roopal Bhatnagar
- Critical Path Institute, Tucson, AZ 85718, USA; (D.S.); (S.S.); (M.L.T.M.M.); (R.B.)
| | - Jamie L. Adams
- Department of Neurology, University of Rochester, Rochester, NY 14642, USA; (J.L.A.); (E.R.D.)
| | - E. Ray Dorsey
- Department of Neurology, University of Rochester, Rochester, NY 14642, USA; (J.L.A.); (E.R.D.)
| | - Josh Cosman
- AbbVie, North Chicago, IL 60064, USA; (A.B.); (J.C.)
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27
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Moving Forward from the COVID-19 Pandemic: Needed Changes in Movement Disorders Care and Research. Curr Neurol Neurosci Rep 2022; 22:113-122. [PMID: 35107786 PMCID: PMC8809223 DOI: 10.1007/s11910-022-01178-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/23/2022]
Abstract
Purpose of Review The COVID-19 pandemic has dramatically affected the health and well-being of individuals with movement disorders. This manuscript reviews these effects, discusses pandemic-related changes in clinical care and research, and suggests improvements to care and research models. Recent Findings During the on-going COVID-19 pandemic, individuals with movement disorders have experienced worsening of symptoms, likely due to decreased access to care, loss of social connection, and decreased physical activity. Through telemedicine, care has moved out of the clinic and into the home. Clinical research has also been significantly disrupted, and there has been a shift to decentralized approaches. The pandemic has highlighted disparities in access to care and representation in research. Summary We must now translate these experiences into better care and research models with a focus on equitable integration of telemedicine, better support of patients and caregivers, the development of meaningful digital endpoints, and optimization of decentralized research designs.
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28
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Clay I, Angelopoulos C, Bailey AL, Blocker A, Carini S, Carvajal R, Drummond D, McManus KF, Oakley-Girvan I, Patel KB, Szepietowski P, Goldsack JC. Sensor Data Integration: A New Cross-Industry Collaboration to Articulate Value, Define Needs, and Advance a Framework for Best Practices. J Med Internet Res 2021; 23:e34493. [PMID: 34751656 PMCID: PMC8663457 DOI: 10.2196/34493] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 01/16/2023] Open
Abstract
Data integration, the processes by which data are aggregated, combined, and made available for use, has been key to the development and growth of many technological solutions. In health care, we are experiencing a revolution in the use of sensors to collect data on patient behaviors and experiences. Yet, the potential of this data to transform health outcomes is being held back. Deficits in standards, lexicons, data rights, permissioning, and security have been well documented, less so the cultural adoption of sensor data integration as a priority for large-scale deployment and impact on patient lives. The use and reuse of trustworthy data to make better and faster decisions across drug development and care delivery will require an understanding of all stakeholder needs and best practices to ensure these needs are met. The Digital Medicine Society is launching a new multistakeholder Sensor Data Integration Tour of Duty to address these challenges and more, providing a clear direction on how sensor data can fulfill its potential to enhance patient lives.
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Affiliation(s)
- Ieuan Clay
- Digital Medicine Society (DiMe), Boston, MA, United States
| | | | | | | | - Simona Carini
- University of California San Francisco, San Francisco, CA, United States
| | - Rodrigo Carvajal
- H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States
| | | | | | | | - Krupal B Patel
- H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, United States
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29
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Hospodková P, Berežná J, Barták M, Rogalewicz V, Severová L, Svoboda R. Change Management and Digital Innovations in Hospitals of Five European Countries. Healthcare (Basel) 2021; 9:1508. [PMID: 34828554 PMCID: PMC8625074 DOI: 10.3390/healthcare9111508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/26/2021] [Accepted: 11/03/2021] [Indexed: 12/13/2022] Open
Abstract
The objective of the paper is to evaluate the quality of systemic change management (CHM) and readiness for change in five Central European countries. The secondary goal is to identify trends and upcoming changes in the field of digital innovations in healthcare. The results show that all compared countries (regardless of their historical context) deal with similar CHM challenges with a rather similar degree of success. A questionnaire distributed to hospitals clearly showed that there is still considerable room for improvement in terms of the use of specific CHM tools. A review focused on digital innovations based on the PRISMA statement showed that there are five main directions, namely, data collection and integration, telemedicine, artificial intelligence, electronic medical records, and M-Health. In the hospital environment, there are considerable reservations in applying change management principles, as well as the absence of a systemic approach. The main factors that must be monitored for a successful and sustainable CHM include a clearly defined and widely communicated vision, early engagement of all stakeholders, precisely set rules, adaptation to the local context and culture, provision of a technical base, and a step-by-step implementation with strong feedback.
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Affiliation(s)
- Petra Hospodková
- Department of Economic Theories, Faculty of Economics and Management, Czech University of Life Sciences Prague, Kamýcká 129, 165 00 Prague, Czech Republic; (P.H.); (L.S.)
- Department of Biomedical Technology, Czech Technical University in Prague, 272 01 Kladno, Czech Republic; (J.B.); (V.R.)
| | - Jana Berežná
- Department of Biomedical Technology, Czech Technical University in Prague, 272 01 Kladno, Czech Republic; (J.B.); (V.R.)
| | - Miroslav Barták
- Department of Master Study Programs, Faculty of Health Studies, J. E. Purkyne University in Ústí nad Labem, 400 96 Ústí nad Labem, Czech Republic;
| | - Vladimír Rogalewicz
- Department of Biomedical Technology, Czech Technical University in Prague, 272 01 Kladno, Czech Republic; (J.B.); (V.R.)
| | - Lucie Severová
- Department of Economic Theories, Faculty of Economics and Management, Czech University of Life Sciences Prague, Kamýcká 129, 165 00 Prague, Czech Republic; (P.H.); (L.S.)
| | - Roman Svoboda
- Department of Economic Theories, Faculty of Economics and Management, Czech University of Life Sciences Prague, Kamýcká 129, 165 00 Prague, Czech Republic; (P.H.); (L.S.)
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30
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Polhemus A, Delgado-Ortiz L, Brittain G, Chynkiamis N, Salis F, Gaßner H, Gross M, Kirk C, Rossanigo R, Taraldsen K, Balta D, Breuls S, Buttery S, Cardenas G, Endress C, Gugenhan J, Keogh A, Kluge F, Koch S, Micó-Amigo ME, Nerz C, Sieber C, Williams P, Bergquist R, Bosch de Basea M, Buckley E, Hansen C, Mikolaizak AS, Schwickert L, Scott K, Stallforth S, van Uem J, Vereijken B, Cereatti A, Demeyer H, Hopkinson N, Maetzler W, Troosters T, Vogiatzis I, Yarnall A, Becker C, Garcia-Aymerich J, Leocani L, Mazzà C, Rochester L, Sharrack B, Frei A, Puhan M. Walking on common ground: a cross-disciplinary scoping review on the clinical utility of digital mobility outcomes. NPJ Digit Med 2021; 4:149. [PMID: 34650191 PMCID: PMC8516969 DOI: 10.1038/s41746-021-00513-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023] Open
Abstract
Physical mobility is essential to health, and patients often rate it as a high-priority clinical outcome. Digital mobility outcomes (DMOs), such as real-world gait speed or step count, show promise as clinical measures in many medical conditions. However, current research is nascent and fragmented by discipline. This scoping review maps existing evidence on the clinical utility of DMOs, identifying commonalities across traditional disciplinary divides. In November 2019, 11 databases were searched for records investigating the validity and responsiveness of 34 DMOs in four diverse medical conditions (Parkinson's disease, multiple sclerosis, chronic obstructive pulmonary disease, hip fracture). Searches yielded 19,672 unique records. After screening, 855 records representing 775 studies were included and charted in systematic maps. Studies frequently investigated gait speed (70.4% of studies), step length (30.7%), cadence (21.4%), and daily step count (20.7%). They studied differences between healthy and pathological gait (36.4%), associations between DMOs and clinical measures (48.8%) or outcomes (4.3%), and responsiveness to interventions (26.8%). Gait speed, step length, cadence, step time and step count exhibited consistent evidence of validity and responsiveness in multiple conditions, although the evidence was inconsistent or lacking for other DMOs. If DMOs are to be adopted as mainstream tools, further work is needed to establish their predictive validity, responsiveness, and ecological validity. Cross-disciplinary efforts to align methodology and validate DMOs may facilitate their adoption into clinical practice.
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Affiliation(s)
- Ashley Polhemus
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Laura Delgado-Ortiz
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Gavin Brittain
- Department of Neuroscience and Sheffield NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust & University of Sheffield, Sheffield, England
| | - Nikolaos Chynkiamis
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University Newcastle, Newcastle, UK
| | - Francesca Salis
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Heiko Gaßner
- Department of Molecular Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Michaela Gross
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Cameron Kirk
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rachele Rossanigo
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Kristin Taraldsen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Diletta Balta
- Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | - Sofie Breuls
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Respiratory Diseases, University hospitals Leuven, Leuven, Belgium
| | - Sara Buttery
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Gabriela Cardenas
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Christoph Endress
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Julia Gugenhan
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Alison Keogh
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland
| | - Felix Kluge
- Department of Artificial Intelligence in Biomedical Engineering, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sarah Koch
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - M Encarna Micó-Amigo
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Corinna Nerz
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Chloé Sieber
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Parris Williams
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ronny Bergquist
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Magda Bosch de Basea
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Ellen Buckley
- Insigneo Institute, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - Clint Hansen
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Lars Schwickert
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Kirsty Scott
- Insigneo Institute, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - Sabine Stallforth
- Department of Molecular Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Janet van Uem
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Beatrix Vereijken
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Andrea Cereatti
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
- Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | - Heleen Demeyer
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Respiratory Diseases, University hospitals Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
| | | | - Walter Maetzler
- Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Thierry Troosters
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Respiratory Diseases, University hospitals Leuven, Leuven, Belgium
| | - Ioannis Vogiatzis
- Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University Newcastle, Newcastle, UK
| | - Alison Yarnall
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Clemens Becker
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Judith Garcia-Aymerich
- ISGlobal, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Letizia Leocani
- Department of Neurology, San Raffaele University, Milan, Italy
| | - Claudia Mazzà
- Insigneo Institute, Department of Mechanical Engineering, University of Sheffield, Sheffield, UK
| | - Lynn Rochester
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Basil Sharrack
- Department of Neuroscience and Sheffield NIHR Translational Neuroscience BRC, Sheffield Teaching Hospitals NHS Foundation Trust & University of Sheffield, Sheffield, England
| | - Anja Frei
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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31
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Picerno P, Iosa M, D'Souza C, Benedetti MG, Paolucci S, Morone G. Wearable inertial sensors for human movement analysis: a five-year update. Expert Rev Med Devices 2021; 18:79-94. [PMID: 34601995 DOI: 10.1080/17434440.2021.1988849] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The aim of the present review is to track the evolution of wearable IMUs from their use in supervised laboratory- and ambulatory-based settings to their application for long-term monitoring of human movement in unsupervised naturalistic settings. AREAS COVERED Four main emerging areas of application were identified and synthesized, namely, mobile health solutions (specifically, for the assessment of frailty, risk of falls, chronic neurological diseases, and for the monitoring and promotion of active living), occupational ergonomics, rehabilitation and telerehabilitation, and cognitive assessment. Findings from recent scientific literature in each of these areas was synthesized from an applied and/or clinical perspective with the purpose of providing clinical researchers and practitioners with practical guidance on contemporary uses of inertial sensors in applied clinical settings. EXPERT OPINION IMU-based wearable devices have undergone a rapid transition from use in laboratory-based clinical practice to unsupervised, applied settings. Successful use of wearable inertial sensing for assessing mobility, motor performance and movement disorders in applied settings will rely also on machine learning algorithms for managing the vast amounts of data generated by these sensors for extracting information that is both clinically relevant and interpretable by practitioners.
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Affiliation(s)
- Pietro Picerno
- SMART Engineering Solutions & Technologies (SMARTEST) Research Center, Università Telematica "Ecampus", Novedrate, Comune, Italy
| | - Marco Iosa
- Department of Psychology, Sapienza University, Rome, Italy.,Irrcs Santa Lucia Foundation, Rome, Italy
| | - Clive D'Souza
- Center for Ergonomics, Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan, USA.,Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maria Grazia Benedetti
- Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
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32
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Karabayir I, Butler L, Goldman SM, Kamaleswaran R, Gunturkun F, Davis RL, Ross GW, Petrovitch H, Masaki K, Tanner CM, Tsivgoulis G, Alexandrov AV, Chinthala LK, Akbilgic O. Predicting Parkinson's Disease and Its Pathology via Simple Clinical Variables. JOURNAL OF PARKINSONS DISEASE 2021; 12:341-351. [PMID: 34602502 PMCID: PMC8842767 DOI: 10.3233/jpd-212876] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Parkinson’s disease (PD) is a chronic, disabling neurodegenerative disorder. Objective: To predict a future diagnosis of PD using questionnaires and simple non-invasive clinical tests. Methods: Participants in the prospective Kuakini Honolulu-Asia Aging Study (HAAS) were evaluated biannually between 1995–2017 by PD experts using standard diagnostic criteria. Autopsies were sought on all deaths. We input simple clinical and risk factor variables into an ensemble-tree based machine learning algorithm and derived models to predict the probability of developing PD. We also investigated relationships of predictive models and neuropathologic features such as nigral neuron density. Results: The study sample included 292 subjects, 25 of whom developed PD within 3 years and 41 by 5 years. 116 (46%) of 251 subjects not diagnosed with PD underwent autopsy. Light Gradient Boosting Machine modeling of 12 predictors correctly classified a high proportion of individuals who developed PD within 3 years (area under the curve (AUC) 0.82, 95%CI 0.76–0.89) or 5 years (AUC 0.77, 95%CI 0.71–0.84). A large proportion of controls who were misclassified as PD had Lewy pathology at autopsy, including 79%of those who died within 3 years. PD probability estimates correlated inversely with nigral neuron density and were strongest in autopsies conducted within 3 years of index date (r = –0.57, p < 0.01). Conclusion: Machine learning can identify persons likely to develop PD during the prodromal period using questionnaires and simple non-invasive tests. Correlation with neuropathology suggests that true model accuracy may be considerably higher than estimates based solely on clinical diagnosis.
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Affiliation(s)
- Ibrahim Karabayir
- Department of Health Informatics, Parkinson School of Health Sciences and Public Health Loyola University Chicago, Maywood, IL, USA.,Kirklareli University, Kirklareli, Turkey
| | - Liam Butler
- Department of Health Informatics, Parkinson School of Health Sciences and Public Health Loyola University Chicago, Maywood, IL, USA
| | - Samuel M Goldman
- University of California San Francisco, San Francisco, CA, USA.,San Francisco VA Health Care System, San Francisco, CA, USA
| | | | - Fatma Gunturkun
- University of Tennessee Health Sciences Center, Knoxville, TN, USA
| | - Robert L Davis
- University of Tennessee Health Sciences Center, Knoxville, TN, USA
| | - G Webster Ross
- Veterans Affairs Pacific Islands Health Care System, Honolulu, HI, USA.,Department of Geriatric Medicine, University of Hawaii, Honolulu, HI, USA
| | - Helen Petrovitch
- Veterans Affairs Pacific Islands Health Care System, Honolulu, HI, USA.,Department of Geriatric Medicine, University of Hawaii, Honolulu, HI, USA
| | - Kamal Masaki
- Department of Geriatric Medicine, University of Hawaii, Honolulu, HI, USA.,Kuakini Medical Center, Honolulu, HI, USA
| | - Caroline M Tanner
- University of California San Francisco, San Francisco, CA, USA.,San Francisco VA Health Care System, San Francisco, CA, USA
| | | | | | | | - Oguz Akbilgic
- Department of Health Informatics, Parkinson School of Health Sciences and Public Health Loyola University Chicago, Maywood, IL, USA
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33
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Abstract
PURPOSE OF REVIEW The COVID-pandemic has facilitated the implementation of telemedicine in both clinical practice and research. We highlight recent developments in three promising areas of telemedicine: teleconsultation, telemonitoring, and teletreatment. We illustrate this using Parkinson's disease as a model for other chronic neurological disorders. RECENT FINDINGS Teleconsultations can reliably administer parts of the neurological examination remotely, but are typically not useful for establishing a reliable diagnosis. For follow-ups, teleconsultations can provide enhanced comfort and convenience to patients, and provide opportunities for blended and proactive care models. Barriers include technological challenges, limited clinician confidence, and a suboptimal clinician-patient relationship. Telemonitoring using wearable sensors and smartphone-based apps can support clinical decision-making, but we lack large-scale randomized controlled trials to prove effectiveness on clinical outcomes. Increasingly many trials are now incorporating telemonitoring as an exploratory outcome, but more work remains needed to demonstrate its clinical meaningfulness. Finding a balance between benefits and burdens for individual patients remains vital. Recent work emphasised the promise of various teletreatment solutions, such as remotely adjustable deep brain stimulation parameters, virtual reality enhanced exercise programs, and telephone-based cognitive behavioural therapy. Personal contact remains essential to ascertain adherence to teletreatment. SUMMARY The availability of different telemedicine tools for remote consultation, monitoring, and treatment is increasing. Future research should establish whether telemedicine improves outcomes in routine clinical care, and further underpin its merits both as intervention and outcome in research settings.
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Affiliation(s)
- Robin van den Bergh
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson & Movement Disorders
| | - Bastiaan R. Bloem
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson & Movement Disorders
| | - Marjan J. Meinders
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
| | - Luc J.W. Evers
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson & Movement Disorders
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Stephenson D, Badawy R, Mathur S, Tome M, Rochester L. Digital Progression Biomarkers as Novel Endpoints in Clinical Trials: A Multistakeholder Perspective. JOURNAL OF PARKINSONS DISEASE 2021; 11:S103-S109. [PMID: 33579873 PMCID: PMC8385507 DOI: 10.3233/jpd-202428] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The burden of Parkinson's disease (PD) continues to grow at an unsustainable pace particularly given that it now represents the fastest growing brain disease. Despite seminal discoveries in genetics and pathogenesis, people living with PD oftentimes wait years to obtain an accurate diagnosis and have no way to know their own prognostic fate once they do learn they have the disease. Currently, there is no objective biomarker to measure the onset, progression, and severity of PD along the disease continuum. Without such tools, the effectiveness of any given treatment, experimental or conventional cannot be measured. Such tools are urgently needed now more than ever given the rich number of new candidate therapies in the pipeline. Over the last decade, millions of dollars have been directed to identify biomarkers to inform progression of PD typically using molecular, fluid or imaging modalities. These efforts have produced novel insights in our understanding of PD including mechanistic targets, disease subtypes and imaging biomarkers. While we have learned a lot along the way, implementation of robust disease progression biomarkers as tools for quantifying changes in disease status or severity remains elusive. Biomarkers have improved health outcomes and led to accelerated drug approvals in key areas of unmet need such as oncology. Quantitative biomarker measures such as HbA1c a standard test for the monitoring of diabetes has impacted patient care and management, both for the healthcare professionals and the patient community. Such advances accelerate opportunities for early intervention including prevention of disease in high-risk individuals. In PD, progression markers are needed at all stages of the disease in order to catalyze drug development-this allows interventions aimed to halt or slow disease progression (very early) but also facilitates symptomatic treatments at moderate stages of the disease. Recently, attention has turned to the role of digital health technologies to complement the traditional modalities as they are relatively low cost, objective and scalable. Success in this endeavor would be transformative for clinical research and therapeutic development. Consequently, significant investment has led to a number of collaborative efforts to identify and validate suitable digital biomarkers of disease progression.
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Affiliation(s)
| | | | | | - Maria Tome
- European Medicines Agency, Amsterdam, The Netherlands
| | - Lynn Rochester
- Institute of Translational and Clinical Research, Newcastle University, Newcastle, UK
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Izmailova ES, Wood WA. Biometric Monitoring Technologies in Cancer: The Past, Present, and Future. JCO Clin Cancer Inform 2021; 5:728-733. [PMID: 34236887 DOI: 10.1200/cci.21.00019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
| | - William A Wood
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Kumar P, Clay I. The Future of Digital Health: Meeting Report. Digit Biomark 2021; 5:74-77. [PMID: 34056517 DOI: 10.1159/000515355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 02/18/2021] [Indexed: 11/19/2022] Open
Abstract
At the end of 2020, Karger's Digital Biomarkers, together with Evidation Health, produced a special issue entitled "The Future of Digital Health." This brief meeting report provides an overview of the expert panel and workshop that were held in early 2021 to explore key topics raised in the special issue.
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Affiliation(s)
- Priya Kumar
- Evidation Health Inc., San Mateo, California, USA
| | - Ieuan Clay
- Evidation Health Inc., San Mateo, California, USA
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37
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Goldsack JC, Dowling AV, Samuelson D, Patrick-Lake B, Clay I. Evaluation, Acceptance, and Qualification of Digital Measures: From Proof of Concept to Endpoint. Digit Biomark 2021; 5:53-64. [PMID: 33977218 DOI: 10.1159/000514730] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/19/2021] [Indexed: 12/12/2022] Open
Abstract
To support the successful adoption of digital measures into internal decision making and evidence generation for medical product development, we present a unified lexicon to aid communication throughout this process, and highlight key concepts including the critical role of participant engagement in development of digital measures. We detail the steps of bringing a successful proof of concept to scale, focusing on key decisions in the development of a new digital measure: asking the right question, optimized approaches to evaluating new measures, and whether and how to pursue qualification or acceptance. Building on the V3 framework for establishing verification and analytical and clinical validation, we discuss strategic and practical considerations for collecting this evidence, illustrated with concrete examples of trailblazing digital measures in the field.
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Affiliation(s)
| | | | | | | | - Ieuan Clay
- Evidation Health Inc., San Mateo, California, USA
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