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Niemeyer MJS, Jochems D, Van Ditshuizen JC, de Kanter J, Cremers L, van Hattem M, Den Hartog D, Houwert RM, Leenen LPH, van Wessem KJP. Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02407-5. [PMID: 38226991 DOI: 10.1007/s00068-023-02407-5] [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: 08/31/2023] [Accepted: 11/12/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE With an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers. METHODS From 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3-6 months post-discharge were collected. RESULTS The study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4-5] vs. UMC-U: 4 [4-5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up. DISCUSSION This study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Menco J S Niemeyer
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Denise Jochems
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan C Van Ditshuizen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Janneke de Kanter
- Department of Radiology, UMC Division Imaging and Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lotte Cremers
- Department of Radiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Martijn van Hattem
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Trauma Center Southwest Netherlands, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roderick Marijn Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Wasserman JA, Brummett AL, Navin MC, Menkes DL. Conscientious Objection to Aggressive Interventions for Patients in a Vegetative State. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023:1-12. [PMID: 38032547 DOI: 10.1080/15265161.2023.2280099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of "futility", but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment.
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Affiliation(s)
- Jason Adam Wasserman
- Oakland University William Beaumont School of Medicine
- Corewell Health - East
- Oakland University Center for Moral Values in Health and Medicine
| | - Abram L Brummett
- Oakland University William Beaumont School of Medicine
- Corewell Health - East
- Oakland University Center for Moral Values in Health and Medicine
| | - Mark Christopher Navin
- Corewell Health - East
- Oakland University Center for Moral Values in Health and Medicine
- Oakland University
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Chen BL, Lien HC, Yang SS, Wu SC, Chiang HH, Lin LC. Impact of Mobile Apps in Conjunction With Percutaneous Endoscopic Gastrostomy on Patients' Complications, Quality of Life, and Health-Related Self-Care Behaviors: Randomized Clinical Trial. JMIR Mhealth Uhealth 2023; 11:e48970. [PMID: 37862072 PMCID: PMC10625096 DOI: 10.2196/48970] [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: 05/13/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is commonly chosen for long-term enteral nutrition support. However, common complications of PEG include wound infection, leakage, obstruction, bleeding, dislodgement, pneumonia, peritonitis, and more. The anticipation of these complications by both patients and their family caregivers underscores the essential requirement of ongoing technical guidance for the daily care of PEG and the adoption of preventative strategies. OBJECTIVE This study aimed to establish and compare a health education program utilizing a tracking system for PEG using a mobile app (PEG app) and instant messaging software versus a paper-based health education program with instant messaging software. Their effectiveness in preventing complications, avoiding hospital readmissions, improving self-care practices, and enhancing quality of life outcomes was assessed. METHODS A randomized controlled trial design was used, and the study sample consisted of patients from a medical center in central Taiwan who underwent thoracic surgery or gastroenterology procedures. Inclusion criteria were being a new case undergoing his or her first gastric tube insertion and having the ability to operate a smartphone. Exclusion criteria were cases requiring tube replacement or nasogastric tubes. A total of 74 participants were enrolled, with 37 participants in the experimental group and 37 participants in the control group. Data collection took place from hospitalization until 1 month after discharge. The experimental group received care using the gastric tube tracking system (PEG app) and the Line app that included phone, text, and photo capture capabilities, while the control group received routine nursing care and used the Line app. RESULTS The experimental group demonstrated a significant reduction in the occurrence of complications compared with the control group (χ21=12.087, P=.001). Specifically, the occurrence of leakage events was significantly lower in the experimental group than in the control group (χ21=12.906, P=.001). However, the experimental group exhibited superior self-care ability compared with the control group (t72=2.203, P=.03). There was no significant difference in overall quality of life scores between the experimental and control groups (t72=1.603, P=.11). However, the experimental group showed better social aspects of quality of life than the control group (t72=2.164, P=.03). CONCLUSIONS Integration of the PEG app with instant messaging can enhance self-care ability, improve social aspects of quality of life, and reduce complications. The study results suggest that the PEG app could be used as an adjunct tool to promote patients' self-directed management of their gastric tube at home, particularly for patients who have undergone their first PEG placement and are being discharged from the hospital. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR2300071271; https://tinyurl.com/4vvy584e.
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Affiliation(s)
- Bi-Lian Chen
- Department of Nursing, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Department of Nursing, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Han-Chung Lien
- Division of Gastroenterology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shyh-Sheng Yang
- The Division of Thoracic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shiao-Chi Wu
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Hsien-Hsien Chiang
- Department of Nursing, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Li-Chan Lin
- Department of Nursing, Asia University, Taichung, Taiwan
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Liyana Arachige M, Seneviratne U, John N, Ma H, Phan TG. Mapping topography and network of brain injury in patients with disorders of consciousness. Front Neurol 2023; 14:1027160. [PMID: 37064187 PMCID: PMC10090673 DOI: 10.3389/fneur.2023.1027160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
BackgroundThere is a growing interest in the topography of brain regions associated with disorders of consciousness. This has caused increased research output, yielding many publications investigating the topic with varying methodologies. The objective of this study was to ascertain the topographical regions of the brain most frequently associated with disorders of consciousness.MethodsWe performed a cross-sectional text-mining analysis of disorders of consciousness studies. A text mining algorithm built in the Python programming language searched documents for anatomical brain terminology. We reviewed primary PubMed studies between January 1st 2000 to 8th February 2023 for the search query “Disorders of Consciousness.” The frequency of brain regions mentioned in these articles was recorded, ranked, then built into a graphical network. Subgroup analysis was performed by evaluating the impact on our results if analyses were based on abstracts, full-texts, or topic-modeled groups (non-negative matrix factorization was used to create subgroups of each collection based on their key topics). Brain terms were ranked by their frequency and concordance was measured between subgroups. Graphical analysis was performed to explore relationships between the anatomical regions mentioned. The PageRank algorithm (used by Google to list search results in order of relevance) was used to determine global importance of the regions.ResultsThe PubMed search yielded 24,944 abstracts and 3,780 full texts. The topic-modeled subgroups contained 2015 abstracts and 283 full texts. Text Mining across all document groups concordantly ranked the thalamus the highest (Savage score = 11.716), followed by the precuneus (Savage score = 4.983), hippocampus (Savage score = 4.483). Graphical analysis had 5 clusters with the thalamus once again having the highest PageRank score (PageRank = 0.0344).ConclusionThe thalamus, precuneus and cingulate cortex are strongly associated with disorders of consciousness, likely due to the roles they play in maintaining awareness and involvement in the default mode network, respectively. The findings also suggest that other areas of the brain like the cerebellum, cuneus, amygdala and hippocampus also share connections to consciousness should be further investigated.
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Affiliation(s)
- Manoj Liyana Arachige
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Clayton, VIC, Australia
| | - Udaya Seneviratne
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Clayton, VIC, Australia
| | - Nevin John
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Clayton, VIC, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Clayton, VIC, Australia
| | - Thanh G. Phan
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Monash Health, Clayton, VIC, Australia
- *Correspondence: Thanh G. Phan,
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Ma H, Zhao K, Jia C, You J, Zhou M, Wang T, Huang C. Effect of transcranial direct current stimulation for patients with disorders of consciousness: A systematic review and meta-analysis. Front Neurosci 2023; 16:1081278. [PMID: 36755882 PMCID: PMC9899861 DOI: 10.3389/fnins.2022.1081278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/31/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Transcranial direct current stimulation (tDCS) could potentially facilitate consciousness improvement in patients with disorders of consciousness (DOC). The aim of this study was to investigate the therapeutic efficacy of tDCS on consciousness recovery for patients with DOC. Methods Eight databases were systematically searched from their inception to June 2022. Quality of included studies were assessed using PEDro score and Cochrane's risk of bias assessment. All statistical analyses were performed using RevMan software. Seventeen studies with 618 patients were identified eligible for this study, and fifteen studies with sufficient data were pooled in the meta-analysis. Results The results of meta-analysis showed a significant effect on increasing GCS scores (MD = 1.73; 95% CI, 1.28-2.18; P < 0.01) and CRS-R scores (MD = 1.28; 95% CI = 0.56-2.00; P < 0.01) in favor of the real stimulation group as compared to sham. The results of subgroup analysis demonstrated that only more than 20 sessions of stimulation could significantly enhance the improvement of GCS scores and the CRS-R scores. Moreover, the effect of tDCS on CRS-R score improvement was predominant in patients with minimal conscious state (MCS) (MD = 1.84; 95% CI = 0.74-2.93; P < 0.01). Conclusion Anodal tDCS with sufficient stimulation doses appears to be an effective approach for patients with MCS, in terms of CRS-R scores. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022336958.
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Affiliation(s)
- Hui Ma
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,School of Rehabilitation Medicine, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Kehong Zhao
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,School of Rehabilitation Medicine, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Chengsen Jia
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Jiuhong You
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,School of Rehabilitation Medicine, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Mei Zhou
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,School of Rehabilitation Medicine, West China School of Medicine, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Tingting Wang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Cheng Huang
- Department of Rehabilitation Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China,*Correspondence: Cheng Huang,
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Nekrasova JY, Kanarsky MM, Borisov IV, Pradhan P, Yankevich DS, Roshka SF, Petrova MV, Grechko AV. Post-Discharge Plight Of Patients With Chronic Disorders Of Consciousness: A Systematic Review Of Socioeconomic And Health Aspects. RUSSIAN OPEN MEDICAL JOURNAL 2022. [DOI: 10.15275/rusomj.2022.0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective — the presented study aims to systematize and structure significant information regarding the problems of patients with disorders of consciousness (DOC) and their families after discharge from the hospital, and to search for possible solutions. Material and Methods — to identify eligible studies, we searched the Medline database (via PubMed) for studies on socioeconomic and medical issues of patients with chronic DOC at the post-hospital stage of rehabilitation for the last 20 years. Results — we included 28 studies with 21 cohorts of patients from 7 different countries in our study. The components of informal caregiver burden and their impact on the quality of life were identified and systematized. These components include high physical load, high economic costs, vast time expenditures, strong emotional involvement, and a top level of expertise in caregiving, all of which are required from the relatives. Conclusion — It was affirmed, that the lack of healthcare system support was a major contributing factor to the overall burden. Our research also showed that delivering care without receiving information, advice, and training is extremely painful for family caregivers.
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Affiliation(s)
- Julia Yu. Nekrasova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Mikhail M. Kanarsky
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Ilya V. Borisov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Pranil Pradhan
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia; Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Dmitry S. Yankevich
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Stanislav F. Roshka
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Marina V. Petrova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia; Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Andrey V. Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
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Irzan H, Pozzi M, Chikhladze N, Cebanu S, Tadevosyan A, Calcii C, Tsiskaridze A, Melbourne A, Strazzer S, Modat M, Molteni E. Emerging Treatments for Disorders of Consciousness in Paediatric Age. Brain Sci 2022; 12:198. [PMID: 35203961 PMCID: PMC8870410 DOI: 10.3390/brainsci12020198] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
Abstract
The number of paediatric patients living with a prolonged Disorder of Consciousness (DoC) is growing in high-income countries, thanks to substantial improvement in intensive care. Life expectancy is extending due to the clinical and nursing management achievements of chronic phase needs, including infections. However, long-known pharmacological therapies such as amantadine and zolpidem, as well as novel instrumental approaches using direct current stimulation and, more recently, stem cell transplantation, are applied in the absence of large paediatric clinical trials and rigorous age-balanced and dose-escalated validations. With evidence building up mainly through case reports and observational studies, there is a need for well-designed paediatric clinical trials and specific research on 0-4-year-old children. At such an early age, assessing residual and recovered abilities is most challenging due to the early developmental stage, incompletely learnt motor and cognitive skills, and unreliable communication; treatment options are also less explored in early age. In middle-income countries, the lack of rehabilitation services and professionals focusing on paediatric age hampers the overall good assistance provision. Young and fast-evolving health insurance systems prevent universal access to chronic care in some countries. In low-income countries, rescue networks are often inadequate, and there is a lack of specialised and intensive care, difficulty in providing specific pharmaceuticals, and lower compliance to intensive care hygiene standards. Despite this, paediatric cases with DoC are reported, albeit in fewer numbers than in countries with better-resourced healthcare systems. For patients with a poor prospect of recovery, withdrawal of care is inhomogeneous across countries and still heavily conditioned by treatment costs as well as ethical and cultural factors, rather than reliant on protocols for assessment and standardised treatments. In summary, there is a strong call for multicentric, international, and global health initiatives on DoC to devote resources to the paediatric age, as there is now scope for funders to invest in themes specific to DoC affecting the early years of the life course.
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Affiliation(s)
- Hassna Irzan
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Marco Pozzi
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
| | - Nino Chikhladze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Serghei Cebanu
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Artashes Tadevosyan
- Department of Public Health and Healthcare Organization, Yerevan State Medical University, Yerevan 0025, Armenia;
| | - Cornelia Calcii
- Faculty of Medicine, Nicolae Testemitanu State University of Medicine and Pharmacy, MD-2004 Chišināu, Moldova; (S.C.); (C.C.)
| | - Alexander Tsiskaridze
- Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, Georgia; (N.C.); (A.T.)
| | - Andrew Melbourne
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 7JE, UK
| | - Sandra Strazzer
- Scientific Institute IRCCS E. Medea, Acquired Brain Injury Unit, 22040 Bosisio Parini, Italy; (M.P.); (S.S.)
- Rehabilitation Service, “Usratuna” Health and Rehabilitation Centre, Juba, South Sudan
| | - Marc Modat
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
| | - Erika Molteni
- School of Biomedical Engineering & Imaging Sciences, King’s College London, London WC2R 2LS, UK; (H.I.); (A.M.); (M.M.)
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