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Pemau RC, González-Palacios P, Kerr KW. How quality of life is measured in studies of nutritional intervention: a systematic review. Health Qual Life Outcomes 2024; 22:9. [PMID: 38267976 PMCID: PMC10809546 DOI: 10.1186/s12955-024-02229-y] [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: 10/10/2023] [Accepted: 01/03/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Nutrition care can positively affect multiple aspects of patient's health; outcomes are commonly evaluated on the basis of their impact on a patient's (i) illness-specific conditions and (ii) health-related quality of life (HRQoL). Our systematic review examined how HRQoL was measured in studies of nutritional interventions. To help future researchers select appropriate Quality of Life Questionnaires (QoLQ), we identified commonly-used instruments and their uses across populations in different regions, of different ages, and with different diseases. METHODS We searched EMCare, EMBASE, and Medline databases for studies that had HRQoL and nutrition intervention terms in the title, the abstract, or the MeSH term classifications "quality of life" and any of "nutrition therapy", "diet therapy", or "dietary supplements" and identified 1,113 studies for possible inclusion.We then reviewed titles, abstracts, and full texts to identify studies for final inclusion. RESULTS Our review of titles, abstracts, and full texts resulted in the inclusion of 116 relevant studies in our final analysis. Our review identified 14 general and 25 disease-specific QoLQ. The most-used general QoLQ were the Short-Form 36-Item Health Survey (SF-36) in 27 studies and EuroQol 5-Dimension, (EQ-5D) in 26 studies. The European Organization for Research and Treatment of Cancer Quality of life Questionnaire (EORTC-QLQ), a cancer-specific QoLQ, was the most frequently used disease-specific QoLQ (28 studies). Disease-specific QoLQ were also identified for nutrition-related diseases such as diabetes, obesity, and dysphagia. Sixteen studies used multiple QoLQ, of which eight studies included both general and disease-specific measures of HRQoL. The most studied diseases were cancer (36 studies) and malnutrition (24 studies). There were few studies focused on specific age-group populations, with only 38 studies (33%) focused on adults 65 years and older and only 4 studies focused on pediatric patients. Regional variation in QoLQ use was observed, with EQ-5D used more frequently in Europe and SF-36 more commonly used in North America. CONCLUSIONS Use of QoLQ to measure HRQoL is well established in the literature; both general and disease-specific instruments are now available for use. We advise further studies to examine potential benefits of using both general and disease-specific QoLQ to better understand the impact of nutritional interventions on HRQoL.
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Affiliation(s)
| | - Patricia González-Palacios
- Department of Nutrition and Food Science, University of Granada, Granada, Spain
- Biomedical Research Institute (IBS), Granada, Spain
| | - Kirk W Kerr
- Abbott Nutrition, 2900 Easton Square Place, Columbus, OH, 43219, USA.
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Coates E, Zarotti N, Williams I, White S, Halliday V, Beever D, Hackney G, Stavroulakis T, White D, Norman P, McDermott C. Patient, carer and healthcare professional perspectives on increasing calorie intake in Amyotrophic Lateral Sclerosis. Chronic Illn 2023; 19:368-382. [PMID: 34935521 PMCID: PMC9999280 DOI: 10.1177/17423953211069090] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Research suggests that higher Body Mass Index is associated with improved survival in people with Amyotrophic Lateral Sclerosis (pwALS). Yet, understanding of the barriers and enablers to increasing calorie intake is limited. This study sought to explore these issues from the perspective of pwALS, informal carers, and healthcare professionals. METHODS Interviews with 18 pwALS and 16 informal carers, and focus groups with 51 healthcare professionals. Data were analysed using template analysis and mapped to the COM-B model and Theoretical Domains Framework (TDF). RESULTS All three COM-B components (Capability, Opportunity and Motivation) are important to achieving high calorie diets in pwALS. Eleven TDF domains were identified: Physical skills (ALS symptoms); Knowledge (about high calorie diets and healthy eating); Memory, attention, and decision processes (reflecting cognitive difficulties); Environmental context/resources (availability of informal and formal carers); Social influences (social aspects of eating); Beliefs about consequences (healthy eating vs. high calorie diets); Identity (interest in health lifestyles); Goals (sense of control); Reinforcement (eating habits); and Optimism and Emotion (low mood, poor appetite). DISCUSSION To promote high calorie diets for pwALS, greater clarity around the rationale and content of recommended diets is needed. Interventions should be tailored to patient symptoms, preferences, motivations, and opportunities.
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Affiliation(s)
- Elizabeth Coates
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield
- Elizabeth Coates, Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Nicolò Zarotti
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Isobel Williams
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Sean White
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Vanessa Halliday
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Daniel Beever
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield
| | - Gemma Hackney
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield
| | - Theocharis Stavroulakis
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - David White
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield
| | - Paul Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
- Elizabeth Coates, Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Christopher McDermott
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
- Elizabeth Coates, Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
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De Marchi F, Serioli M, Collo A, Belotti EG, Alloatti F, Biroli G, Bolioli A, Cantello R, Riso S, Mazzini L. A Telehealth Intervention for Nutritional Counseling in Amyotrophic Lateral Sclerosis Patients. J Clin Med 2022; 11:jcm11154286. [PMID: 35893377 PMCID: PMC9331838 DOI: 10.3390/jcm11154286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 12/10/2022] Open
Abstract
Nutritional status is one of the most relevant prognostic factors in Amyotrophic Lateral Sclerosis (ALS), and close monitoring can help avoid severe weight loss over the disease course. We describe the impact of a Chatbot webapp on improving the communications between physicians, patients, and/or caregivers for dietary monitoring. We developed a chatbot that provides patients with a tool to register their meals through an intuitive and carefully designed conversational interface. Patients recorded their dietary intake twice weekly and received an adequate nutritional recommendation monthly. We monitored their functional and nutritional parameters. The data were compared with a control group followed up by standard counseling. We enrolled 26 patients. Regarding feasibility, 96% of participants completed the three-month follow-up, and 77% ended the six months. Regarding the change in weight in the Chatbot group, we observed a weight stabilization (F = 1.874, p-value: 0.310 for changes) over the telehealth compared to the control group (F = 1.710, p-value: 0.024 for changes). A telehealth approach for nutritional support is feasible and reproducible in an ALS setting: frequent monitoring turned out to help prevent further weight loss, allowing an early nutritional strategy adjustment.
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Affiliation(s)
- Fabiola De Marchi
- ALS Centre, Department of Neurology, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (E.G.B.); (R.C.); (L.M.)
- Correspondence: ; Tel.: +39-0321-3733962
| | - Marcella Serioli
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, 28100 Novara, Italy; (M.S.); (A.C.); (G.B.); (S.R.)
| | - Alessandro Collo
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, 28100 Novara, Italy; (M.S.); (A.C.); (G.B.); (S.R.)
| | - Evelyn Gisell Belotti
- ALS Centre, Department of Neurology, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (E.G.B.); (R.C.); (L.M.)
| | | | - Giampaolo Biroli
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, 28100 Novara, Italy; (M.S.); (A.C.); (G.B.); (S.R.)
| | | | - Roberto Cantello
- ALS Centre, Department of Neurology, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (E.G.B.); (R.C.); (L.M.)
| | - Sergio Riso
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, 28100 Novara, Italy; (M.S.); (A.C.); (G.B.); (S.R.)
| | - Letizia Mazzini
- ALS Centre, Department of Neurology, Maggiore della Carità Hospital, University of Piemonte Orientale, 28100 Novara, Italy; (E.G.B.); (R.C.); (L.M.)
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Barkmeijer A, Molder HT, Janssen M, Jager-Wittenaar H. Towards effective dietary counseling: a scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:1801-1817. [PMID: 34953620 DOI: 10.1016/j.pec.2021.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/29/2021] [Accepted: 12/15/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The aim of this scoping review was to identify and map available evidence concerning counseling strategies that contribute to effective DC. METHODS Following the PRISMA SCR-Scoping Reviews Statement and Checklist, a systematic search in electronic databases was performed in March 2020. RESULTS Synthesis of recurring themes in the 28 included studies revealed seven core counseling strategies that effectively contribute to DC: 1) connecting to motivation, 2) tailoring the modality of DC, 3) providing recurring feedback, 4) using integrated dietetic support tools, 5) showing empathy, 6) including clients' preferences, wishes, and expectations during decision-making, and 7) dietitians having high self-efficacy. CONCLUSIONS Multiple counseling strategies contributing to effective DC have been identified and mapped. The counseling strategies identified seem to interrelate, and their conceived interrelatedness reveals that strategies can both compliment or contrast each other. Therefore, advancing effective DC requires further development towards an integrated approach to DC that includes combinations of strategies that form a unified whole. PRACTICAL IMPLICATIONS Insights from this scoping review provide a foundation for dietitians to effectively carry out DC and serve as a starting point to further work towards effective DC.
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Affiliation(s)
- Alyanne Barkmeijer
- Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands; Hanze University of Applied Sciences, School of Health Care Studies, Nutrition and Dietetics Programme, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands.
| | - Hedwig Te Molder
- Vrije Universiteit Amsterdam, Faculty of Humanities: Language, Literature, and Communication, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands.
| | - Mariam Janssen
- Hanze University of Applied Sciences, School of Health Care Studies, Nutrition and Dietetics Programme, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands.
| | - Harriët Jager-Wittenaar
- Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands; University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
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Pugliese R, Sala R, Regondi S, Beltrami B, Lunetta C. Emerging technologies for management of patients with amyotrophic lateral sclerosis: from telehealth to assistive robotics and neural interfaces. J Neurol 2022; 269:2910-2921. [PMID: 35059816 PMCID: PMC8776511 DOI: 10.1007/s00415-022-10971-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 12/17/2022]
Abstract
Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease, is characterized by the degeneration of both upper and lower motor neurons, which leads to muscle weakness and subsequently paralysis. It begins subtly with focal weakness but spreads relentlessly to involve most muscles, thus proving to be effectively incurable. Typically, death due to respiratory paralysis occurs in 3–5 years. To date, it has been shown that the management of ALS patients is best achieved with a multidisciplinary approach, and with the help of emerging technologies ranging from multidisciplinary teleconsults (for monitoring the dysphagia, respiratory function, and nutritional status) to brain-computer interfaces and eye tracking for alternative augmentative communication, until robotics, it may increase effectiveness. The COVID-19 pandemic created a spasmodic need to accelerate the development and implementation of such technologies in clinical practice, to improve the daily lives of both ALS patients and caregivers. However, despite the remarkable strides that have been made in the field, there are still issues to be addressed. This review will be discussed on the eureka moment of emerging technologies for ALS, used as a blueprint not only for neurodegenerative diseases, examining the current technologies already in place or being evaluated, highlighting the pros and cons for future clinical applications.
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Affiliation(s)
| | - Riccardo Sala
- NeMO Lab, ASST Niguarda Cà Granda Hospital, Milan, Italy
| | - Stefano Regondi
- NeMO Lab, ASST Niguarda Cà Granda Hospital, Milan, Italy
- NEuroMuscolar Omnicentre, Milan, Italy
| | | | - Christian Lunetta
- NeMO Lab, ASST Niguarda Cà Granda Hospital, Milan, Italy.
- NEuroMuscolar Omnicentre, Milan, Italy.
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Telehealth in Neurodegenerative Diseases: Opportunities and Challenges for Patients and Physicians. Brain Sci 2021; 11:brainsci11020237. [PMID: 33668641 PMCID: PMC7917616 DOI: 10.3390/brainsci11020237] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 02/06/2023] Open
Abstract
Telehealth, by definition, is distributing health-related services while using electronic technologies. This narrative Review describes the technological health services (telemedicine and telemonitoring) for delivering care in neurodegenerative diseases, Alzheimer's disease, Parkinson's Disease, and amyotrophic lateral Sclerosis, among others. This paper aims to illustrate this approach's primary experience and application, highlighting the strengths and weaknesses, with the goal of understanding which could be the most useful application for each one, in order to facilitate telehealth improvement and use in standard clinical practice. We also described the potential role of the COVID-19 pandemic to speed up this service's use, avoiding a sudden interruption of medical care.
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Pinto S, Quintarelli S, Silani V. New technologies and Amyotrophic Lateral Sclerosis - Which step forward rushed by the COVID-19 pandemic? J Neurol Sci 2020; 418:117081. [PMID: 32882437 PMCID: PMC7403097 DOI: 10.1016/j.jns.2020.117081] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/09/2020] [Accepted: 08/01/2020] [Indexed: 12/11/2022]
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a fast-progressive neurodegenerative disease leading to progressive physical immobility with usually normal or mild cognitive and/or behavioural involvement. Many patients are relatively young, instructed, sensitive to new technologies, and professionally active when developing the first symptoms. Older patients usually require more time, encouragement, reinforcement and a closer support but, nevertheless, selecting user-friendly devices, provided earlier in the course of the disease, and engaging motivated carers may overcome many technological barriers. ALS may be considered a model for neurodegenerative diseases to further develop and test new technologies. From multidisciplinary teleconsults to telemonitoring of the respiratory function, telemedicine has the potentiality to embrace other fields, including nutrition, physical mobility, and the interaction with the environment. Brain-computer interfaces and eye tracking expanded the field of augmentative and alternative communication in ALS but their potentialities go beyond communication, to cognition and robotics. Virtual reality and different forms of artificial intelligence present further interesting possibilities that deserve to be investigated. COVID-19 pandemic is an unprecedented opportunity to speed up the development and implementation of new technologies in clinical practice, improving the daily living of both ALS patients and carers. The present work reviews the current technologies for ALS patients already in place or being under evaluation with published publications, prompted by the COVID-19 pandemic.
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Affiliation(s)
- Susana Pinto
- Translational and Clinical Physiology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.
| | - Stefano Quintarelli
- AgID - Italian digital agency and Clusit - Italian Computer Security Association, Italy
| | - Vincenzo Silani
- Department of Neurology-Stroke Unit and Laboratory of Neuroscience, Istituto Auxologico Italiano IRCCS - Department of Pathophysiology and Transplantation, “Dino Ferrari” Center and Center for Neurotechnology and Brain Therapeutics, Università degli Studi di Milano, Milan, Italy
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Telemedicine for management of patients with amyotrophic lateral sclerosis through COVID-19 tail. Neurol Sci 2020; 42:9-13. [PMID: 33025327 PMCID: PMC7538170 DOI: 10.1007/s10072-020-04783-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/26/2020] [Indexed: 12/12/2022]
Abstract
Over the last months, due to coronavirus disease (COVID-19) pandemic, containment measures have led to important social restriction. Healthcare systems have faced a complete rearrangement of resources and spaces, with the creation of wards devoted to COVID-19 patients. In this context, patients affected by chronic neurological diseases, such as amyotrophic lateral sclerosis (ALS), are at risk to be lost at follow-up, leading to a higher risk of morbidity and mortality. Telemedicine may allow meet the needs of these patients. In this commentary, we briefly discuss the digital tools to remotely monitor and manage ALS patients. Focusing on detecting disease progression and preventing life-threatening conditions, we propose a toolset able to improve ALS management during this unprecedented situation.
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De Marchi F, Cantello R, Ambrosini S, Mazzini L. Telemedicine and technological devices for amyotrophic lateral sclerosis in the era of COVID-19. Neurol Sci 2020; 41:1365-1367. [PMID: 32440978 PMCID: PMC7240164 DOI: 10.1007/s10072-020-04457-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/07/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Fabiola De Marchi
- Department of Neurology and ALS Centre, University of Piemonte Orientale, Maggiore della Carità Hospital, Corso Mazzini 18, 28100, Novara, Italy.
| | - Roberto Cantello
- Department of Neurology and ALS Centre, University of Piemonte Orientale, Maggiore della Carità Hospital, Corso Mazzini 18, 28100, Novara, Italy
| | | | - Letizia Mazzini
- Department of Neurology and ALS Centre, University of Piemonte Orientale, Maggiore della Carità Hospital, Corso Mazzini 18, 28100, Novara, Italy
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Mezoian T, Belt E, Garry J, Hubbard J, Breen CT, Miller L, Levine-Weinberg M, Nalipinski P, Sullivan S, Chan J, Wills AM. Loss of appetite in amyotrophic lateral sclerosis is associated with weight loss and decreased calorie consumption independent of dysphagia. Muscle Nerve 2020; 61:230-234. [PMID: 31650547 DOI: 10.1002/mus.26749] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/14/2019] [Accepted: 10/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Loss of appetite has been reported to affect up to half of people with amyotrophic lateral sclerosis (ALS) and to be associated with weight loss. We wished to test whether loss of appetite correlates with reduced dietary intake independent of dysphagia. METHODS Appetite was measured repeatedly using the Council on Nutrition Appetite Questionnaire (CNAQ) in participants in the Electronic health Application To Measure Outcomes REmotely study. Dietary intake and weight were compared to appetite, ALS Functional Rating Scale-Revised total and bulbar scores (dysphagia). RESULTS The average baseline CNAQ score was 30.4 (n = 61; SD = 3.9) with 18.0% scoring <28 points (severe loss of appetite). Lower CNAQ scores correlated with greater weight loss since diagnosis (Pearson correlation coefficient, r = -0.34; P = 0.009) and lower baseline energy intake (P = 0.007), independent of dysphagia. CONCLUSIONS Our results support an association between loss of appetite and decreased calorie intake and weight in ALS which is independent of dysphagia.
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Affiliation(s)
- Taylor Mezoian
- Neurology Clinical Research Institute and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Belt
- Neurology Clinical Research Institute and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jamie Garry
- Clinical Research Center, Massachusetts General Hospital, member of the Harvard Catalystl, The Harvard Clinical and Translational Science Center, Boston, Massachusetts
| | - Jane Hubbard
- Clinical Research Center, Massachusetts General Hospital, member of the Harvard Catalystl, The Harvard Clinical and Translational Science Center, Boston, Massachusetts
| | - Christopher T Breen
- Neurology Clinical Research Institute and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Leah Miller
- Neurology Clinical Research Institute and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark Levine-Weinberg
- Neurology Clinical Research Institute and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paige Nalipinski
- Department of Speech, Language, Swallowing and Reading Disabilities, Massachusetts General Hospital, Boston, Massachusetts
| | - Stacey Sullivan
- Department of Speech, Language, Swallowing and Reading Disabilities, Massachusetts General Hospital, Boston, Massachusetts
| | - James Chan
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne-Marie Wills
- Neurology Clinical Research Institute and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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