1
|
Bhidayasiri R, Udomsirithamrong O, de Leon A, Maetzler W, Pilotto A. Empowering the management of early-onset Parkinsons' disease: The role of technology. Parkinsonism Relat Disord 2024:107052. [PMID: 38991885 DOI: 10.1016/j.parkreldis.2024.107052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/23/2024] [Accepted: 06/30/2024] [Indexed: 07/13/2024]
Abstract
Early-onset Parkinson's disease (EOPD) is defined as PD with an age of onset after 21 years of age but before 50 years. It displays many important differences to late-onset PD in terms of its pathology, phenotype, presentation and disease course, all of which have consequences for achieving a definitive diagnosis, the choice of therapy and approach to management. Studies show that this younger population is keen to embrace digital technologies as part of PD care, being familiar with using digital tools in their daily lives. Although most of the literature relating to the use of technology in PD applies to the broad population, this review focuses on evidence and potential benefits of the use of digital technologies to support clinical management in EOPD as well as its value in empowering patients to achieve self-management and in improving their quality of life. Digital technologies also have important and increasing roles in providing telehealth, including rehabilitation strategies for motor and non-motor PD symptoms. EOPD is known to be associated with a higher risk of motor fluctuations, so technologies such as wearable sensors have a valuable role for monitoring symptoms, providing timely feedback, and informing treatment decisions. In addition, digital technologies allow easy provision and equitable access to education and networking opportunities that will enable patients to have a better understanding of their condition.
Collapse
Affiliation(s)
- Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; The Academy of Science, The Royal Society of Thailand, Bangkok, Thailand.
| | - Ornanong Udomsirithamrong
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Adrian de Leon
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Department of Neurology, Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Walter Maetzler
- Department of Neurology, University Hospital Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Laboratory of Digital Neurology and Biosensors, University of Brescia, Brescia, Italy; Neurology Unit, Department of Continuity of Care and Frailty, ASST Spedali Civili Brescia Hospital, Brescia, Italy
| |
Collapse
|
2
|
Post E, Hall DA, Bloem BR. Reply to "An Apple a Day Will Not Keep the (Parkinson's Disease) Doctor at Bay!". Ann Neurol 2024; 95:1013-1014. [PMID: 38558217 DOI: 10.1002/ana.26937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Erik Post
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behavior, Nijmegen, the Netherlands
| | - Deborah A Hall
- Department of Neurological Sciences, Rush University, Chicago, Illinois, USA
| | - Bastiaan R Bloem
- Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behavior, Nijmegen, the Netherlands
| |
Collapse
|
3
|
Luckhaus JL, Clareborn A, Hägglund M, Riggare S. Balancing feeling 'prepared' without feeling 'devoured': A qualitative study of self-care from the perspective of self-empowered persons living with Parkinson's disease in Sweden. Health Expect 2024; 27:e14027. [PMID: 38528674 DOI: 10.1111/hex.14027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/13/2024] [Accepted: 03/12/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Parkinson's Disease (PD) is a complex neurodegenerative disease resulting in a wide range of motor and nonmotor symptoms for which the treatment regimen is often complex. People with Parkinson's (PwP) spend time daily on self-care practices including self-tracking signs and symptoms or seeking disease-specific knowledge. Research suggests self-care interventions yield promising care and health outputs for PwP, yet most research focuses on the provider perspective rather than that of those conducting the self-care. This study explores the meaning of self-care, disease-specific knowledge, and self-tracking from the perspective of PwP in Sweden. METHODS Qualitative data from three data sets were analyzed and compared using qualitative content analysis: one focus group on self-care (n = 14), one free-text survey on disease-specific knowledge (n = 197) and one free-text survey on self-tracking (n = 33). FINDINGS The analysis resulted in three categories: illness-related tasks, internal resources and external resources. Illness-related tasks describe various tasks PwP carry out in self-care, including lifestyle choices, treatments, and self-tracking. Internal resources include personal knowledge/skills as well as mindsets which could facilitate or challenge completing these tasks. Finally, external resources include other PwP, literature, clinicians and other sources of disease-specific knowledge. Self-care was found to fluctuate between beneficial and burdensome depending on such resources. CONCLUSIONS In conclusion, self-care needs to be acknowledged and discussed more often in PD and other complex conditions. Future self-care interventions should consider self-tracking and disease-specific knowledge as well as internal and external resources in their design and implementation. PATIENT OR PUBLIC CONTRIBUTION A researcher with PD was actively involved in all phases of the research: study design, data collection and analysis, and preparing the manuscript.
Collapse
Affiliation(s)
- Jamie L Luckhaus
- Department of Women's and Children's Health, Participatory eHealth and Health Data, Uppsala University, Uppsala, Sweden
| | - Anna Clareborn
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Maria Hägglund
- Department of Women's and Children's Health, Participatory eHealth and Health Data, Uppsala University, Uppsala, Sweden
| | - Sara Riggare
- Department of Women's and Children's Health, Participatory eHealth and Health Data, Uppsala University, Uppsala, Sweden
- Uppsala University Centre for Disability Studies, Uppsala University, Uppsala, Sweden
| |
Collapse
|
4
|
Jafarzadeh Esfahani M, Sikder N, Ter Horst R, Daraie AH, Appel K, Weber FD, Bevelander KE, Dresler M. Citizen neuroscience: Wearable technology and open software to study the human brain in its natural habitat. Eur J Neurosci 2024; 59:948-965. [PMID: 38328991 DOI: 10.1111/ejn.16227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 11/09/2023] [Accepted: 11/30/2023] [Indexed: 02/09/2024]
Abstract
Citizen science allows the public to participate in various stages of scientific research, including study design, data acquisition, and data analysis. Citizen science has a long history in several fields of the natural sciences, and with recent developments in wearable technology, neuroscience has also become more accessible to citizen scientists. This development was largely driven by the influx of minimal sensing systems in the consumer market, allowing more do-it-yourself (DIY) and quantified-self (QS) investigations of the human brain. While most subfields of neuroscience require sophisticated monitoring devices and laboratories, the study of sleep characteristics can be performed at home with relevant noninvasive consumer devices. The strong influence of sleep quality on waking life and the accessibility of devices to measure sleep are two primary reasons citizen scientists have widely embraced sleep research. Their involvement has evolved from solely contributing to data collection to engaging in more collaborative or autonomous approaches, such as instigating ideas, formulating research inquiries, designing research protocols and methodology, acting upon their findings, and disseminating results. In this article, we introduce the emerging field of citizen neuroscience, illustrating examples of such projects in sleep research. We then provide overviews of the wearable technologies for tracking human neurophysiology and various open-source software used to analyse them. Finally, we discuss the opportunities and challenges in citizen neuroscience projects and suggest how to improve the study of the human brain outside the laboratory.
Collapse
Affiliation(s)
| | - Niloy Sikder
- Donders Institute for Brain, Behaviour, and Cognition, Radboudumc, Nijmegen, The Netherlands
- Faculty of Technology and Bionics, Rhine-Waal University of Applied Sciences, Kleve, Germany
| | - Rob Ter Horst
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Amir Hossein Daraie
- Donders Institute for Brain, Behaviour, and Cognition, Radboudumc, Nijmegen, The Netherlands
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Frederik D Weber
- Donders Institute for Brain, Behaviour, and Cognition, Radboudumc, Nijmegen, The Netherlands
- Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
| | - Kirsten E Bevelander
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Primary and Community Care, Radboud University and Medical Center, Nijmegen, The Netherlands
| | - Martin Dresler
- Donders Institute for Brain, Behaviour, and Cognition, Radboudumc, Nijmegen, The Netherlands
| |
Collapse
|
5
|
van den Bergh R, Evers LJW, de Vries NM, Silva de Lima AL, Bloem BR, Valenti G, Meinders MJ. Usability and utility of a remote monitoring system to support physiotherapy for people with Parkinson's disease. Front Neurol 2023; 14:1251395. [PMID: 37900610 PMCID: PMC10601712 DOI: 10.3389/fneur.2023.1251395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/07/2023] [Indexed: 10/31/2023] Open
Abstract
Background Physiotherapy for persons with Parkinson's disease (PwPD) could benefit from objective and continuous tracking of physical activity and falls in daily life. Objectives We designed a remote monitoring system for this purpose and describe the experiences of PwPD and physiotherapists who used the system in daily clinical practice. Methods Twenty-one PwPD (15 men) wore a sensor necklace to passively record physical activity and falls for 6 weeks. They also used a smartphone app to self-report daily activities, (near-)falls and medication intake. They discussed those data with their PD-specialized physiotherapist (n = 9) during three regular treatment sessions. User experiences and aspects to be improved were gathered through interviews with PwPD and physiotherapists, resulting in system updates. The system was evaluated in a second pilot with 25 new PwPD (17 men) and eight physiotherapists. Results We applied thematic analysis to the interview data resulting in two main themes: usability and utility. First, the usability of the system was rated positively, with the necklace being easy to use. However, some PwPD with limited digital literacy or cognitive impairments found the app unclear. Second, the perceived utility of the system varied among PwPD. While many PwPD were motivated to increase their activity level, others were not additionally motivated because they perceived their activity level as high. Physiotherapists appreciated the objective recording of physical activity at home and used the monitoring of falls to enlarge awareness of the importance of falls for PwPD. Based on the interview data of all participants, we drafted three user profiles for PwPD regarding the benefits of remote monitoring for physiotherapy: for profile 1, a monitoring system could act as a flagging dashboard to signal the need for renewed treatment; for profile 2, a monitoring system could be a motivational tool to maintain physical activity; for profile 3, a monitoring system could passively track physical activity and falls at home. Finally, for a subgroup of PwPD the burdens of monitoring will outweigh the benefits. Conclusions Overall, both PwPD and physiotherapists underline the potential of a remote monitoring system to support physiotherapy by targeting physical activity and (near-)falls. Our findings emphasize the importance of personalization in remote monitoring technology, as illustrated by our user profiles.
Collapse
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 and Movement Disorders, Nijmegen, Netherlands
| | - Luc J. W. Evers
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
- Radboud University, Institute for Computing and Information Sciences, Department of Data Science, Nijmegen, Netherlands
| | - Nienke M. de Vries
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
| | - Ana L. Silva de Lima
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
| | - Bastiaan R. Bloem
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
| | - Giulio Valenti
- Philips Research, Department of Connected Care and Remote Patient Management, Eindhoven, Netherlands
| | - Marjan J. Meinders
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, Netherlands
| |
Collapse
|
6
|
LoBuono DL, Shea KS, Reed M, Tovar A, Leedahl SN, Xu F, Mahler L, Lofgren IE. The Facilitators and Barriers to Digital Health for Managing Nutrition in People With Parkinson's Disease and Their Caregivers: A Formative, Qualitative Study. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2023; 55:553-563. [PMID: 37562920 DOI: 10.1016/j.jneb.2023.05.252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Identify techniques to assist in designing digital health platforms for nutrition services for people with Parkinson's disease and caregivers to improve their quality of life. DESIGN Semistructured, dyadic interviews with 20 dyads (20 people with Parkinson's disease and 20 caregivers). SETTING Home visits were conducted in the northeast US. PARTICIPANTS People with Parkinson's disease and their caregivers were recruited via email, flyers, news articles and announcements at support groups. PHENOMENON OF INTEREST Identification of facilitators and barriers to using digital health platforms to inform future digital nutrition services. ANALYSIS Interviews were recorded, transcribed and double-coded using a framework analysis method. RESULTS Reported digital health platforms utilization facilitators were: knowledge acquisition, convenience, intention to use, socializing, enjoyment, and forced adoption. Barriers included: negative feelings toward technology, lack of access or knowledge, disinterest, product design, frustration and functional reliability, and applying health information. CONCLUSIONS AND IMPLICATIONS Although dyads often lack knowledge on both how to use technology and nutrition, they are willing to use digital health platforms to increase their nutrition knowledge if platforms are convenient. Based on the identified facilitators and barriers, the added benefits of access and training nutrition digital health platforms must be clearly communicated to end-users to improve their quality of life.
Collapse
Affiliation(s)
- Dara Lyn LoBuono
- Department of Health and Exercise Science, Rowan University, Glassboro, NJ.
| | - Kyla S Shea
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI
| | - Megan Reed
- Department of Health and Exercise Science, Rowan University, Glassboro, NJ
| | - Alison Tovar
- Department of Behavioral and Social Sciences, Brown University, Providence, RI
| | - Skye N Leedahl
- Department of Human Development and Family Science, University of Rhode Island, Kingston, RI
| | - Furong Xu
- School of Education, University of Rhode Island, Kingston, RI
| | - Leslie Mahler
- Department of Communicative Disorders, University of Rhode Island, Kingston, RI
| | - Ingrid E Lofgren
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI
| |
Collapse
|
7
|
Evers LJW, Peeters JM, Bloem BR, Meinders MJ. Need for personalized monitoring of Parkinson's disease: the perspectives of patients and specialized healthcare providers. Front Neurol 2023; 14:1150634. [PMID: 37213910 PMCID: PMC10192863 DOI: 10.3389/fneur.2023.1150634] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023] Open
Abstract
Background Digital tools such as wearable sensors may help to monitor Parkinson's disease (PD) in daily life. To optimally achieve the expected benefits, such as personized care and improved self-management, it is essential to understand the perspective of both patients and the healthcare providers. Objectives We identified the motivations for and barriers against monitoring PD symptoms among PD patients and healthcare providers. We also investigated which aspects of PD were considered most important to monitor in daily life, and which benefits and limitations of wearable sensors were expected. Methods Online questionnaires were completed by 434 PD patients and 166 healthcare providers who were specialized in PD care (86 physiotherapists, 55 nurses, and 25 neurologists). To gain further understanding in the main findings, we subsequently conducted homogeneous focus groups with patients (n = 14), physiotherapists (n = 5), and nurses (n = 6), as well as individual interviews with neurologists (n = 5). Results One third of the patients had monitored their PD symptoms in the past year, most commonly using a paper diary. Key motivations were: (1) discuss findings with healthcare providers, (2) obtain insight in the effect of medication and other treatments, and (3) follow the progression of the disease. Key barriers were: (1) not wanting to focus too much on having PD, (2) symptoms being relatively stable, and (3) lacking an easy-to-use tool. Prioritized symptoms of interest differed between patients and healthcare providers; patients gave a higher priority to fatigue, problems with fine motor movements and tremor, whereas professionals more frequently prioritized balance, freezing and hallucinations. Although both patients and healthcare providers were generally positive about the potential of wearable sensors for monitoring PD symptoms, the expected benefits and limitations varied considerably between groups and within the patient group. Conclusion This study provides detailed information about the perspectives of patients, physiotherapists, nurses and neurologists on the merits of monitoring PD in daily life. The identified priorities differed considerably between patients and professionals, and this information is critical when defining the development and research agenda for the coming years. We also noted considerable differences in priorities between individual patients, highlighting the need for personalized disease monitoring.
Collapse
Affiliation(s)
- Luc J. W. Evers
- Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
- Institute for Computing and Information Sciences, Radboud University, Nijmegen, Netherlands
- *Correspondence: Luc J. W. Evers,
| | - José M. Peeters
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bastiaan R. Bloem
- Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marjan J. Meinders
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
8
|
Noordegraaf MA, van den Berg SW, Bloem BR. Hopamine as Personalized Medicine for Persons with Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2023; 13:271-277. [PMID: 36806516 PMCID: PMC10041418 DOI: 10.3233/jpd-230012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Prescribing dopamine replacement therapy remains the most common approach used by physicians who strive to support persons with Parkinson's disease. In this viewpoint, we argue that instead of merely prescribing dopamine, healthcare professionals should particularly encourage and enable persons with Parkinson's disease to draft their own personalized prescription of "hopamine". The term hopamine is a self-invented neologism representing the uniquely personal set of hopes, desires, experiences, and skills of each individual with a dopamine deficit. As such, the concept of hopamine-as a reflection of the unique personal characteristics of each person with Parkinson's disease-really supplements that of dopamine-as a reflection of each person's unique physical characteristics. Whereas a prescription of dopamine replacement medication necessitates the diagnosed individual to lay his or her fate in the hands of medical professionals, adding a personalized dose of hopamine to the therapeutic mix empowers persons to self-manage daily life with Parkinson's disease. In this viewpoint, we argue that hopamine is a prerequisite for personalized medicine and offer several practical recommendations for how medical professionals can introduce the concept of hopamine in daily clinical practice.
Collapse
Affiliation(s)
- Marina A Noordegraaf
- Patient Advocate and Patient Researcher at the Dutch Parkinson's Association, The Netherlands
| | - Sanne W van den Berg
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology; Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology; Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| |
Collapse
|
9
|
Linking social features of fitness apps with physical activity among Chinese users: Evidence from self-reported and self-tracked behavioral data. Inf Process Manag 2022. [DOI: 10.1016/j.ipm.2022.103096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
10
|
Hägglund M, Cajander Å, Rexhepi H, Kane B. Editorial: Personalized Digital Health and Patient-Centric Services. FRONTIERS IN COMPUTER SCIENCE 2022. [DOI: 10.3389/fcomp.2022.862358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
11
|
Riggare S, Hägglund M, Bredenoord AL, de Groot M, Bloem BR. Ethical Aspects of Personal Science for Persons with Parkinson's Disease: What Happens When Self-Tracking Goes from Selfcare to Publication? JOURNAL OF PARKINSON'S DISEASE 2022; 11:1927-1933. [PMID: 34120915 PMCID: PMC8609698 DOI: 10.3233/jpd-212647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/29/2022]
Abstract
Using Parkinson's disease as an exemplary chronic condition, this Commentary discusses ethical aspects of using self-tracking for personal science, as compared to using self-tracking in the context of conducting clinical research on groups of study participants. Conventional group-based clinical research aims to find generalisable answers to clinical or public health questions. The aim of personal science is different: to find meaningful answers that matter first and foremost to an individual with a particular health challenge. In the case of personal science, the researcher and the participant are one and the same, which means that specific ethical issues may arise, such as the need to protect the participant against self-harm. To allow patient-led research in the form of personal science in the Parkinson field to evolve further, the development of a specific ethical framework for self-tracking for personal science is needed.
Collapse
Affiliation(s)
- Sara Riggare
- Uppsala University, Department of Women’s and Children’s Health, Healthcare Sciences and e-Health, Uppsala, Sweden
| | - Maria Hägglund
- Uppsala University, Department of Women’s and Children’s Health, Healthcare Sciences and e-Health, Uppsala, Sweden
| | - Annelien L. Bredenoord
- University Medical Center Utrecht, Utrecht University, Department of Medical Humanities, Utrecht, The Netherlands
| | - Martijn de Groot
- Radboud University Medical Centre, Health Innovation Labs, Nijmegen, The Netherlands
| | - Bastiaan R. Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
| |
Collapse
|
12
|
Riggare S, Stamford J, Hägglund M. A Long Way to Go: Patient Perspectives on Digital Health for Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 11:S5-S10. [PMID: 33682728 PMCID: PMC8385497 DOI: 10.3233/jpd-202408] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Digital health promises to improve healthcare, health, and wellness through the use of digital technologies. The purpose of this commentary is to review and discuss the field of digital health for Parkinson’s disease (PD) focusing on the needs, expectations, and wishes of people with PD (PwP). Our analysis shows that PwP want to use digital technologies to actively manage the full complexity of living with PD on an individual level, including the unpredictability and variability of the condition. Current digital health projects focusing on PD, however, does not live up to the expectations of PwP. We conclude that for digital health to reach its full potential, the right of PwP to access their own data needs to be recognised, PwP should routinely receive personalised feedback based on their data, and active involvement of PwP as an equal partner in digital health development needs to be the norm.
Collapse
Affiliation(s)
- Sara Riggare
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Jon Stamford
- Gentleman Neuroscientist and Independent Parkinson's Patient Advocate, UK
| | - Maria Hägglund
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| |
Collapse
|
13
|
Simonet C, Noyce AJ. Domotics, Smart Homes, and Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 11:S55-S63. [PMID: 33612494 PMCID: PMC8385512 DOI: 10.3233/jpd-202398] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Technology has an increasing presence and role in the management of Parkinson’s disease. Whether embraced or rebuffed by patients and clinicians, this is an undoubtedly growing area. Wearable sensors have received most of the attention so far. This review will focus on technology integrated into the home setting; from fixed sensors to automated appliances, which are able to capture information and have the potential to respond in an unsupervised manner. Domotics also have the potential to provide ‘real world’ context to kinematic data and therapeutic opportunities to tackle challenging motor and non-motor symptoms. Together with wearable technology, domotics have the ability to gather long-term data and record discrete events, changing the model of the cross-sectional outpatient assessment. As clinicians, our ultimate goal is to maximise quality of life, promote autonomy, and personalise care. In these respects, domotics may play an essential role in the coming years.
Collapse
Affiliation(s)
- Cristina Simonet
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Alastair J Noyce
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK.,Department of Clinical and Movement Neurosciences, Institute of Neurology, University College London, London, UK
| |
Collapse
|
14
|
Feng S, Mäntymäki M, Dhir A, Salmela H. How Self-tracking and the Quantified Self Promote Health and Well-being: Systematic Review. J Med Internet Res 2021; 23:e25171. [PMID: 34546176 PMCID: PMC8493454 DOI: 10.2196/25171] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/10/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Self-tracking technologies are widely used in people's daily lives and health care. Academic research on self-tracking and the quantified self has also accumulated rapidly in recent years. Surprisingly, there is a paucity of research that reviews, classifies, and synthesizes the state of the art with respect to self-tracking and the quantified self. OBJECTIVE Our objective was to identify the state of the art of self-tracking and the quantified self in terms of health and well-being. METHODS We have undertaken a systematic literature review on self-tracking and the quantified self in promoting health and well-being. After a rigorous literature search, followed by inclusions, exclusions, and the application of article quality assessment protocols, 67 empirical studies qualified for the review. RESULTS Our results demonstrate that prior research has focused on 3 stakeholders with respect to self-tracking and the quantified self, namely end users, patients and people with illnesses, and health care professionals and caregivers. We used these stakeholder groups to cluster the research themes of the reviewed studies. We identified 11 research themes. There are 6 themes under the end-user cluster: user motivation and goal setting, usage and effects of self-tracking, continuance intention and long-term usage, management of personal data, rejection and discontinuance, and user characteristics. The patient and people with illnesses cluster contains three themes: usage experience of patients and people with illnesses, management of patient-generated data, and advantages and disadvantages in the clinical context. The health care professional and caregiver cluster contains two themes: collaboration among patients, health care professionals, and caregivers, and changes in the roles of patients and professionals. Moreover, we classified the future research suggestions given in the literature into 5 directions in terms of research designs and research topics. Finally, based on our reflections on the observations from the review, we suggest four future research directions: (1) users' cognitions and emotions related to processing and interpreting the information produced by tracking devices and apps; (2) the dark side of self-tracking (eg, its adverse psychosocial consequences); (3) self-tracking as a societal phenomenon; and (4) systemic impacts of self-tracking on health care and the actors involved. CONCLUSIONS This systematic literature review contributes to research and practice by assisting future research activities and providing practitioners with a concise overview of the state of the art of self-tracking and the quantified self.
Collapse
Affiliation(s)
- Shan Feng
- Department of Management and Entrepreneurship, Turku School of Economics, University of Turku, Turku, Finland
| | - Matti Mäntymäki
- Department of Management and Entrepreneurship, Turku School of Economics, University of Turku, Turku, Finland
| | - Amandeep Dhir
- Department of Management, School of Business and Law, University of Agder, Kristiansand, Norway
| | - Hannu Salmela
- Department of Management and Entrepreneurship, Turku School of Economics, University of Turku, Turku, Finland
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Benz HL, Caldwell B, Ruiz JP, Saha A, Ho M, Christopher S, Bardot D, Sheehan M, Donnelly A, McLaughlin L, Mange B, Hauber AB, Gwinn K, Heetderks WJ, Sheldon M. Patient-Centered Identification of Meaningful Regulatory Endpoints for Medical Devices to Treat Parkinson's Disease. MDM Policy Pract 2021; 6:23814683211021380. [PMID: 34277950 PMCID: PMC8255597 DOI: 10.1177/23814683211021380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction. A growing literature has developed on identifying outcomes that matter to patients. This study demonstrates an approach involving patient and regulatory perspectives to identify outcomes that are meaningful in the context of medical devices for Parkinson’s disease (PD). Methods. A systematic process was used for specifying relevant regulatory endpoints by synthesizing inputs of various sources and stakeholders. First, a literature review was conducted to identify important benefits, risks, and other considerations for medical devices to treat PD; patient discussion groups (n = 6) were conducted to refine the list of considerations, followed by a survey (n = 29) to prioritize them; and patient and Food and Drug Administration (FDA) reviewers informed specification of the final endpoints. Two FDA clinicians gave clinical and regulatory perspectives at each step. Results. Movement symptoms were ranked as most important (ranked 1 or 2 by 72% of participants) and psychological and cognitive symptoms as the next most important (ranked 1 or 2 by 52% of participants). Within movement symptoms, falls, impaired movement, bradykinesia, resting tremor, stiffness, and rigidity were ranked highly. Overall, nine attributes were identified and prioritized as patient-centric for use in clinical trial design and quantitative patient preference studies. These attributes were benefits and risks related to therapeutics for PD as well as other considerations, including time until a medical device is available for patient use. Discussion. This prospective approach identified meaningful and relevant benefits, risks, and other considerations that may be used for clinical trial design and quantitative patient preference studies. Although PD was the focus of this study, the approach can be used to study patient perspectives about other disease or treatment areas.
Collapse
Affiliation(s)
- Heather L Benz
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - Brittany Caldwell
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - John P Ruiz
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - Anindita Saha
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | - Martin Ho
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | | | - Dawn Bardot
- Medical Device Innovation Consortium, Arlington, Virginia
| | - Margaret Sheehan
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York
| | - Anne Donnelly
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York
| | - Lauren McLaughlin
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York
| | - Brennan Mange
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - A Brett Hauber
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Katrina Gwinn
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| | | | - Murray Sheldon
- US FDA Center for Devices and Radiological Health, Silver Spring, Maryland
| |
Collapse
|
17
|
Boving AT, Shuster CL, Walls TA, Brothers T. Personal digital health in Parkinson's disease: Case histories and commentary. Digit Health 2021; 7:20552076211061925. [PMID: 35173980 PMCID: PMC8842464 DOI: 10.1177/20552076211061925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/02/2021] [Indexed: 11/15/2022] Open
Abstract
The use of self-tracking of bio-behavioral states along with prescription dosing information is increasingly popular in the care and study of many human diseases. Parkinson’s Disease is particularly amenable to such tracking, as patients live with the progressive disease for many years, increasing motivation to pursue quality of life changes through careful monitoring of symptoms and self-guided management of their medications and lifestyle choices. Through the use of digital self-tracking technologies, patients independently or in conjunction with professional medical advice are modulating their medications and behavioral regimens based on self-tracking data. Self-trackers engage in self-experimentation with their health, and more broadly, in personal digital health. This paper briefly depicts notable, recent patient accounts of self-tracking and the uses of digital health in Parkinson’s disease: those of Sara Riggare and Kevin Krejci. It also highlights important facets of a previously unreported case: Velva Walden’s care as managed jointly by her caregiver son. Key aspects of self-tracking inherent to these cases are examined and potential opportunities to advance personalized medicine through the use of digital health and self-experimentation are outlined.
Collapse
Affiliation(s)
- Aidan T Boving
- Department of Cell and Molecular Biology and Health Studies, University of Rhode Island, USA
| | | | | | - Todd Brothers
- Department of Pharmacy Practice, University of Rhode Island, USA
| |
Collapse
|
18
|
Maetzler W, Rochester L, Bhidayasiri R, Espay AJ, Sánchez-Ferro A, van Uem JMT. Modernizing Daily Function Assessment in Parkinson's Disease Using Capacity, Perception, and Performance Measures. Mov Disord 2020; 36:76-82. [PMID: 33191498 DOI: 10.1002/mds.28377] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/28/2022] Open
Abstract
Many disease symptoms restrict the quality of life of the affected. This usually occurs indirectly, at least in most neurological diseases. Here, impaired daily function is interposed between the symptoms and the reduced quality of life. This is reflected in the International Classification of Function, Disability and Health model published by the World Health Organization in 2001. This correlation between symptom, daily function, and quality of life makes it clear that to evaluate the success of a therapy and develop new therapies, daily function must also be evaluated as accurately as possible. However, daily function is a complex construct and therefore difficult to quantify. To date, daily function has been measured primarily by capacity (clinical assessments) and perception (surveys and patient-reported outcomes) assessment approaches. Now, daily function can be captured in a new dimension, that is, performance, through new digital technologies that can be used in the home environment of patients. This viewpoint discusses the differences and interdependencies of capacity, perception, and performance assessment types using the example of Parkinson's disease. Options regarding how future study protocols should be designed to get the most comprehensive and validated picture of daily function in patients are presented. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Walter Maetzler
- Department of Neurology, Kiel University and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Lynn Rochester
- Translational and Clinical Research Institute Campus for Ageing and Vitality, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Roongroj Bhidayasiri
- Department of Medicine, Faculty of Medicine, Chulalongkorn Center of Excellence for Parkinson's Disease & Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Alberto J Espay
- Department of Neurology, Gardner Center for Parkinson's Disease and Movement Disorders, University of Cincinnati, Cincinnati, Ohio, USA
| | | | - Janet M T van Uem
- Department of Neurology, Kiel University and University Hospital Schleswig-Holstein, Kiel, Germany
| |
Collapse
|
19
|
De Moya J, Pallud J. From panopticon to heautopticon: A new form of surveillance introduced by quantified‐self practices. INFORMATION SYSTEMS JOURNAL 2020. [DOI: 10.1111/isj.12284] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Jessie Pallud
- EM Strasbourg Business School Université de Strasbourg, Humanis (UR 7308)
| |
Collapse
|
20
|
Dorsey ER, Omberg L, Waddell E, Adams JL, Adams R, Ali MR, Amodeo K, Arky A, Augustine EF, Dinesh K, Hoque ME, Glidden AM, Jensen-Roberts S, Kabelac Z, Katabi D, Kieburtz K, Kinel DR, Little MA, Lizarraga KJ, Myers T, Riggare S, Rosero SZ, Saria S, Schifitto G, Schneider RB, Sharma G, Shoulson I, Stevenson EA, Tarolli CG, Luo J, McDermott MP. Deep Phenotyping of Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2020; 10:855-873. [PMID: 32444562 PMCID: PMC7458535 DOI: 10.3233/jpd-202006] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/01/2020] [Indexed: 12/13/2022]
Abstract
Phenotype is the set of observable traits of an organism or condition. While advances in genetics, imaging, and molecular biology have improved our understanding of the underlying biology of Parkinson's disease (PD), clinical phenotyping of PD still relies primarily on history and physical examination. These subjective, episodic, categorical assessments are valuable for diagnosis and care but have left gaps in our understanding of the PD phenotype. Sensors can provide objective, continuous, real-world data about the PD clinical phenotype, increase our knowledge of its pathology, enhance evaluation of therapies, and ultimately, improve patient care. In this paper, we explore the concept of deep phenotyping-the comprehensive assessment of a condition using multiple clinical, biological, genetic, imaging, and sensor-based tools-for PD. We discuss the rationale for, outline current approaches to, identify benefits and limitations of, and consider future directions for deep clinical phenotyping.
Collapse
Affiliation(s)
- E. Ray Dorsey
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Emma Waddell
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
| | - Jamie L. Adams
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Roy Adams
- Machine Learning, AI and Healthcare Lab, Johns Hopkins University, Baltimore, MD, USA
| | | | - Katherine Amodeo
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Abigail Arky
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
| | - Erika F. Augustine
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Karthik Dinesh
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, NY, USA
| | | | - Alistair M. Glidden
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
| | - Stella Jensen-Roberts
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
| | - Zachary Kabelac
- Department of Computer Science and Artificial Intelligence, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Dina Katabi
- Department of Computer Science and Artificial Intelligence, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Karl Kieburtz
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Daniel R. Kinel
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Max A. Little
- School of Computer Science, University of Birmingham, UK
- Massachusetts Institute of Technology, MA, USA
| | - Karlo J. Lizarraga
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Taylor Myers
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
| | - Sara Riggare
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | | | - Suchi Saria
- Machine Learning, AI and Healthcare Lab, Johns Hopkins University, Baltimore, MD, USA
- Department of Computer Science, Statistics, and Health Policy, Johns Hopkins University, MD, USA
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ruth B. Schneider
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Gaurav Sharma
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, NY, USA
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, USA
| | - Ira Shoulson
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
- Grey Matter Technologies, Sarasota, FL, USA
| | - E. Anna Stevenson
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher G. Tarolli
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Jiebo Luo
- Department of Computer Science, University of Rochester, Rochester, NY, USA
| | - Michael P. McDermott
- Center for Health + Technology, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|