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Janssen Daalen JM, Doesburg D, Hunik L, Kessel R, Herngreen T, Knol D, Ruys T, van den Bemt BJF, Schers HJ. Model-Informed Precision Dosing Using Machine Learning for Levothyroxine in General Practice: Development, Validation and Clinical Simulation Trial. Clin Pharmacol Ther 2024. [PMID: 38711388 DOI: 10.1002/cpt.3293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
Levothyroxine is one of the most prescribed drugs in the western world. Dosing is challenging due to high-interindividual differences in effective dosage and the narrow therapeutic window. Model-informed precision dosing (MIPD) using machine learning could assist general practitioners (GPs), but no such models exist for primary care. Furthermore, introduction of decision-support algorithms in healthcare is limited due to the substantial gap between developers and clinicians' perspectives. We report the development, validation, and a clinical simulation trial of the first MIPD application for primary care. Stable maintenance dosage of levothyroxine was the model target. The multiclass model generates predictions for individual patients, for different dosing classes. Random forest was trained and tested on a national primary care database (n = 19,004) with a final weighted AUC across dosing options of 0.71, even in subclinical hypothyroidism. TSH, fT4, weight, and age were most predictive. To assess the safety, feasibility, and clinical impact of MIPD for levothyroxine, we performed clinical simulation studies in GPs and compared MIPD to traditional prescription. Fifty-one GPs selected starting dosages for 20 primary hypothyroidism cases without and then with MIPD 2 weeks later. Overdosage and underdosage were defined as higher and lower than 12.5 μg relative to stable maintenance dosage. MIPD decreased overdosage in number (30.5 to 23.9%, P < 0.01) and magnitude (median 50 to 37.5 μg, P < 0.01) and increased optimal starting dosages (18.3 to 30.2%, P < 0.01). GPs considered lab results more often with MIPD and most would use the model frequently. This study demonstrates the clinical relevance, safety, and effectiveness of MIPD for levothyroxine in primary care.
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Affiliation(s)
- Jules M Janssen Daalen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Liesbeth Hunik
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rogier Kessel
- Amsterdam Data Collective, Amsterdam, The Netherlands
| | | | - Dennis Knol
- Amsterdam Data Collective, Amsterdam, The Netherlands
| | - Thony Ruys
- Amsterdam Data Collective, Amsterdam, The Netherlands
| | - Bart J F van den Bemt
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Henk J Schers
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Janssen Daalen JM, Gerritsen A, Gerritse G, Gouman J, Meijerink H, Rietdijk LE, Darweesh SKL. How Lifetime Evolution of Parkinson's Disease Could Shape Clinical Trial Design: A Shared Patient-Clinician Viewpoint. Brain Sci 2024; 14:358. [PMID: 38672010 PMCID: PMC11048137 DOI: 10.3390/brainsci14040358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Parkinson's disease (PD) has a long, heterogeneous, pre-diagnostic phase, during which pathology insidiously accumulates. Increasing evidence suggests that environmental and lifestyle factors in early life contribute to disease risk and progression. Thanks to the extensive study of this pre-diagnostic phase, the first prevention trials of PD are being designed. However, the highly heterogenous evolution of the disease across the life course is not yet sufficiently taken into account. This could hamper clinical trial success in the advent of biological disease definitions. In an interdisciplinary patient-clinician study group, we discussed how an approach that incorporates the lifetime evolution of PD may benefit the design of disease-modifying trials by impacting population, target and outcome selection. We argue that the timepoint of exposure to risk and protective factors plays a critical role in PD subtypes, influencing population selection. In addition, recent developments in differential disease mechanisms, aided by biological disease definitions, could impact optimal treatment targets. Finally, multimodal biomarker panels using this lifetime approach will likely be most sensitive as progression markers for more personalized trials. We believe that the lifetime evolution of PD should be considered in the design of clinical trials, and that such initiatives could benefit from more patient-clinician partnerships.
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Affiliation(s)
- Jules M. Janssen Daalen
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, 6525 GA Nijmegen, The Netherlands; (J.M.J.D.); (A.G.)
| | - Aranka Gerritsen
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, 6525 GA Nijmegen, The Netherlands; (J.M.J.D.); (A.G.)
| | - Gijs Gerritse
- Dutch Parkinson’s Patient Association, P.O. Box 46, 3980 CA Bunnik, The Netherlands; (G.G.); (J.G.); (H.M.); (L.E.R.)
| | - Jan Gouman
- Dutch Parkinson’s Patient Association, P.O. Box 46, 3980 CA Bunnik, The Netherlands; (G.G.); (J.G.); (H.M.); (L.E.R.)
| | - Hannie Meijerink
- Dutch Parkinson’s Patient Association, P.O. Box 46, 3980 CA Bunnik, The Netherlands; (G.G.); (J.G.); (H.M.); (L.E.R.)
| | - Leny E. Rietdijk
- Dutch Parkinson’s Patient Association, P.O. Box 46, 3980 CA Bunnik, The Netherlands; (G.G.); (J.G.); (H.M.); (L.E.R.)
| | - Sirwan K. L. Darweesh
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Center of Expertise for Parkinson & Movement Disorders, 6525 GA Nijmegen, The Netherlands; (J.M.J.D.); (A.G.)
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Janssen Daalen JM, Koopman WJH, Saris CGJ, Meinders MJ, Thijssen DHJ, Bloem BR. The Hypoxia Response Pathway: A Potential Intervention Target in Parkinson's Disease? Mov Disord 2024; 39:273-293. [PMID: 38140810 DOI: 10.1002/mds.29688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
Parkinson's disease (PD) is a progressive neurodegenerative disorder for which only symptomatic treatments are available. Both preclinical and clinical studies suggest that moderate hypoxia induces evolutionarily conserved adaptive mechanisms that enhance neuronal viability and survival. Therefore, targeting the hypoxia response pathway might provide neuroprotection by ameliorating the deleterious effects of mitochondrial dysfunction and oxidative stress, which underlie neurodegeneration in PD. Here, we review experimental studies regarding the link between PD pathophysiology and neurophysiological adaptations to hypoxia. We highlight the mechanistic differences between the rescuing effects of chronic hypoxia in neurodegeneration and short-term moderate hypoxia to improve neuronal resilience, termed "hypoxic conditioning". Moreover, we interpret these preclinical observations regarding the pharmacological targeting of the hypoxia response pathway. Finally, we discuss controversies with respect to the differential effects of hypoxia response pathway activation across the PD spectrum, as well as intervention dosing in hypoxic conditioning and potential harmful effects of such interventions. We recommend that initial clinical studies in PD should focus on the safety, physiological responses, and mechanisms of hypoxic conditioning, as well as on repurposing of existing pharmacological compounds. © 2023 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jules M Janssen Daalen
- Center of Expertise for Parkinson and Movement Disorders, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands, Nijmegen, The Netherlands
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Werner J H Koopman
- Department of Pediatrics, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Mitochondrial Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Human and Animal Physiology, Wageningen University, Wageningen, The Netherlands
| | - Christiaan G J Saris
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
- Radboud Center for Mitochondrial Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjan J Meinders
- Center of Expertise for Parkinson and Movement Disorders, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands, Nijmegen, The Netherlands
| | - Dick H J Thijssen
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Center of Expertise for Parkinson and Movement Disorders, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands, Nijmegen, The Netherlands
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
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Janssen Daalen JM, Oosterhof TH, Bloem BR, Darweesh SKL. Wearables for Parkinson's: Fast-Paced toward Novel Outcome Measures. Mov Disord 2023; 38:1988-1989. [PMID: 37776035 DOI: 10.1002/mds.29608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 10/01/2023] Open
Affiliation(s)
- Jules M Janssen Daalen
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Nijmegen, the Netherlands
| | - Thomas H Oosterhof
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Nijmegen, the Netherlands
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Nijmegen, the Netherlands
| | - Sirwan K L Darweesh
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Department of Neurology, Nijmegen, the Netherlands
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Janssen Daalen JM, Meinders MJ, Straatsma IR, Ainslie PN, Thijssen DHJ, Bloem BR. Reply to: Hypoxia treatment of Parkinson's disease may disrupt the circadian system. BMC Neurol 2023; 23:235. [PMID: 37337147 DOI: 10.1186/s12883-023-03281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023] Open
Affiliation(s)
- Jules M Janssen Daalen
- Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands.
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands.
- Department of Physiology, Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Marjan J Meinders
- Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Isabel R Straatsma
- Department of Physiology, Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philip N Ainslie
- Center for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, Canada
| | - Dick H J Thijssen
- Department of Physiology, Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Center of Expertise for Parkinson & Movement Disorders, Nijmegen, The Netherlands
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
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Geerlings AD, Janssen Daalen JM, Ypinga JHL, Bloem BR, Meinders MJ, Munneke M, Darweesh SKL. Case management interventions in chronic disease reduce anxiety and depressive symptoms: A systematic review and meta-analysis. PLoS One 2023; 18:e0282590. [PMID: 37058492 PMCID: PMC10104285 DOI: 10.1371/journal.pone.0282590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/18/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND There is no systematic insight into the effect of case management on common complications of chronic diseases, including depressive symptoms and symptoms of anxiety. This is a significant knowledge gap, given that people with a chronic disease such as Parkinson Disease or Alzheimer's Disease have identified care coordination as one of their highest priorities. Furthermore, it remains unclear whether the putative beneficial effects of case management would vary by crucial patient characteristics, such as their age, gender, or disease characteristics. Such insights would shift from "one size fits all" healthcare resource allocation to personalized medicine. OBJECTIVE We systematically examined the effectiveness of case management interventions on two common complications associated PD and other chronic health conditions: Depressive symptoms and symptoms of anxiety. METHODS We identified studies published until November 2022 from PubMed and Embase databases using predefined inclusion criteria. For each study, data were extracted independently by two researchers. First, descriptive and qualitative analyses of all included studies were performed, followed by random-effects meta-analyses to assess the impact of case management interventions on anxiety and depressive symptoms. Second, meta-regression was performed to analyze potential modifying effects of demographic characteristics, disease characteristics and case management components. RESULTS 23 randomized controlled trials and four non-randomized studies reported data on the effect of case management on symptoms of anxiety (8 studies) or depressive symptoms (26 studies). Across meta-analyses, we observed a statistically significant effect of case management on reducing symptoms of anxiety (Standardized Mean Difference [SMD] = - 0.47; 95% confidence interval [CI]: -0.69, -0.32) and depressive symptoms (SMD = - 0.48; CI: -0.71, -0.25). We found large heterogeneity in effect estimates across studies, but this was not explained by patient population or intervention characteristics. CONCLUSIONS Among people with chronic health conditions, case management has beneficial effects on symptoms of depressive symptoms and symptoms of anxiety. Currently, research on case management interventions are rare. Future studies should assess the utility of case management for potentially preventative and common complications, focusing on the optimal content, frequency, and intensity of case management.
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Affiliation(s)
- Angelika D Geerlings
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jules M Janssen Daalen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan H L Ypinga
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjan J Meinders
- Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marten Munneke
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sirwan K L Darweesh
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Center of Expertise for Parkinson & Movement Disorders, Radboud University Medical Center, Nijmegen, The Netherlands
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Janssen Daalen JM, Hubbers J, Sharifi Bonab M, Mathur S, Thijssen DH, Bloem BR, Meinders MJ. How Vacations Affect Parkinson's Disease. Mov Disord Clin Pract 2022; 10:151-153. [PMID: 36698995 PMCID: PMC9847288 DOI: 10.1002/mdc3.13597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/15/2022] [Accepted: 08/28/2022] [Indexed: 01/28/2023] Open
Affiliation(s)
- Jules M. Janssen Daalen
- Center of Expertise for Parkinson and Movement Disorders, Department of NeurologyRadboud University Medical Center, Donders Institute for Brain, Cognition and BehaviorNijmegenThe Netherlands
| | - Jessica Hubbers
- Center of Expertise for Parkinson and Movement Disorders, Department of NeurologyRadboud University Medical Center, Donders Institute for Brain, Cognition and BehaviorNijmegenThe Netherlands,Department of Research and InnovationHelse FonnaHaugesundNorway
| | - Mirmohsen Sharifi Bonab
- Clinical Research Development Unit of Tabriz Valiasr HospitalTabriz University of Medical SciencesTabrizIran
| | | | - Dick H.J. Thijssen
- Department of PhysiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Bastiaan R. Bloem
- Center of Expertise for Parkinson and Movement Disorders, Department of NeurologyRadboud University Medical Center, Donders Institute for Brain, Cognition and BehaviorNijmegenThe Netherlands
| | - Marjan J. Meinders
- Center of Expertise for Parkinson and Movement Disorders, Department of NeurologyRadboud University Medical Center, Donders Institute for Brain, Cognition and BehaviorNijmegenThe Netherlands,IQ Healthcare, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
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Janssen Daalen JM, Schootemeijer S, Richard E, Darweesh SKL, Bloem BR. Lifestyle Interventions for the Prevention of Parkinson Disease: A Recipe for Action. Neurology 2022; 99:42-51. [PMID: 35970584 DOI: 10.1212/wnl.0000000000200787] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
The prevalence of Parkinson disease (PD) is growing fast, amplifying the quest for disease-modifying therapies in early disease phases where pathology is still limited. Lifestyle interventions offer a promising avenue for preventing progression from prodromal to manifest PD. We illustrate this primarily for 1 specific lifestyle intervention, namely aerobic exercise because the case for the other main lifestyle factor (dietary interventions) to modify the course of prodromal PD is currently less persuasive. Various observations have hinted at the disease-modifying potential of exercise. First, studies in rodents with experimental parkinsonism showed that exercise elicits adaptive neuroplasticity in basal ganglia circuitries. Second, exercise is associated with a reduced risk of developing PD, suggesting a disease-modifying potential. Third, 2 large trials in persons with manifest PD indicate that exercise can help to stabilize motor parkinsonism, although this could also reflect a symptomatic effect. In addition, exercise seems to be a feasible intervention, given its minimal risk of side effects. Theoretical risks include an increase in fall incidents and cardiovascular complications, but these concerns seem to be acceptably low. Innovative approaches using gamification elements indicate that adequate long-term compliance with regular exercise programs can be achieved, although more work remains necessary to demonstrate enduring adherence for multiple years. Advances in digital technology can be used to deliver the exercise intervention in the participant's own living environment and also to measure the outcomes remotely, which will help to further boost long-term compliance. When delivering exercise to prodromal participants, outcome measures should focus not just on phenoconversion to manifest PD (which may well take many years to occur) but also on measurable intermediate outcomes, such as physical fitness or prodromal nonmotor symptoms. Taken together, there seems to be sufficient evidence to advocate the first judicious attempt of investigating exercise as a disease-modifying treatment in prodromal PD.
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Affiliation(s)
- Jules M Janssen Daalen
- From the Department of Neurology (J.M.J.D., S.S., E.R., S.K.L.D., B.R.B.), Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior; Center of Expertise for Parkinson & Movement Disorders (J.M.J.D., S.S., S.K.L.D., B.R.B.); and Radboud University Medical Center Alzheimer Center (E.R.), the Netherlands
| | - Sabine Schootemeijer
- From the Department of Neurology (J.M.J.D., S.S., E.R., S.K.L.D., B.R.B.), Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior; Center of Expertise for Parkinson & Movement Disorders (J.M.J.D., S.S., S.K.L.D., B.R.B.); and Radboud University Medical Center Alzheimer Center (E.R.), the Netherlands
| | - Edo Richard
- From the Department of Neurology (J.M.J.D., S.S., E.R., S.K.L.D., B.R.B.), Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior; Center of Expertise for Parkinson & Movement Disorders (J.M.J.D., S.S., S.K.L.D., B.R.B.); and Radboud University Medical Center Alzheimer Center (E.R.), the Netherlands
| | - Sirwan K L Darweesh
- From the Department of Neurology (J.M.J.D., S.S., E.R., S.K.L.D., B.R.B.), Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior; Center of Expertise for Parkinson & Movement Disorders (J.M.J.D., S.S., S.K.L.D., B.R.B.); and Radboud University Medical Center Alzheimer Center (E.R.), the Netherlands
| | - Bastiaan R Bloem
- From the Department of Neurology (J.M.J.D., S.S., E.R., S.K.L.D., B.R.B.), Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior; Center of Expertise for Parkinson & Movement Disorders (J.M.J.D., S.S., S.K.L.D., B.R.B.); and Radboud University Medical Center Alzheimer Center (E.R.), the Netherlands.
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Janssen Daalen JM, Meinders MJ, Giardina F, Roes KCB, Stunnenberg BC, Mathur S, Ainslie PN, Thijssen DHJ, Bloem BR. Multiple N-of-1 trials to investigate hypoxia therapy in Parkinson's disease: study rationale and protocol. BMC Neurol 2022; 22:262. [PMID: 35836147 PMCID: PMC9281145 DOI: 10.1186/s12883-022-02770-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022] Open
Abstract
Background Parkinson’s disease (PD) is a neurodegenerative disease, for which no disease-modifying therapies exist. Preclinical and clinical evidence suggest that hypoxia-based therapy might have short- and long-term benefits in PD. We present the contours of the first study to assess the safety, feasibility and physiological and symptomatic impact of hypoxia-based therapy in individuals with PD. Methods/Design In 20 individuals with PD, we will investigate the safety, tolerability and short-term symptomatic efficacy of continuous and intermittent hypoxia using individual, double-blind, randomized placebo-controlled N-of-1 trials. This design allows for dose finding and for including more individualized outcomes, as each individual serves as its own control. A wide range of exploratory outcomes is deployed, including the Movement Disorders Society Unified Parkinson’s Disease Rating scale (MDS-UPDRS) part III, Timed Up & Go Test, Mini Balance Evaluation Systems (MiniBES) test and wrist accelerometry. Also, self-reported impression of overall symptoms, motor and non-motor symptoms and urge to take dopaminergic medication will be assessed on a 10-point Likert scale. As part of a hypothesis-generating part of the study, we also deploy several exploratory outcomes to probe possible underlying mechanisms of action, including cortisol, erythropoietin and platelet-derived growth factor β. Efficacy will be assessed primarily by a Bayesian analysis. Discussion This evaluation of hypoxia therapy could provide insight in novel pathways that may be pursued for PD treatment. This trial also serves as a proof of concept for deploying an N-of-1 design and for including individualized outcomes in PD research, as a basis for personalized treatment approaches. Trial registration ClinicalTrials.gov Identifier: NCT05214287 (registered January 28, 2022).
Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02770-7.
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Affiliation(s)
- Jules M Janssen Daalen
- Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjan J Meinders
- Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands.,IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Federica Giardina
- Department of Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Section Biostatistics, Nijmegen, The Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Section Biostatistics, Nijmegen, The Netherlands
| | - Bas C Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
| | | | - Philip N Ainslie
- Center for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Kelowna, Canada
| | - Dick H J Thijssen
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan R Bloem
- Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands, Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, The Netherlands.
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Abstract
OBJECTIVE In this systematic review on drug price comparison studies, we report on recent determinants of drug prices in a national and international context to facilitate regulation of drug prices by purchasers and policymakers worldwide. Determinants of drug prices were divided into non-modifiable and modifiable and were categorised as pertaining to a country's income level, pharmaceutical market system and its policies and government. PRIMARY OUTCOME Determinants of drug prices or price variance. DESIGN We systematically searched PubMed, EMBASE, Web of Science and Cochrane Library for peer-reviewed articles published between 2004 and 22 July 2020 that reported an association of the primary outcome with one or more determinants. We performed a best-evidence synthesis of these associations for determinants covered in at least three studies. RESULTS 31 publications were included. Only one publication described net drug prices and 30 described retail drug prices. Five modifiable determinants were associated with lower retail prices: generic market portion, discounts, tendering policies, central (governmental) purchasing and pricing regulation schemes. The originators market portion and a system in which mark-ups are common were associated with higher retail prices. Retail prices were highest in the USA, even compared with other high-income countries. A positive association between national income level and drug retail prices could not be established among middle-income and high-income countries. Retail prices were highest in low-income countries when adjusted for purchasing power parity. CONCLUSIONS Literature on determinants of net drug prices is extremely sparse. Various healthcare system interventions, market-specific and governmental regulations are consistently associated with lower retail prices. Some interventions are easily implementable in developing or middle-income countries, such as tendering, central purchasing and fixed pricing regulation schemes. Net drug price comparison studies are needed to overcome the lack of price transparency and to quantify the effectiveness of policy measures on net drug prices.
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Affiliation(s)
- Jules M Janssen Daalen
- Faculty of Medical Sciences, Radboud University, Nijmegen, The Netherlands
- Staff Board of Directors, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Anouk den Ambtman
- Staff Board of Directors, Sint Maartenskliniek, Nijmegen, The Netherlands
- Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Mark Van Houdenhoven
- Staff Board of Directors, Sint Maartenskliniek, Nijmegen, The Netherlands
- Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center +, Maastricht, Netherlands
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11
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Janssen Daalen JM, Tosserams A, Mahlknecht P, Seppi K, Bloem BR, Darweesh SKL. Towards subgroup-specific risk estimates: A meta-analysis of longitudinal studies on olfactory dysfunction and risk of Parkinson's disease. Parkinsonism Relat Disord 2021; 84:155-163. [PMID: 33487544 DOI: 10.1016/j.parkreldis.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 12/17/2020] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Interest has risen in identifying individuals at high risk of incident Parkinson's disease (PD) to facilitate inclusion in neuroprotective treatment trials. Current risk estimates of prodromal markers are based on aggregated data of an entire population, but this approach disregards differences in risk estimates by subgroups of a population. In this proof of concept, we determine subgroup-specific risk estimates of olfactory dysfunction for incident PD. METHODS PubMed, EMBASE and Cochrane were searched for prospective studies investigating the association between olfactory dysfunction and incident PD. Random-effects meta-analysis, subgroup analyses and meta-regression were performed to investigate general and subgroup risk estimates. RESULTS Individuals with odor identification dysfunction seemed to be at greater risk of incident PD compared to controls without olfactory dysfunction (OR = 4.18; 95%CI [2.47-7.07]). Risk estimates were higher in studies that included higher percentages of women (regression slope β = 0.053 increase in log odds ratio per 1% increase 1%, p = 0.0006), increased with mean study age (β = 0.21 per one year increase; p = 0.005) and in REM-sleep behavior disorder cohorts (β = 1.95; p = 0.03). Furthermore, the association between olfactory dysfunction and incident PD was most distinct in studies with shorter follow-up duration (ß = -0.56; p = 0.0047). CONCLUSION The presence of olfactory dysfunction conveys a considerably elevated risk of incident PD, likely more in studies with a higher proportion of women, older individuals or short follow-up duration. Individual patient data are warranted to confirm these findings and to yield subgroup-specific risk estimates of other common markers to refine prodromal PD criteria.
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Affiliation(s)
- Jules M Janssen Daalen
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology; Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands.
| | - Anouk Tosserams
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology; Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands.
| | | | - Klaus Seppi
- Department of Neurology, Medical University Innsbruck, Austria.
| | - Bastiaan R Bloem
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology; Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands.
| | - Sirwan K L Darweesh
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology; Center of Expertise for Parkinson & Movement Disorders; Nijmegen, the Netherlands; Department of Epidemiology; Erasmus MC University Medical Centre; the Netherlands.
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12
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Janssen Daalen JM, Loeffen D, Martens J, Sanaan B, Viering DH, Henssen DJ, de Jong GA. Neurosurgery summer event for students by students: sharing interests. Br J Neurosurg 2019; 33:341-342. [DOI: 10.1080/02688697.2018.1540768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Jules M. Janssen Daalen
- RAMS International Summer Event Committee 2017, Faculty of Medical Sciences, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Dirk Loeffen
- RAMS International Summer Event Committee 2017, Faculty of Medical Sciences, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Jill Martens
- RAMS International Summer Event Committee 2017, Faculty of Medical Sciences, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Barof Sanaan
- RAMS International Summer Event Committee 2017, Faculty of Medical Sciences, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Daan H.H.M. Viering
- RAMS International Summer Event Committee 2017, Faculty of Medical Sciences, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Dylan J.H.A. Henssen
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Anatomy, Donders Institute of Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Guido A. de Jong
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
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