Translating digital healthcare to enhance clinical management: a protocol for an observational study using a digital health technology system to monitor medication adherence and its effect on mobility in people with Parkinson's

INTRODUCTION

In people with Parkinson's (PwP) impaired mobility is associated with an increased falls risk. To improve mobility, dopaminergic medication is typically prescribed, but complex medication regimens result in suboptimal adherence. Exploring medication adherence and its impact on mobility in PwP will provide essential insights to optimise medication regimens and improve mobility. However, this is typically assessed in controlled environments, during one-off clinical assessments. Digital health technology (DHT) presents a means to overcome this, by continuously and remotely monitoring mobility and medication adherence. This study aims to use a novel DHT system (DHTS) (comprising of a smartphone, smartwatch and inertial measurement unit (IMU)) to assess self-reported medication adherence, and its impact on digital mobility outcomes (DMOs) in PwP.

METHODS AND ANALYSIS

This single-centre, UK-based study, will recruit 55 participants with Parkinson's. Participants will complete a range of clinical, and physical assessments. Participants will interact with a DHTS over 7 days, to assess self-reported medication adherence, and monitor mobility and contextual factors in the real world. Participants will complete a motor complications diary (ON-OFF-Dyskinesia) throughout the monitoring period and, at the end, a questionnaire and series of open-text questions to evaluate DHTS usability. Feasibility of the DHTS and the motor complications diary will be assessed. Validated algorithms will quantify DMOs from IMU walking activity. Time series modelling and deep learning techniques will model and predict DMO response to medication and effects of contextual factors. This study will provide essential insights into medication adherence and its effect on real-world mobility in PwP, providing insights to optimise medication regimens.

ETHICS AND DISSEMINATION

Ethical approval was granted by London-142 Westminster Research Ethics Committee (REC: 21/PR/0469), protocol V.2.4. Results will be published in peer-reviewed journals. All participants will provide written, informed consent.

TRIAL REGISTRATION NUMBER

ISRCTN13156149.

Feasibility and usability of a digital health technology system to monitor mobility and assess medication adherence in mild-to-moderate Parkinson's disease

Introduction

Parkinson's disease (PD) is a neurodegenerative disorder which requires complex medication regimens to mitigate motor symptoms. The use of digital health technology systems (DHTSs) to collect mobility and medication data provides an opportunity to objectively quantify the effect of medication on motor performance during day-to-day activities. This insight could inform clinical decision-making, personalise care, and aid self-management. This study investigates the feasibility and usability of a multi-component DHTS to remotely assess self-reported medication adherence and monitor mobility in people with Parkinson's (PwP).

Methods

Thirty participants with PD [Hoehn and Yahr stage I (n = 1) and II (n = 29)] were recruited for this cross-sectional study. Participants were required to wear, and where appropriate, interact with a DHTS (smartwatch, inertial measurement unit, and smartphone) for seven consecutive days to assess medication adherence and monitor digital mobility outcomes and contextual factors. Participants reported their daily motor complications [motor fluctuations and dyskinesias (i.e., involuntary movements)] in a diary. Following the monitoring period, participants completed a questionnaire to gauge the usability of the DHTS. Feasibility was assessed through the percentage of data collected, and usability through analysis of qualitative questionnaire feedback.

Results

Adherence to each device exceeded 70% and ranged from 73 to 97%. Overall, the DHTS was well tolerated with 17/30 participants giving a score > 75% [average score for these participants = 89%, from 0 (worst) to 100 (best)] for its usability. Usability of the DHTS was significantly associated with age (ρ = −0.560, BCa 95% CI [−0.791, −0.207]). This study identified means to improve usability of the DHTS by addressing technical and design issues of the smartwatch. Feasibility, usability and acceptability were identified as key themes from PwP qualitative feedback on the DHTS.

Conclusion

This study highlighted the feasibility and usability of our integrated DHTS to remotely assess medication adherence and monitor mobility in people with mild-to-moderate Parkinson's disease. Further work is necessary to determine whether this DHTS can be implemented for clinical decision-making to optimise management of PwP.

Feasibility and utility of enhanced sleep management on in-patient psychiatry wards

AIMS AND METHOD

Sleep disturbance is common in psychiatry wards despite poor sleep worsening mental health. Contributory factors include the ward environment, frequent nightly checks on patients and sleep disorders including sleep apnoea. We evaluated the safety and feasibility of a package of measures to improve sleep across a mental health trust, including removing hourly checks when safe, sleep disorder screening and improving the ward environment.

RESULTS

During the pilot there were no serious adverse events; 50% of in-patients were able to have protected overnight sleep. Hypnotic issuing decreased, and feedback from patients and staff was positive. It was possible to offer cognitive-behavioural therapy for insomnia to selected patients.

CLINICAL IMPLICATIONS

Many psychiatry wards perform standardised, overnight checks, which are one cause of sleep disruption. A protected sleep period was safe and well-tolerated alongside education about sleep disturbance and mental health. Future research should evaluate personalised care rather than blanket observation policies.

Biological contamination of Mars. I. Survival of terrestrial microorganisms in simulated Martian environments

It has been postulated that the accidental introduction of terrestrial microorganisms to other planets during the course of space exploration might impede or bias the detection of organic matter and possible indigenous organisms, and thereby confuse subsequent studies of extraterrestrial life. To assess the likelihood of biological contamination of Mars, we have applied the principle of natural selection on a laboratory scale. Terrestrial microorganisms were collected from a variety of environments, including regions of high alkalinity, low mean daily temperature, and low annual rainfall. The air-dried soils were then subjected to a simulated Martian environment involving 12-hour freeze-thaw cycles from about -60 degrees C to about +20 degrees C; atmospheres of 95 per cent nitrogen, 5 percent carbon dioxide and low moisture content: < or = 0.1 atm pressure; and a total ultraviolet dose at 2537 angstrom of 10(9) erg cm-2. In some experiments, organic supplements were provided. Survivors were scored on supplemented agar. Preliminary results indicate a wide variety of survivors, even when no organic supplements were introduced. Survivors included obligate and facultative anaerobic spore-formers and non-spore-forming facultative anaerobic bacteria. Diurnal freezing and thawing was continued for six months. There was no significant loss of viability after the first freeze-thaw cycle. An extensive literature survey shows that survival of terrestrial microorganisms under individual simulated Martian conditions has been known for decades. The present investigation shows the absence of pronounced synergistic effects inhibiting survival. The probable existence of organic matter and moisture on Mars, at least in restricted locales and times, makes it especially likely that terrestrial microorganisms can also reproduce on Mars. The demonstration that all samples of terrestrial soil tested contain a population of microorganisms which survive in simulated Martian environments strongly underscores the need for scrupulous sterilization of all spacecraft intended for Mars landing.

Relationship of chronic endurance exercise to the somatotropic and sex hormone status of older men

To investigate putative abrogating effects of habitual endurance exercise on age-related changes in endocrine function and body composition, we compared insulin-like growth factor-I (IGF-I), sex hormonal status and body composition in 15 Masters runners and 15 minimally exercising men (MEM) aged 60-70 years. A higher maximal oxygen uptake (VO2 max.) in the runners (41.4+/-1.6 compared with 27.3+/-1.4 ml/kg/min, P=0.0001; mean+/-S.E.M.) reflected our group allocations. Analysis of body composition and bone mineral density (BMD) by dual energy X-ray absorptiometry showed no group differences in lean tissue mass or in regional or whole body BMD, but MEM were heavier, reflecting greater adiposity. Of nine muscle groups tested, only quadriceps strength differed significantly, being greater in runners (60.3+/-2.8 compared with 51.1+/-2.3 kg, P=0.02). Total IGF-I (129+/-10 compared with 124+/-11 ng/ml, P=0.72) and IGF-binding protein-3 (2854+/-94 compared with 2623+/-128ng/ml, P=0.16), were similarly depressed compared with young adult norms in both groups. There was no relationship between total or bioavailable IGF-I and any body composition, BMD or muscle strength variable. In the runners, concentrations of total testosterone (19.1+/-0.8 compared with 15.0+/-0.9 nmol/l, P=0.002) and sex hormone binding globulin (SHBG) (124.4+/-21.6 compared with 67.7+/-11.6 nmol/l, P=0.03) were significantly greater, but the free androgen index was significantly lower (20.7+/-2.7 compared with 31.4+/-4.1, P=0.04). Directly measured free testosterone, however, was similar between the runners and MEM (47.9+/-1.8 compared with 47.1+/-2.0 nmol/l P=0.80). Therefore the group differences in total testosterone and free androgen index were due to their different SHBG concentrations. Although estrone concentration was higher in MEM (85.1+/-5.2 compared with 108+/-6.7 pmol/l, P=0.03), estradiol concentration was similar between groups (73.0+/-6.3 compared with 81.8+/-8.0 pmol/l, P=0.18), indicating that estrogens were not responsible for the increased SHBG in runners. These results indicate that even high levels of regular endurance exercise do not prevent the decline in the somatotropic axis that occurs with aging. Furthermore, the somatic effects of exercise in older men (reduced adiposity and increased regional muscle strength) occurred independently of somatotropic or androgen status. Although habitual exercise does not influence free testosterone concentrations in older men, it appears to enhance the age-associated increase in SHBG synthesis.

Effects of aluminum hydroxide on the parathyroid-vitamin D axis of postmenopausal women

In previous studies we proposed that estrogen increases circulating calcitriol in postmenopausal women by reducing plasma phosphorus concentrations. For this model to be plausible, a reduction in plasma phosphorus must be itself be sufficient to increase circulating calcitriol in elderly women. To assess this question we studied the effects of Al(OH)3 on daylong circulating levels of phosphorus, calcium, PTH, and calcitriol in 14 postmenopausal women. Subjects were studied on two 7-day periods of dietary control, in which calculated intakes for phosphorus, calcium, and sodium were 950, 800, and 3000 mg/day, respectively. During one randomly assigned period, subjects were given Al(OH)3 with each meal. Al(OH)3 significantly lowered daylong plasma phosphorus concentrations by 17% (0.95 +/- 0.02 mmol/L vs. 1.15 +/- 0.02, P less than 0.0005) (2.94 +/- 0.06 mg/dL vs. 3.57 +/- 0.07), and this was associated with a 38% rise in circulating calcitriol from 61.8 +/- 10.3 pmol/L to 85.2 +/- 10.1 pmol/L (25.7 +/- 4.3 pg/ml to 35.5 +/- 4.2 pg/ml) (P less than 0.0001). The rise in calcitriol correlated significantly with the reduction in phosphorus (r = 0.51, P = 0.03). Al(OH)3 did not significantly alter average daily circulating total calcium (2.32 +/- 0.008 vs. 2.32 +/- 0.005 mmol/L) (9.31 +/- 0.03 vs. 9.29 +/- 0.02 mg/dL), ionized calcium (1.19 +/- 0.003 vs. 1.19 +/- .004 mmol/L), or intact PTH (24.6 +/- 0.6 vs. 24.2 +/- 0.8 ng/L). Moreover, neither the renal phosphorus reabsorption maximum (TmP/GFR), baseline excretion of cAMP, nor the phosphaturic, cAMP, or calcitriol responses to infused hPTH(1-34) were altered by Al(OH)3. We conclude that Al(OH)3 treatment of older women lowers plasma phosphorus concentrations by restricting intestinal phosphorus absorption, and that older women retain the capacity to increase calcitriol levels in response to phosphorus restriction.

Effects of estrogen on daylong circulating calcium, phosphorus, 1,25-dihydroxyvitamin D, and parathyroid hormone in postmenopausal women

We studied the effects of estrogen on daylong circulating levels of calcium, inorganic phosphorus, parathyroid hormone (PTH), and 1,25-(OH)2D3 (calcitriol) in a group of 10 postmenopausal women (68.5 +/- 1.4 years, mean +/- SEM). The study was conducted under strict dietary control, with mean calcium and phosphorus intakes of 845 and 970 mg. After treatment with conjugated equine estrogens, 1.25 mg/day, for 1 month, significant decreases in fasting (0800 h) serum levels were observed for calcium (9.09 +/- 0.08 versus 9.46 +/- 0.10 mg/dl, p less than 0.01) and phosphorus (3.38 +/- 0.10 versus 3.73 +/- 0.08 mg/dl, p less than 0.01). On the 0800 h fasting specimen, midmolecule PTH concentrations were higher (44.0 +/- 7.9 versus 34 +/- 8.2 pg/ml, p less than 0.05), but intact PTH was unchanged (28.6 +/- 2.7 versus 29.1 +/- 1.7 pg/ml) and a rise in circulating calcitriol (39.8 +/- 4.3 versus 31.6 +/- 2.1 pg/ml) was marginally significant (p = 0.07). When data represented multiple samples averaged over 7 and 15 h, significant estrogen-related reductions in serum calcium and phosphorus concentrations were observed. In addition, estrogen was associated with a significant rise in the daylong (15 h) level of calcitriol (39.4 +/- 4 versus 30.5 +/- 2.4 pg/ml, p less than 0.01). Daylong mid- and intact PTH concentrations were unchanged on estrogen compared to baseline values. No significant correlations were observed between changes in fasting calcitriol level and changes in fasting concentrations of calcium, phosphorus, or PTH. Further, the rise in daylong calcitriol concentration did not correlate significantly with changes in fasting or integrated values of calcium or PTH.(ABSTRACT TRUNCATED AT 250 WORDS)

Purchasing infant shoes: attitudes of parents, pediatricians, and store managers

Questionnaires designed to collect data about the purchase of shoes for normal infants were completed by 104 parents in a university ambulatory unit, 127 practicing pediatricians, and 36 shoe store managers. Infants received their first pair of walking shoes at an average age of 8.1 months (range: 4 to 12 months) and at an average cost of $14.56 (range: $2 to $43). Most of these shoes had laces (95%), high tops (87%), hard soles (74%), and special arch supports (50%). Of the 104 children, 73 had shoes before they were walking (average cost: $13.21) and 35 wore walking shoes before they were even standing (average cost: $12.68). Parents obtained much more information about shoes from friends and relatives than from physicians. Those parents who obtained most of their information from salespersons spent the most for shoes. The average cost of shoes recommended by store managers was $18.74. Although 77% of pediatricians felt that inexpensive canvas sneakers are adequate, only 28% of the salespersons and 37% of the parents believed that wearing sneakers is healthy.