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Results
PMC10403822
Participant recruitment and retention
RECRUITMENT
Thirty-one participants who attended the memory clinic were screened for inclusion in the present pilot study, of which 21 were included in the study and provided baseline data. The reasons for exclusion at the screening stage are included in the flow diagram in Fig.  Recruitment flow diagram. Participant characterist...
PMC10403822
Completeness of data
Of the 18 participants who completed the follow-up assessment, all provided physical function, cognitive function, and health, wellbeing and psychological outcome data across all tests. Sixteen of the 18 participants returned their exercise snacking logbooks, which showed a reported adherence rate of 80% of all exercis...
PMC10403822
Acceptability
The quantitative scores indicated an overall acceptability rating from the exercise snacking intervention by completers of the study of 4.6 out of 5. The highest rated aspects of the TFA by study participants were self-efficacy (4.3) and affective response (4.1), followed by ethicality (3.9), coherence (3.8) and effect...
PMC10403822
Exploratory analysis of outcome data
SECONDARY
Changes were observed from baseline to follow-up for total SPPB score (8 (1) vs. 9 (3), Individual changes in (a) total Short Physical Performance Battery (SPPB) score, (b) 60-second sit-to-stand score, (c) timed up and go (TUG) time following 28-days of exercise snacking, and (d) left leg single balance time (to 60 s...
PMC10403822
Discussion
cognitive impairment
This study provides preliminary evidence that a simple homebased, twice daily exercise snacking programme appears to be acceptable to pre-frail older adult memory clinic attendees. Qualitative data from 15 of the 18 completers suggested that the simplicity of the exercises, and the short, simple to do nature of exercis...
PMC10403822
Electronic supplementary material
Below is the link to the electronic supplementary material. Additional file 1
PMC10403822
Acknowledgements
We are extremely grateful to the participants, and the RICE research staff Melissa Nolan and Bethany Fine for their support with the study. Financial support for this work came from an NIHR Research Capability Funding award distributed by the Royal United Hospitals, Bath.
PMC10403822
Authors’ contributions
RECRUITMENT
MW, OP, and TW conceived and designed the study, and obtained funding. VB and KK were responsible for participant recruitment and data collection. MW and OP analysed data and prepared the manuscript, and all authors read and approved the final manuscript.
PMC10403822
Funding
This study was funded by a Research Capability Fund award from the Royal United Hospitals, Bath. The funding body were not involved in the design of the study, the collection, analysis, or interpretation of data, or in writing the manuscript.
PMC10403822
Data Availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
PMC10403822
Declarations
PMC10403822
Ethics approval and consent to participate
WEST
The protocol was approved by the National Health Service (NHS) South West – Frenchay Research Ethics Committee (Ref: 22/SW/0084), conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000, and registered on ClinicalTrials.gov (Identifier: NCT05439252, 30/06/2022). Informed consent was obtained f...
PMC10403822
Consent for publication
Informed consent from all subjects and/or their legal guardian(s) was received for publication of identifying information/images in an online open-access publication.
PMC10403822
Competing interests
The authors declare no competing interests.
PMC10403822
References
PMC10403822
Background
inflammation
INFLAMMATION, LUNG DISEASES, NON-CYSTIC FIBROSIS BRONCHIECTASIS
Brensocatib is an oral, selective, reversible inhibitor of dipeptidyl peptidase-1 (DPP-1), responsible for activating neutrophil serine proteases (NSPs) including neutrophil elastase (NE), proteinase 3 (PR3), and cathepsin G (CatG). In chronic inflammatory lung diseases such as non-cystic fibrosis bronchiectasis (NCFBE...
PMC10189992
Methods
The 24-week WILLOW trial (NCT03218917) was a randomized, double-blind, placebo-controlled, parallel-group trial in patients with NCFBE conducted at 116 sites across 14 countries. In this trial, treatment with brensocatib was associated with improvements in clinical outcomes including time to first exacerbation, reducti...
PMC10189992
Results
POSITIVE
NE, PR3 and CatG activities were reduced in sputum and NE activity was reduced in WBC extracts in a dose-dependent manner after four weeks of brensocatib treatment, with a return to baseline four weeks after the end of treatment. Brensocatib produced the greatest reduction in the sputum activity of CatG, followed by NE...
PMC10189992
Supplementary Information
The online version contains supplementary material available at 10.1186/s12931-023-02444-z.
PMC10189992
Keywords
PMC10189992
Background
respiratory disease
RESPIRATORY DISEASE, NON-CYSTIC FIBROSIS BRONCHIECTASIS
Non-cystic fibrosis bronchiectasis (NCFBE) is a chronic, progressive respiratory disease defined by permanent dilatation of the bronchi [Dipeptidyl peptidase-1 (DPP-1, EC 3.4.14.1), also known as cathepsin C, is an enzyme responsible for activating NE, PR3, and CatG zymogens in promyelocytes during neutrophil different...
PMC10189992
Methods
PMC10189992
Trial design and data analysis
alpha1-antitrypsin deficiency, bronchiectasis, asthma
ALPHA1-ANTITRYPSIN DEFICIENCY, BRONCHIECTASIS, HYPOGAMMAGLOBULINEMIA, PERIODONTITIS, CYSTIC FIBROSIS, COMMON VARIABLE IMMUNODEFICIENCY, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, SECONDARY, ASTHMA
The WILLOW trial (ClinicalTrials.gov: NCT03218917; EudraCT: 2017-002533-32) was a randomized, double-blind, placebo-controlled, parallel-group trial conducted at 116 sites across 14 countries [Key exclusion criteria included bronchiectasis due to a clinical diagnosis of cystic fibrosis, hypogammaglobulinemia, common va...
PMC10189992
WBC collection procedure
BLOOD
Blood was collected from participating patients at each of the following visits: Day 1 (pre-dose), weeks 2, 4, 12, 24 (the end of the treatment period), and at week 28 (4 weeks after the end of the treatment period) [
PMC10189992
NE extraction from WBC pellets
agitation
An NSP extraction methodology utilizing surfactant and mechanical agitation has previously been described and qualified [
PMC10189992
Quantitation of WBC NE activities
To quantify the activity of NE in the WBC pellets, kinetic enzymatic assays were applied to the WBC lysate samples as previously described [For the data analyses, only patients with baseline WBC extract NE values were evaluated to enable a determination of the change in NE activity from baseline. There were patients wi...
PMC10189992
Sputum collection procedure
Sputum was collected from participating patients at each of the following visits: Screening Visit, Day 1 (pre-dose), weeks 2, 4, 12, 24 (the end of the treatment period), and at week 28 (4 weeks after the end of the treatment period) [
PMC10189992
Quantitation of sputum NSP activity
®
SECONDARY
To measure the activity of NE, PR3, and CatG in sputum, the ProAxsis ProteaseTag® Active NSP Immunoassays (ProAxsis, Belfast, UK) were used as a sandwich ELISA assay. Immunoassay plates were coated with a capture tag which allowed selective bindings to the active form of the specific NSP (NE, PR3 or CatG) on the plates...
PMC10189992
Sputum NSP data analysis criteria
The baseline sputum NSP values represented the average of the sputum NSP values from the subject’s Screening visit and Day 1 (pre-dose) visit as both visits were prior to the initiation of treatment. If one of the Screening or the Day 1 NSP values was below the quantification limit (BQL), then the non-BQL value was use...
PMC10189992
Correlation of sputum NSPs
The correlation of sputum NSP activities was determined for all patients combined, irrespective of treatment arms at baseline and for all timepoints. The correlations of sputum NSP activities were further analyzed according to treatment group: placebo, 10 mg brensocatib, or 25 mg brensocatib at baseline and for each ti...
PMC10189992
Results
PMC10189992
Distribution analysis of WBC and sputum NSP activities
The WILLOW trial randomized 256 patients, and 89, 81 and 85 had sputum NSP activity data in the 25 mg brensocatib, 10 mg brensocatib, and placebo groups, respectively. Baseline and post-baseline NE activity data in blood was reportable for 37, 30 and 35 patients, respectively. The prespecified analysis of sputum NSP ac...
PMC10189992
Effect of brensocatib treatment on active NE levels in WBCs
±
The total number of reportable NE activities from the blood samples at baseline and over the course of the trial was 256 for placebo, 239 for 10 mg brensocatib, and 299 for 25 mg brensocatib. The effect of treatment on NE activity in WBCs was also evaluated. Active NE levels in WBC extracts were reduced by brensocatib ...
PMC10189992
Correlation of effect on active sputum NSP levels
REGRESSION
We were further interested in understanding any possible correlations among the sputum NSP activities. The three pairs of sputum NSP biomarkers are plotted in Fig. Correlation of sputum NSP activities from all treatment arms. Pearson correlation analysis within sputum NSPs at (The slightly less positive NSP correlation...
PMC10189992
Discussion
bronchiectasis, bacterial infection, reductions in airway inflammation, inflammatory disorder, A1AT, reductions in lung inflammation
LUNG INFLAMMATION, BRONCHIECTASIS, INFLAMMATORY RESPONSE, BACTERIAL INFECTION, RECRUITMENT, INFLAMMATORY DISORDER, AIRWAY DISEASE, BRONCHIECTASIS
Bronchiectasis is an inflammatory disorder and neutrophils dominate the airway inflammatory profile in the majority of bronchiectasis patients. NSPs such as NE, PR3 and CatG are released from neutrophil granules when neutrophils are activated and during the formation of neutrophil extracellular traps [There are current...
PMC10189992
Conclusions
reductions in blood NE
Brensocatib demonstrated dose dependent reductions in blood NE and sputum NSP activity in the WILLOW study. These data suggest a broad anti-inflammatory effect of brensocatib underlying its clinical efficacy observed in NCFBE patients.
PMC10189992
Acknowledgements
The authors acknowledge Jun Zou who supported the biostats analysis for the WILLOW study and the following Insmed colleagues who contributed to the analysis of the NE activity in the WILLOW blood samples: Amruta Sabnis, Arielle Dorfman, Kuan-Ju Chen, Franziska Leifer, Xizhe Zhao, Jeong Yeong Kang, Mary Atalla, Sadikul ...
PMC10189992
Author contributions
JZ, BK, JDC, CF, KCM, WRP, EJS, and DC provided the concept for this manuscript. JZ, JB, DL, CF, KCM, WRP, EJS, and DC designed the methodology. JZ, JB, DL and DC conducted the formal analysis and data curation. Writing—Original Draft Preparation: JZ and DC authored the original manuscript. JZ, BK, JDC, JB, DL, CF, AT,...
PMC10189992
Funding
This research was funded by Insmed Incorporated.
PMC10189992
Availability of data and materials
All data generated or analysed during this study are included in this published article [and its Additional information files].
PMC10189992
Declarations
PMC10189992
Ethics approval and consent to participate
The WILLOW trial was performed in accordance with the ethical principles of the Declaration of Helsinki, International Conference on Harmonisation Good Clinical Practice guidelines, and applicable regulatory requirements. Approvals from independent ethics committees were obtained. Informed consent was obtained from all...
PMC10189992
Consent for publication
Not applicable.
PMC10189992
Competing interests
Zambon
DC, JS, DL, CF, AT, KGM, JZ, WP and EJS are employees of Insmed Incorporated, Bridgewater, New Jersey. JDC has received grants and personal fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Zambon, and Insmed Incorporated; a grant from Gilead; and personal fees from Novartis and Chiesi. BK has received pers...
PMC10189992
References
PMC10189992
Key Points
PMC10755607
Question
insomnia
Which first-stage treatment is optimal for improving daytime functions among patients with insomnia, and which second-stage treatment offers the best added value for patients whose insomnia has not remitted?
PMC10755607
Findings
depressive symptoms, fatigue, insomnia disorder
In a randomized clinical trial of 211 adults with insomnia disorder, first-stage treatment with behavioral therapy (BT) or zolpidem produced significant improvements for various daytime outcomes, including depressive symptoms, fatigue, functional impairments, and mental health, that were no different between groups. Ad...
PMC10755607
Meaning
insomnia
These findings support the comparable efficacy between sequential treatments starting with BT and zolpidem for addressing the daytime consequences of insomnia.
PMC10755607
Importance
insomnia, Daytime functional impairments
Daytime functional impairments are the primary reasons for patients with insomnia to seek treatment, yet little is known about what the optimal treatment is for improving daytime functions and how best to proceed with treatment for patients whose insomnia has not remitted.
PMC10755607
Objectives
insomnia
To compare the efficacy of behavioral therapy (BT) and zolpidem as initial therapies for improving daytime functions among patients with insomnia and evaluate the added value of a second treatment for patients whose insomnia has not remitted.
PMC10755607
Design, Setting, and Participants
DISORDER, MAY, CHRONIC INSOMNIA
In this sequential multiple-assignment randomized clinical trial conducted at institutions in Canada and the US, 211 adults with chronic insomnia disorder were enrolled between May 1, 2012, and December 31, 2015, and followed up for 12 months. Statistical analyses were performed on an intention-to-treat basis in April ...
PMC10755607
Interventions
insomnia
Participants were randomly assigned to either BT or zolpidem as first-stage therapy, and those whose insomnia had not remitted received a second-stage psychological therapy (BT or cognitive therapy) or medication therapy (zolpidem or trazodone).
PMC10755607
Main Outcomes and Measures
mood disturbances, insomnia, fatigue
Study outcomes were daytime symptoms of insomnia, including mood disturbances, fatigue, functional impairments of insomnia, and scores on the 36-item Short-Form Health Survey (SF-36) physical and mental health components.
PMC10755607
Results
−7.3, Anxiety, fatigue, anxiety, insomnia, depressive symptoms, −6.7, Depression, −4.7, Fatigue
Among 211 adults with insomnia (132 women [63%]; mean [SD] age, 45.6 [14.9] years), 104 were allocated to BT and 107 to zolpidem at the first stage. First-stage treatment with BT or zolpidem yielded significant and equivalent benefits for most of the daytime outcomes, including depressive symptoms (Beck Depression Inve...
PMC10755607
Conclusions and Relevance
insomnia, insomnia disorder
In this randomized clinical trial of adults with insomnia disorder, BT and zolpidem produced improvements for various daytime symptoms of insomnia that were no different between treatments. Adding a second treatment offered an added value with further improvements of daytime functions.
PMC10755607
Trial Registration
insomnia
ClinicalTrials.gov Identifier: This randomized clinical trial compares the efficacy of behavioral therapy and zolpidem as initial therapies for improving daytime functions among patients with insomnia and evaluates the added value of a second treatment for patients whose insomnia has not remitted.
PMC10755607
Introduction
insomnia, Insomnia, sleep disorder
SECONDARY
Insomnia is a highly prevalent sleep disorder that tends to be persistent or recurrentCurrent recommended treatments for insomnia in clinical practice guidelines include 2 major approaches: psychological therapies (ie, cognitive behavioral therapy [CBT]) and medications (eg, benzodiazepine-receptor agonists and sedatin...
PMC10755607
Methods
PMC10755607
Study Design
insomnia, comorbid psychiatric disorder
This study is part of an RCT that aimed to examine the comparative efficacy of 4 treatment sequences involving psychological and medication therapies for insomnia with and without comorbid psychiatric disorder (trial protocol in This project adopted a sequential multiple assignment randomized trial (SMART) design with ...
PMC10755607
Participant Flow in the Sequential Treatment for Insomnia
Reprinted with permission from Morin et al.
PMC10755607
Participants
psychiatric disorders
CHRONIC INSOMNIA
A total of 211 adults with chronic insomnia were recruited from the community through media advertisements and physician referrals. All participants included in the study met the following criteria: (1) aged 21 years or older, (2) persistent (>1 month) difficulties initiating or maintaining sleep despite adequate oppor...
PMC10755607
Outcome Measures
mood disturbances, insomnia, fatigue
The current study focused on changes in daytime functional outcomes, including mood disturbances, fatigue, functional impairments of insomnia, and the 36-item Short-Form Health Survey (SF-36) physical and mental health components.
PMC10755607
Treatments
PMC10755607
Cognitive Behavioral Therapy
The first-stage psychological therapy consisted of BT, which included sleep restriction
PMC10755607
Medication
depressive symptoms
The first-stage medication treatment involved sublingual zolpidem, 5 mg to 10 mg, taken nightly at bedtime. The second-stage pharmacotherapy consisted of trazodone, 50 to 150 mg, taken 30 minutes before bedtime. As a serotonin receptor antagonist and reuptake inhibitor antidepressant, trazodone can alleviate a wide ran...
PMC10755607
Statistical Analysis
The intention-to-treat analyses were performed in April and October 2023. To evaluate each treatment sequence while taking into account the nature of the SMART design (ie, 2 randomizations, where the second is conditional on the response to the first), the analytic strategy was based on recommendations from Nahum-Shani...
PMC10755607
Results
PMC10755607
Participants
insomnia disorder
A total of 211 adults (132 women [63%]; mean [SD] age, 45.6 [14.9] years; 14 Black participants [7%], 11 Hispanic participants [5%], 182 White participants [86%], and 4 participants [2%] of other race or ethnicity [Asian (n = 2), Middle Eastern origin (n = 1), and not specified (n = 1)]) who met criteria for insomnia d...
PMC10755607
Sociodemographic and Clinical Characteristics of Participants
Reprinted with permission from Morin et al.Asian (n = 2), Middle Eastern origin (n = 1), and not specified (n = 1).Percentages do not total 100 due to missing data.Of the 211 randomized participants, 168 completed first-stage therapy (
PMC10755607
Follow-Up Assessments
anxiety
Both conditions starting with BT showed significant improvements from post2 to 12-month follow-up for anxiety symptoms (mean change in STAI-Trait score: BT plus zolpidem, −4.6 [95% CI, −7.7 to −1.5];
PMC10755607
Subgroup Analysis for Participants With Psychiatric Comorbidity
psychiatric comorbidity
The findings in the subgroup analysis by psychiatric comorbidity (absent vs present) were similar to those from the main analysis for most of the outcomes. However, they are not reported in detail here due to the small sample sizes and reduced power for those analyses.
PMC10755607
Discussion
depressive, insomnia, depressive symptoms
The current study showed that first-stage treatment with BT or zolpidem was effective in reducing daytime symptoms of insomnia, with no significant differences between groups. The addition of a second-stage therapy resulted in an added value in enhancing daytime functions. In particular, immediate effects of second-sta...
PMC10755607
Limitations
mood disturbances, daytime impairments, insomnia, fatigue
REMISSION
Some of the findings need to be interpreted cautiously given some methodological limitations. First, the lack of a control condition and the relatively small sample sizes for each treatment sequence may reduce the statistical power to detect more significant group differences. Second, only patients whose insomnia did n...
PMC10755607
Conclusions
insomnia, anxiety
The present study documented the efficacy of BT and zolpidem for improving daytime functional outcomes among patients with insomnia and the effect of BT on reducing anxiety symptoms. Adding a second treatment offered an added value for further improvements of daytime functions. Future developments of insomnia treatment...
PMC10755607
1. Introduction
cough, throat
COLD, FLU
These authors contributed equally to this work.There is wide variation in how individuals perceive the chemosensory attributes of liquid formulations of ibuprofen, encompassing both adults and children. To understand personal variation in the taste and chemesthesis properties of this medicine, and how to measure it, ou...
PMC10487938
2. Results
PMC10487938
2.1. Panel Characteristics
The 154 panelists (64 males; 90 females) who met the inclusion criteria had a mean age of 34 ± 1 years and represented the diversity of the city where they lived: Philadelphia, PA, USA [
PMC10487938
2.2. Chemosensory Phenotypes
cough, throat, epiglottis
As shown in Psychophysical ratings varied widely across panelists for all conditions. Sip-and-spit ratings for sweetness, irritation, bitterness, and palatability were predictors of ratings after swallowing (A greater proportion of panelists experienced the urge to cough and throat tingling/scratching in the swallow co...
PMC10487938
3. Discussion
Chemesthetic sensations, throat, human immunodeficiency virus
HUMAN IMMUNODEFICIENCY VIRUS
We found reproducible individual differences among adults in the taste and palatability of a popular OTC ibuprofen-containing pediatric formulation and two of its sweetening excipients, and genetic variation contributed to some of these differences. Swallowing the formulation intensified perceived irritation and bitter...
PMC10487938
4. Materials and Methods
PMC10487938
4.1. Participants and Stimuli
Healthy adults trained as sensory panelists were enrolled in a multisession study as trained sensory panelists to evaluate the taste of a variety of pediatric liquid formulations and excipients, one of which was an over-the-counter (OTC) sweetened suspension containing ibuprofen (100 mg/5 mL, 2% The study was temporari...
PMC10487938
4.2. Phenotyping
numbing, stinging, taste sensations, sneeze, throat, cough, palate, epiglottis
Using a double-blind study design, panelists were tested in closed rooms designed specifically for sensory testing, with red light illumination to eliminate the effect of the color of the solution, if any, on sensory ratings. During the first session, panelists were trained individually to identify basic taste sensatio...
PMC10487938
4.3. Genotyping, Genetic Ancestry, and Candidate Single-Nucleotide Polymorphisms (SNPs)
Saliva samples were collected from each enrolled panelist (Kinship analysis was performed with KING (version 2.2.7) [The imputation of genotypes to a greater portion of the human genome was performed on Michigan Imputation Server (
PMC10487938
4.4. Statistical Analyses
Salty
We computed descriptive statistics and used the Shapiro–Wilk test to assess for normality. Salty and savory ratings were rarely provided and therefore eliminated from the analysis. The gLMS ratings for sweetness were normally distributed (First, we focused on phenotyping data from 154 panelists. Separate ANOVA tests de...
PMC10487938
Supplementary Materials
The supporting information can be downloaded at Click here for additional data file.
PMC10487938
Author Contributions
Study concept and design, and project administration: J.A.M. and E.D.L.; methodology: J.A.M.; acquisition, analysis, or interpretation of data: J.A.M., M.K., M.Y.P., B.E.H., E.D.L., L.R.S. and J.D.M.; writing—original draft preparation: J.A.M. and M.K.; writing—review and editing: J.A.M., M.K., M.Y.P., B.E.H., L.R.S. a...
PMC10487938
Institutional Review Board Statement
The study complied with the Declaration of Helsinki for Medical Research involving Human Subjects and was approved by the Office of Regulatory Affairs at the University of Pennsylvania and the Institutional Review Board of the Children’s Hospital of Philadelphia (protocol number 829945; date of approval: 28 June 2018).
PMC10487938
Informed Consent Statement
Written informed consent was obtained from all subjects involved in the study.
PMC10487938
Data Availability Statement
Summary statistics for SNP–phenotype associations and R codes for statistical analysis are available upon reasonable request and the Data Usage Agreement should be sent to corresponding authors Julie A. Mennella (
PMC10487938
Conflicts of Interest
The authors declare no conflict of interest. The funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
PMC10487938
Appendix A
allergies
ALLERGIES
Study flow chart. The study population consisted of women and men who were non-smokers; had no known allergies or sensitivities to any of the medications or stimuli included in the taste panel; and who were not taking and had not taken in the recent past any medication that was contraindicated to those included in the ...
PMC10487938
Background
Scientists often make cognitive claims (eg, the results of their work) and normative claims (eg, what should be done based on those results). Yet, these types of statements contain very different information and implications. This randomized controlled trial sought to characterize the granular effects of using normativ...
PMC10131812
Objective
Our study examined whether viewing a social media post containing scientific claims about face masks for COVID-19 using both normative and cognitive language (intervention arm) would reduce perceptions of trust and credibility in science and scientists compared with an identical post using only cognitive language (cont...
PMC10131812
Methods
This was a 2-arm, parallel group, randomized controlled trial. We aimed to recruit 1500 US adults (age 18+) from the Prolific platform who were representative of the US population census by cross sections of age, race/ethnicity, and gender. Participants were randomly assigned to view 1 of 2 images of a social media pos...
PMC10131812
Results
From September 4, 2022, to September 6, 2022, 1526 individuals completed the study. For the sample as a whole (eg, without interaction terms), there was no evidence that a single exposure to normative language affected perceptions of trust or credibility in science or scientists. When including the interaction term (st...
PMC10131812
Conclusions
SECONDARY
This study does not support the authors’ original hypotheses that single exposures to normative language can reduce perceptions of trust or credibility in science or scientists for all people. However, the secondary preregistered analyses indicate the possibility that political orientation may differentially mediate th...
PMC10131812
Trial Registration
OSF
OSF Registries osf.io/kb3yh; https://osf.io/kb3yh
PMC10131812
International Registered Report Identifier (IRRID)
RR2-10.2196/41747
PMC10131812