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Cay G, Finco M, Garcia J, McNitt-Gray JL, Armstrong DG, Najafi B. Towards a Remote Patient Monitoring Platform for Comprehensive Risk Evaluations for People with Diabetic Foot Ulcers. SENSORS (BASEL, SWITZERLAND) 2024; 24:2979. [PMID: 38793835 PMCID: PMC11124849 DOI: 10.3390/s24102979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/28/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
Diabetic foot ulcers (DFUs) significantly affect the lives of patients and increase the risk of hospital stays and amputation. We suggest a remote monitoring platform for better DFU care. This system uses digital health metrics (scaled from 0 to 10, where higher scores indicate a greater risk of slow healing) to provide a comprehensive overview through a visual interface. The platform features smart offloading devices that capture behavioral metrics such as offloading adherence, daily steps, and cadence. Coupled with remotely measurable frailty and phenotypic metrics, it offers an in-depth patient profile. Additional demographic data, characteristics of the wound, and clinical parameters, such as cognitive function, were integrated, contributing to a comprehensive risk factor profile. We evaluated the feasibility of this platform with 124 DFU patients over 12 weeks; 39% experienced unfavorable outcomes such as dropout, adverse events, or non-healing. Digital biomarkers were benchmarked (0-10); categorized as low, medium, and high risk for unfavorable outcomes; and visually represented using color-coded radar plots. The initial results of the case reports illustrate the value of this holistic visualization to pinpoint the underlying risk factors for unfavorable outcomes, including a high number of steps, poor adherence, and cognitive impairment. Although future studies are needed to validate the effectiveness of this visualization in personalizing care and improving wound outcomes, early results in identifying risk factors for unfavorable outcomes are promising.
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Affiliation(s)
- Gozde Cay
- Digital Health and Access Center (DiHAC), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA; (G.C.)
| | - M.G. Finco
- Digital Health and Access Center (DiHAC), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA; (G.C.)
| | - Jason Garcia
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Jill L. McNitt-Gray
- Department of Biological Sciences, Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, CA 90007, USA
- Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90007, USA
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Bijan Najafi
- Digital Health and Access Center (DiHAC), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA; (G.C.)
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Pouwer F, Mizokami-Stout K, Reeves ND, Pop-Busui R, Tesfaye S, Boulton AJM, Vileikyte L. Psychosocial Care for People With Diabetic Neuropathy: Time for Action. Diabetes Care 2024; 47:17-25. [PMID: 38117989 DOI: 10.2337/dci23-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/23/2023] [Indexed: 12/22/2023]
Abstract
Psychological factors and psychosocial care for individuals with diabetic neuropathy (DN), a common and burdensome complication of diabetes, are important but overlooked areas. In this article we focus on common clinical manifestations of DN, unremitting neuropathic pain, postural instability, and foot complications, and their psychosocial impact, including depression, anxiety, poor sleep quality, and specific problems such as fear of falling and fear of amputation. We also summarize the evidence regarding the negative impact of psychological factors such as depression on DN, self-care tasks, and future health outcomes. The clinical problem of underdetection and undertreatment of psychological problems is described, together with the value of using brief assessments of these in clinical care. We conclude by discussing trial evidence regarding the effectiveness of current pharmacological and nonpharmacological approaches and also future directions for developing and testing new psychological treatments for DN and its clinical manifestations.
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Affiliation(s)
- Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense, Odense, Denmark
- Department of Medical Psychology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI
- Lieutenant Colonel Charles S. Kettles Veteran Affairs Medical Center, Ann Arbor, MI
| | - Neil D Reeves
- Department of Life Sciences, Faculty of Science and Engineering, Manchester, U.K
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI
| | - Solomon Tesfaye
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Andrew J M Boulton
- Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, U.K
- Department of Dermatology, University of Miami, Miami, FL
| | - Loretta Vileikyte
- Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, U.K
- Department of Dermatology, University of Miami, Miami, FL
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Crossland SR, Siddle HJ, Brockett CL, Culmer P. Evaluating the use of a novel low-cost measurement insole to characterise plantar foot strain during gait loading regimes. Front Bioeng Biotechnol 2023; 11:1187710. [PMID: 37662427 PMCID: PMC10469908 DOI: 10.3389/fbioe.2023.1187710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction: Under plantar loading regimes, it is accepted that both pressure and shear strain biomechanically contribute to formation and deterioration of diabetic foot ulceration (DFU). Plantar foot strain characteristics in the at-risk diabetic foot are little researched due to lack of measurement devices. Plantar pressure comparatively, is widely quantified and used in the characterisation of diabetic foot ulceration risk, with a range of clinically implemented pressure measurement devices on the market. With the development of novel strain quantification methods in its infancy, feasibility testing and validation of these measurement devices for use is required. Initial studies centre on normal walking speed, reflecting common activities of daily living, but evaluating response to differing gait loading regimes is needed to support the use of such technologies for potential clinical translation. This study evaluates the effects of speed and inclination on stance time, strain location and strain response using a low-cost novel strain measurement insole. Methods: The STrain Analysis and Mapping of the Plantar Aspect (STAMPS) insole has been developed, and feasibility tested under self-selected normal walking speeds to characterise plantar foot strain, with testing beyond this limited regime required. A treadmill was implemented to standardise speed and inclination for a range of daily plantar loading conditions. A small cohort, comprising of five non-diabetic participants, were examined at slow (0.75 m/s), normal (1.25 m/s) and brisk (2 m/s) walking speeds and normal speed at inclination (10% gradient). Results: Plantar strain active regions were seen to increase with increasing speed across all participants. With inclination, it was seen that strain active regions reduce in the hindfoot and show a tendency to forefoot with discretionary changes to strain seen. Stance time decreases with increasing speed, as expected, with reduced stance time with inclination. Discussion: Comparison of the strain response and stance time should be considered when evaluating foot biomechanics in diabetic populations to assess strain time interval effects. This study supports the evaluation of the STAMPS insole to successfully track strain changes under differing plantar loading conditions and warrants further investigation of healthy and diabetic cohorts to assess the implications for use as a risk assessment tool for DFU.
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Affiliation(s)
- Sarah R. Crossland
- School of Mechanical Engineering, Institute of Functional Surfaces, University of Leeds, Leeds, United Kingdom
| | - Heidi J. Siddle
- School of Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Claire L. Brockett
- Deparment of Mechanical Engineering, INSIGNEO Institute for in Silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Peter Culmer
- School of Mechanical Engineering, Institute of Design, Robotics and Optimisation, University of Leeds, Leeds, United Kingdom
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Srass H, Ead JK, Armstrong DG. Adherence and the Diabetic Foot: High Tech Meets High Touch? SENSORS (BASEL, SWITZERLAND) 2023; 23:6898. [PMID: 37571682 PMCID: PMC10422535 DOI: 10.3390/s23156898] [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: 02/24/2023] [Revised: 07/20/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023]
Abstract
Diabetic foot ulcers, which are a common complication of diabetes, can have a negative impact on a person's physical and mental health, including an increased risk of depression. Patients suffering from depression are less likely to keep up with diabetic foot care, thus increasing the risk of developing ulcers. However, with the use of artificial intelligence (AI), at-home patient care has become easier, which increases adherence. To better understand how new technologies, including machine learning algorithms and wearable sensors, might improve patient adherence and outcomes, we conducted a literature review of several sensor technologies, including SmartMat© and Siren Care© socks for temperature, SurroSense Rx/Orpyx© for pressure, and Orthotimer© for adherence. An initial search identified 143 peer-reviewed manuscripts, from which we selected a total of 10 manuscripts for further analysis. We examined the potential benefits of personalized content and clinician support for those receiving mobile health interventions. These findings may help to demonstrate the current and future utility of advanced technologies in improving patient adherence and outcomes, particularly in the context of diabetes management and the link between behavior and complications in diabetes, such as diabetic foot ulcers.
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Affiliation(s)
- Hadia Srass
- Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine of University of Southern California, 1450 San Pablo St #6200, Los Angeles, CA 90033, USA
- College of Engineering, University of California, Riverside, 900 University Ave., Riverside, CA 92521, USA
| | - J. Karim Ead
- Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine of University of Southern California, 1450 San Pablo St #6200, Los Angeles, CA 90033, USA
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine of University of Southern California, 1450 San Pablo St #6200, Los Angeles, CA 90033, USA
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Hemler SL, Ntella SL, Jeanmonod K, Köchli C, Tiwari B, Civet Y, Perriard Y, Pataky Z. Intelligent plantar pressure offloading for the prevention of diabetic foot ulcers and amputations. Front Endocrinol (Lausanne) 2023; 14:1166513. [PMID: 37469988 PMCID: PMC10352841 DOI: 10.3389/fendo.2023.1166513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
The high prevalence of lower extremity ulceration and amputation in people with diabetes is strongly linked to difficulties in achieving and maintaining a reduction of high plantar pressures (PPs) which remains an important risk factor. The effectiveness of current offloading footwear is opposed in part by poor patient adherence to these interventions which have an impact on everyday living activities of patients. Moreover, the offloading devices currently available utilize primarily passive techniques, whereas PP distribution is a dynamically changing process with frequent shifts of high PP areas under different areas of the foot. Thus, there is a need for pressure offloading footwear capable of regularly and autonomously adapting to PPs of people with diabetes. The aim of this article is to summarize the concepts of intelligent pressure offloading footwear under development which will regulate PPs in people with diabetes to prevent and treat diabetic foot ulcers. Our team is creating this intelligent footwear with an auto-contouring insole which will continuously read PPs and adapt its shape in the forefoot and heel regions to redistribute high PP areas. The PP-redistribution process is to be performed consistently while the footwear is being worn. To improve adherence, the footwear is designed to resemble a conventional shoe worn by patients in everyday life. Preliminary pressure offloading and user perceptions assessments in people without and with diabetes, respectively, exhibit encouraging results for the future directions of the footwear. Overall, this intelligent footwear is designed to prevent and treat diabetic foot ulcers while enhancing patient usability for the ultimate prevention of lower limb amputations.
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Affiliation(s)
- Sarah L. Hemler
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Unit of Therapeutic Patient Education, WHO Collaborating Centre, Division of Endocrinology, Diabetology, Nutrition and Therapeutic Patient Education, Geneva University Hospitals, Geneva, Switzerland
| | - Sofia Lydia Ntella
- Integrated Actuators Laboratory (LAI), École polytechnique fédérale de Lausanne (EPFL), Neuchâtel, Switzerland
| | - Kenny Jeanmonod
- Integrated Actuators Laboratory (LAI), École polytechnique fédérale de Lausanne (EPFL), Neuchâtel, Switzerland
| | - Christian Köchli
- Integrated Actuators Laboratory (LAI), École polytechnique fédérale de Lausanne (EPFL), Neuchâtel, Switzerland
| | - Bhawnath Tiwari
- Integrated Actuators Laboratory (LAI), École polytechnique fédérale de Lausanne (EPFL), Neuchâtel, Switzerland
| | - Yoan Civet
- Integrated Actuators Laboratory (LAI), École polytechnique fédérale de Lausanne (EPFL), Neuchâtel, Switzerland
| | - Yves Perriard
- Integrated Actuators Laboratory (LAI), École polytechnique fédérale de Lausanne (EPFL), Neuchâtel, Switzerland
| | - Zoltan Pataky
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Unit of Therapeutic Patient Education, WHO Collaborating Centre, Division of Endocrinology, Diabetology, Nutrition and Therapeutic Patient Education, Geneva University Hospitals, Geneva, Switzerland
- Faculty Diabetes Centre, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Jeong BO, Jeong SJ, Park K, Kim BH, Yim SV, Kim S. Effects of three-dimensional image based insole for healthy volunteers: a pilot clinical trial. Transl Clin Pharmacol 2023; 31:49-58. [PMID: 37034127 PMCID: PMC10079510 DOI: 10.12793/tcp.2023.31.e5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
Insoles are used to treat various foot diseases, including plantar foot, diabetic foot ulcers, and refractory plantar fasciitis. In this study, we investigated the effects of 3-dimensional image-based (3-D) insole in healthy volunteers with no foot diseases. Additionally, the comfort of the 3-D insole was compared with that of a custom-molded insole. A single-center, randomized, open clinical trial was conducted to address the effectiveness of insole use in a healthy population with no foot or knee disease. Two types of arch support insoles were evaluated for their effectiveness: a 3-D insole and a custom-molded insole. Fifty Korean volunteers participated in the study and were randomly allocated into the "3-D insole" (n = 40) or "custom-molding insole" (n = 10) groups. All subjects wore 3-D insoles or custom-molded insoles for 2 weeks. The sense of wearing shoes (Visual Analog Scale [VAS] and score) and fatigue of the foot were used to assess the insole effects at the end of the 2-week study period. The 3-D insole groups showed significantly improved sense of wearing shoes (VAS, p = 0.0001; score, p = 0.0002) and foot fatigue (p = 0.0005) throughout the study period. Although the number of subjects was different, the custom-molding insole group showed no significant changes in the sense of wearing shoes (VAS, 0.1188; score, p = 0.1483). Foot fatigue in the 3-D insole group improved significantly (p = 0.0005), which shows that a 3-D insole might have favorable effects on foot health in a healthy population. Trial Registration Clinical Research Information Service Identifier: KCT0008100.
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Affiliation(s)
- Bi O Jeong
- Department of Orthopedic Surgery, Kyung Hee University Medical Center, Seoul 02447, Korea
| | - Su Jin Jeong
- Medical Science Research Institute, Kyung Hee University Medical Center, Seoul 02447, Korea
| | | | - Bo-Hyung Kim
- Department of Clinical Pharmacology and Therapeutics, Kyung Hee University Medical Center, Seoul 02447, Korea
- East-West Medical Research Institute, Kyung Hee University, Seoul 02447, Korea
| | - Sung-Vin Yim
- Department of Clinical Pharmacology and Therapeutics, Kyung Hee University Medical Center, Seoul 02447, Korea
| | - Sehyun Kim
- Graduate School of Dankook University, Yongin 16890, Korea
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7
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Jarl G, Rusaw DF, Terrill AJ, Barnett CT, Woodruff MA, Lazzarini PA. Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers. J Diabetes Sci Technol 2023; 17:99-106. [PMID: 35658555 PMCID: PMC9846383 DOI: 10.1177/19322968221101632] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Non-removable knee-high devices are the gold-standard offloading treatments to heal plantar diabetic foot ulcers (DFUs). These devices are underused in practice for a variety of reasons. Recommending these devices for all patients, regardless of their circumstances and preferences influencing their ability to tolerate the devices, does not seem a fruitful approach. PURPOSE The aim of this article is to explore the potential implications of a more personalized approach to offloading DFUs and suggest avenues for future research and development. METHODS Non-removable knee-high devices effectively heal plantar DFUs by reducing plantar pressure and shear at the DFU, reducing weight-bearing activity and enforcing high adherence. We propose that future offloading devices should be developed that aim to optimize these mechanisms according to each individual's needs. We suggest three different approaches may be developed to achieve such personalized offloading treatment. First, we suggest modular devices, where different mechanical features (rocker-bottom sole, knee-high cast walls/struts, etc.) can be added or removed from the device to accommodate different patients' needs and the evolving needs of the patient throughout the treatment period. Second, advanced manufacturing techniques and novel materials could be used to personalize the design of their devices, thereby improving common hindrances to their use, such as devices being heavy, bulky, and hot. Third, sensors could be used to provide real-time feedback to patients and clinicians on plantar pressures, shear, weight-bearing activity, and adherence. CONCLUSIONS By the use of these approaches, we could provide patients with personalized devices to optimize plantar tissue stress, thereby improving clinical outcomes.
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Affiliation(s)
- Gustav Jarl
- Department of Prosthetics and
Orthotics, Faculty of Medicine and Health, Örebro University, Örebro,
Sweden
- University Health Care Research
Center, Faculty of Medicine and Health, Örebro University, Örebro,
Sweden
- Gustav Jarl, PhD, University Health
Care Research Center, Örebro University Hospital, S-huset, vån 1,
Örebro, SE-701 85, Sweden.
| | - David F. Rusaw
- School of Health and Welfare,
Jönköping University, Jönköping, Sweden
| | - Alexander J. Terrill
- School of Mechanical, Medical and
Process Engineering, Queensland University of Technology, Brisbane, QLD,
Australia
- Centre for Biomedical
Technologies, Queensland University of Technology, Brisbane, QLD,
Australia
- Faculty of Health, Southern Cross
University, Gold Coast, QLD, Australia
| | | | - Maria A. Woodruff
- School of Mechanical, Medical and
Process Engineering, Queensland University of Technology, Brisbane, QLD,
Australia
- Centre for Biomedical
Technologies, Queensland University of Technology, Brisbane, QLD,
Australia
| | - Peter A. Lazzarini
- School of Public Health and
Social Work, Queensland University of Technology, Brisbane, Australia
- Allied Health Research
Collaborative, The Prince Charles Hospital, Brisbane, Australia
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Khandakar A, Mahmud S, Chowdhury MEH, Reaz MBI, Kiranyaz S, Mahbub ZB, Md Ali SH, Bakar AAA, Ayari MA, Alhatou M, Abdul-Moniem M, Faisal MAA. Design and Implementation of a Smart Insole System to Measure Plantar Pressure and Temperature. SENSORS (BASEL, SWITZERLAND) 2022; 22:7599. [PMID: 36236697 PMCID: PMC9572216 DOI: 10.3390/s22197599] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/01/2022] [Accepted: 10/02/2022] [Indexed: 06/16/2023]
Abstract
An intelligent insole system may monitor the individual's foot pressure and temperature in real-time from the comfort of their home, which can help capture foot problems in their earliest stages. Constant monitoring for foot complications is essential to avoid potentially devastating outcomes from common diseases such as diabetes mellitus. Inspired by those goals, the authors of this work propose a full design for a wearable insole that can detect both plantar pressure and temperature using off-the-shelf sensors. The design provides details of specific temperature and pressure sensors, circuit configuration for characterizing the sensors, and design considerations for creating a small system with suitable electronics. The procedure also details how, using a low-power communication protocol, data about the individuals' foot pressure and temperatures may be sent wirelessly to a centralized device for storage. This research may aid in the creation of an affordable, practical, and portable foot monitoring system for patients. The solution can be used for continuous, at-home monitoring of foot problems through pressure patterns and temperature differences between the two feet. The generated maps can be used for early detection of diabetic foot complication with the help of artificial intelligence.
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Affiliation(s)
- Amith Khandakar
- Department of Electrical Engineering, Qatar University, Doha 2713, Qatar
- Department of Electrical, Electronics and Systems Engineering, Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Sakib Mahmud
- Department of Electrical Engineering, Qatar University, Doha 2713, Qatar
| | | | - Mamun Bin Ibne Reaz
- Department of Electrical, Electronics and Systems Engineering, Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Serkan Kiranyaz
- Department of Electrical Engineering, Qatar University, Doha 2713, Qatar
| | - Zaid Bin Mahbub
- Department of Physics and Mathematics, North South University, Dhaka 1229, Bangladesh
| | - Sawal Hamid Md Ali
- Department of Electrical, Electronics and Systems Engineering, Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Ahmad Ashrif A. Bakar
- Department of Electrical, Electronics and Systems Engineering, Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Mohamed Arselene Ayari
- Department of Civil and Architectural Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
- Technology Innovation and Engineering Education, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Mohammed Alhatou
- Neuromuscular Division, Hamad General Hospital and Department of Neurology; Al Khor Hospital, Doha 3050, Qatar
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