Smartphone App to Self-Monitor Nausea During Pediatric Chemotherapy Treatment: User-Centered Design Process

Fact-finding and risk factor analysis of chemotherapy-induced nausea and vomiting in children with solid tumors: a prospective observational study

OBJECTIVE

The aim of the study was to describe the control of acute chemotherapy-induced nausea and vomiting (CINV) in children with solid tumors receiving highly emetogenic chemotherapy (HEC) at our center. Additionally, the study aimed to explore the risk factors for chemotherapy-induced vomiting (CIV) with the ultimate goal of enhancing CINV management for children.

METHODS

Children aged 1-18 years with solid tumors treated with HEC were enrolled. A structured diary was used to record CINV data, and the pediatric nausea assessment tool (PeNAT) was employed to assess the degree of nausea. The primary outcome was achieving complete CIV control in the acute phase for all children, and secondary outcomes included the control of acute phase CINV, CIV, and chemotherapy-induced nausea (CIN) in children aged ≥ 4 years. Data on children were prospectively collected, and univariate and multivariate logistic regression was used to explore risk factors for complete CIV control.

RESULTS

A total of 181 children were included, with 52.5% (95/181) experiencing acute phase complete CIV control. Eighty-six children aged ≥ 4 years could be evaluated for acute phase CINV control, and complete CINV control was achieved in 27.9% (24/86), with CIV, CIN complete control rates were 41.9% (36/86) and 34.9% (30/86), respectively. The results of multivariate logistic regression showed age (< 2 years vs. >6 years: OR = 0.186, 95% CI 0.062 ~ 0.56; 2 ~ 6 years vs. >6 years: OR = 0.322, 95% CI 0.145 ~ 0.715), female (OR = 2.034, 95% CI 1.035 ~ 3.994), duration of chemotherapy block (OR = 1.611, 95%CI 1.039 ~ 2.499), and antiemetic regimen (5-hydroxytryptamine-3 receptor antagonists (5HT3RA) vs. 5HT3RA + dexamethasone: OR = 0.395, 95% CI 0.171 ~ 0.914) were statistically significant in complete CIV control (P < 0.05).

CONCLUSIONS

Children with solid tumors treated with HEC at our center experienced suboptimal control of CINV. Older age, female, and a longer duration of the chemotherapy block were identified as risk factors for complete CIV control. Receipt of 5HT3RA plus dexamethasone had a higher likelihood of acute phase complete CIV control versus 5HT3RA. In the future, individualized management of nausea and vomiting, based on existing CINV guidelines and the unique characteristics of children, will be necessary to reduce the incidence of CINV and improve the quality of life for these children.

User Experience and Extended Technology Acceptance Model in Commercial Health Care App Usage Among Patients With Cancer: Mixed Methods Study

BACKGROUND

The shift in medical care toward prediction and prevention has led to the emergence of digital health care as a valuable tool for managing health issues. Aiding long-term follow-up care for cancer survivors and contributing to improved survival rates. However, potential barriers to mobile health usage, including age-related disparities and challenges in user retention for commercial health apps, highlight the need to assess the impact of patients' abilities and health status on the adoption of these interventions.

OBJECTIVE

This study aims to investigate the app adherence and user experience of commercial health care apps among cancer survivors using an extended technology acceptance model (TAM).

METHODS

The study enrolled 264 cancer survivors. We collected survey results from May to August 2022 and app usage records from the app companies. The survey questions were created based on the TAM.

RESULTS

We categorized 264 participants into 3 clusters based on their app usage behavior: short use (n=77), medium use (n=101), and long use (n=86). The mean usage days were 9 (SD 11) days, 58 (SD 20) days, and 84 (SD 176) days, respectively. Analysis revealed significant differences in perceived usefulness (P=.01), interface satisfaction (P<.01), equity (P<.01), and utility (P=.01) among the clusters. Structural equation modeling indicated that perceived ease-of-use significantly influenced perceived usefulness (β=0.387, P<.01), and both perceived usefulness and attitude significantly affected behavioral intention and actual usage.

CONCLUSIONS

This study showed the importance of positive user experience and clinician recommendations in facilitating the effective usage of digital health care tools among cancer survivors and contributing to the evolving landscape of medical care.

Utilizing Digital Tools for Self-Report Symptom Assessment and Management in Pediatric Oncology: A Systematic Review

CONTEXT

The evaluation of digital tools for measuring self-reported symptoms in children and adolescents undergoing cancer treatment is a critical area of research with significant implications for clinical practice and patient outcomes.

OBJECTIVE

This study aims to identify, evaluate, and summarize evidence on digital tools that enable self-reported symptom assessment and management for pediatric oncology patients.

METHODS

Seven academic databases, including PubMed, Cochrane Library, Scopus, Web of Science, CINAHL, and Medline (OVID), were searched systematically from inception until February 28, 2024. Inclusion criteria were the following: (a) study subjects were pediatric oncology patients and young adults, (b) using digital tools, (c) self-report symptom assessment and management, (d) employed either qualitative or quantitative study design, (e) written in English (f) published in peer-reviewed journals. This is a systematic review, and its protocol was registered in PROSPERO (ID: CRD42024528285). The study was conducted following the PRISMA statement.

RESULTS

Twenty-seven studies were included in this systematic review. All included studies were conducted to develop digital tools for assessing and managing the symptoms. Eight of these studies focused only on the pain; three were only for nausea and vomiting, one for nausea, and the other 15 for all symptoms. The studies' quality ranged from low to high, with overall scores ranging between 4 and 24 out of 28.

CONCLUSION

It shows that studies have generally focused on developing digital tools to address pain, nausea, vomiting, and other symptoms commonly experienced by pediatric oncology patients. While the quality of the included studies ranged from low to high, the overall findings show promise for the effectiveness and usability of these digital tools for symptom assessment and management in pediatric oncology care.

The Digital Platform and Its Emerging Role in Decentralized Clinical Trials

Decentralized clinical trials (DCTs) are becoming increasingly popular. Digital clinical trial platforms are software environments where users complete designated clinical trial tasks, providing investigators and trial participants with efficient tools to support trial activities and streamline trial processes. In particular, digital platforms with a modular architecture lend themselves to DCTs, where individual trial activities can correspond to specific platform modules. While design features can allow users to customize their platform experience, the real strengths of digital platforms for DCTs are enabling centralized data capture and remote monitoring of trial participants and in using digital technologies to streamline workflows and improve trial management. When selecting a platform for use in a DCT, sponsors and investigators must consider the specific trial requirements. All digital platforms are limited in their functionality and technical capabilities. Integrating additional functional modules into a central platform may solve these challenges, but few commercial platforms are open to integrating third-party components. The lack of common data standardization protocols for clinical trials will likely limit the development of one-size-fits-all digital platforms for DCTs. This viewpoint summarizes the current role of digital platforms in supporting decentralized trial activities, including a discussion of the potential benefits and challenges of digital platforms for investigators and participants. We will highlight the role of the digital platform in the development of DCTs and emphasize where existing technology is functionally limiting. Finally, we will discuss the concept of the ideal fully integrated and unified DCT and the obstacles developers must address before it can be realized.

Experiences with Wearable Sensors in Oncology during Treatment: Lessons Learned from Feasibility Research Projects in Denmark

BACKGROUND

The fraction of elderly people in the population is growing, the incidence of some cancers is increasing, and the number of available cancer treatments is evolving, causing a challenge to healthcare systems. New healthcare tools are needed, and wearable sensors could partly be potential solutions. The aim of this case report is to describe the Danish research experience with wearable sensors in oncology reporting from three oncological wearable research projects.

CASE STUDIES

Three planned case studies investigating the feasibility of different wearable sensor solutions during cancer treatment are presented, focusing on study design, population, device, aim, and planned outcomes. Further, two actual case studies performed are reported, focusing on patients included, data collected, results achieved, further activities planned, and strengths and limitations.

RESULTS

Only two of the three planned studies were performed. In general, patients found the technical issues of wearable sensors too challenging to deal with during cancer treatment. However, at the same time it was demonstrated that a large amount of data could be collected if the framework worked efficiently.

CONCLUSION

Wearable sensors have the potential to help solve challenges in clinical oncology, but for successful research projects and implementation, a setup with minimal effort on the part of patients is requested.

Translation and Psychometric Evaluation of the Hindi Language Version of the Pediatric Nausea Assessment Tool (PeNAT) in the Indian Population

OBJECTIVES

To translate the Pediatric Nausea Assessment Tool (PeNAT) into Hindi and validate it in Indian pediatric cancer patients and survivors.

METHODS

The PeNAT-Hindi was finalized by forward and backward translations, and pilot testing. The PeNAT-Hindi was administered to 200 Hindi-speaking pediatric (4-18 y) cancer patients/survivors, in three groups. These included pediatric cancer patients who had recently received chemotherapy (n = 150); who received no chemotherapy within 5 d (n = 25) and survivors (n = 25). Construct validity was tested by comparing scores among the three groups. Test-retest reliability and criterion validity were estimated by the correlation of the first PeNAT score with the second (taken 1 h later) PeNAT score and the number of vomiting/retching episodes, respectively. Convergent validity and discriminant validity were estimated by correlating PeNAT scores with parent-assessed nausea severity, and pain, respectively. The responsiveness was tested by comparing second PeNAT scores with subsequent divergent PeNAT scores among patients reporting subjective change (improvement and worsening, respectively) in nausea severity.

RESULTS

Test-retest reliability of PeNAT-Hindi was good (intraclass correlation = 0.791). The initial PeNAT score had moderate correlation with the number of vomiting/retching episodes (Spearman ρ = 0.401). Median PeNAT scores in group 1 versus groups 2 and 3 were significantly different (p < 0.001). Initial PeNAT scores showed a moderate correlation with parent-assessed nausea (Spearman ρ = 0.657) and a weak correlation with parent-assessed pain (Spearman ρ = 0.319). The responsiveness (standardized response mean) of PeNAT-Hindi to the change in nausea severity was -1.79 (improvement) and 2.19 (worsening), respectively.

CONCLUSION

PeNAT-Hindi showed good reliability and acceptable validity. It may be used among Hindi-speaking children for measuring nausea. The responsiveness of PeNAT-Hindi needs further evaluation.

Supporting data driven translational patient-centered care using network analysis to visualize symptom distress in children with serious illness

PURPOSE

There are an increasing number of techniques and tools to improve the capacity for children to relay their perceptions of their symptom experience while undergoing blood and marrow transplant (BMT). Network analysis (NA) is a tool that can illustrate associations between symptoms and the distress they cause. We aimed to develop a biopsychosocial assessment clinical analytic tool to examine symptom relationships for children undergoing BMT to find actionable relationships for intervention to improve clinical outcomes including mood.

DESIGN AND METHODS

This pilot study used an analytical mobile application tool to support a wide scope of 15 biopsychosocial symptom distress levels and five mood assessments. Children recorded their symptom distress and mood using the app. NA was used to explore relationships between symptom distress and mood.

RESULTS

Four children, 11-14 years old, undergoing BMT used the app daily during hospitalization. We found a strong presence of emotional distress and its associations symptom distress and mood. Multiple symptom associations were identified including associations between the set of symptoms difficulty breathing and fever (0.557), sad and worried (0.429). Of note, pain distress had a strong capacity to bridge other symptoms and was connected directly to many symptoms.

PRACTICE IMPLICATIONS

We found the significance of patient struggles with emotional and symptom distress and the importance of this relationship to other clinical outcomes. This provides valuable insights and an improved understanding of the child's symptoms. Our findings support early assessment, intervention, and improved symptom communication to enhance sense of well-being and the child's care experience.

Risk factors associated with nausea and vomiting in children with cancer receiving chemotherapy

INTRODUCTION

Despite treatment with antiemetic medications, nausea remains uncontrolled for many children receiving chemotherapy. One reason is that risk factors for nausea in children remain poorly explored. The purpose of this study was to identify risk factors for chemotherapy-induced nausea (CIN) in children.

METHODS

Prospective, observational study including 101 children (median age 6.4 years, range 0.8-17.9) with cancer receiving moderately or highly emetogenic chemotherapy. Primary endpoints were complete control of acute and delayed CIN, defined as no nausea in the acute phase 0-24 h after chemotherapy and in the delayed phase starting after the acute phase and ending 5 days later. Multivariable analyses included age, sex, cancer type, susceptibility to motion sickness, chemotherapy duration, numbers of antiemetics, co-administration with opioids or tricyclic antidepressants, and previously uncontrolled nausea or vomiting.

RESULTS

Acute CIN was associated with susceptibility to motion sickness (odds ratio [OR] 5.73, 95% confidence interval [CI] 1.36-33.7) and older age (OR 4.19, 95% CI 1.30-14.7), comparing age group 8-18 years with 0-3 years. Delayed CIN was associated with uncontrolled acute nausea or vomiting (OR 10.3, 95% CI 2.65-50.9), highly emetogenic chemotherapy (OR 8.26, 95% CI 1.17-76.8), and having a hematologic cancer type (OR 7.81, 95% CI 1.05-79.2).

CONCLUSIONS

Susceptibility to motion sickness and age can influence the risk of acute CIN. More research is needed on how best to integrate risk information in preventive antiemetic strategies. Sufficient acute nausea and vomiting control are crucial to prevent delayed CIN.

Finnish emergency medical services managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues: a qualitative study

OBJECTIVES

This study aimed to describe emergency medical services (EMS) managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues in the EMS.

DESIGN

The study used a descriptive qualitative approach. Five focus groups and two individuals were interviewed using a semi-structured guide with open-ended questions. The data were analysed using reflexive thematic analysis. Consolidated criteria for Reporting Qualitative research was used to guide the reporting of this study.

SETTING

EMS organisations from Finland's five healthcare districts.

PARTICIPANTS

EMS medical directors (n=5) and EMS managers (n=14). Purposive sampling was used.

RESULTS

Two main themes, 'Patient safety considered an organisational responsibility' and 'EMS patients' opportunities and obstacles to speaking up', were generated from the data. Under the main theme, 'Patient safety considered an organisational responsibility', were three subthemes: patient safety considered part of the quality in EMS, system-level models for handling and observing patient safety in EMS, and management's ability to find a balance when using patients' feedback for patient safety development. Under the other main theme were four subthemes: 'social and feedback skills of EMS personnel and management', 'managements' assumptions of patients' reasons for not speaking up', 'EMS organisations' different but unsystematic ways of collecting feedback' and 'management's openness to develop patient participation'.

CONCLUSIONS

The nature of the EMS organisations and EMS assignments could affect a patient's participation in developing patient safety in EMS. However, EMS managers and medical directors are receptive to collaborating with patients concerning patient safety issues if they have sufficient resources and a coherent way to collect patient safety concerns. The management is open to collaborating with patients, but there is a need to develop a systematic method with enough resources to facilitate the management's collaborating with patients.

Advancing Digital Health Innovation in Oncology: Priorities for High-Value Digital Transformation in Cancer Care

Although health care delivery is becoming increasingly digitized, driven by the pursuit of improved access, equity, efficiency, and effectiveness, progress does not appear to be equally distributed across therapeutic areas. Oncology is renowned for leading innovation in research and in care; digital pathology, digital radiology, real-world data, next-generation sequencing, patient-reported outcomes, and precision approaches driven by complex data and biomarkers are hallmarks of the field. However, remote patient monitoring, decentralized approaches to care and research, "hospital at home," and machine learning techniques have yet to be broadly deployed to improve cancer care. In response, the Digital Medicine Society and Moffitt Cancer Center convened a multistakeholder roundtable discussion to bring together leading experts in cancer care and digital innovation. This viewpoint highlights the findings from these discussions, in which experts agreed that digital innovation is lagging in oncology relative to other therapeutic areas. It reports that this lag is most likely attributed to poor articulation of the challenges in cancer care and research best suited to digital solutions, lack of incentives and support, and missing standardized infrastructure to implement digital innovations. It concludes with suggestions for actions needed to bring the promise of digitization to cancer care to improve lives.

Challenges in the Adoption of eHealth and mHealth for Adult Mental Health Management—Evidence from Romania

New methods of connecting physicians and patients have arisen. Technology is playing a crucial role and the concept of hybrid doctor–patient relationship is considered relevant for the competitive health management system. At the same time, the need for knowledge about implementing policies and best practices into the system is highly demanding. Digital tools, such as eHealth or mHealth can improve the traditional approach to consulting patients without requiring face-to-face interaction. However, due to the discussion surrounding the adoption of these technologies, the authors performed the study with two marketing research methods. The first is qualitative and is related to the opinions, attitudes, and beliefs of Romanian experts on the use of eHealth and mHealth for the prevention, detection, and treatment of mild mental disorders. The second method quantifies the opinions, attitudes, and behaviours of Romanian adults on their openness to adopt new technologies for mental health management. The main findings of the research highlight three factors that can increase the chances of adults using technology for health-related needs: (1) accessibility (2) data security, and (3) content. These are the main aspects that influence the well-being of both young and older adults, who both need support regarding mental health management.

A scoping review of nausea, vomiting and retching measurement methods in children with cancer

Evaluation of chemotherapy-induced nausea and vomiting (CINV) in the pediatric population is subject to diverse approaches. This scoping review summarizes the methods used in clinical studies that assessed nausea, vomiting or retching in children with cancer. We conducted a literature search of studies indexed in EMBASE and Ovid MEDLINE after 2000. Studies were included if they involved patients ≤18 years of age diagnosed with cancer, and had nausea, vomiting or retching as a primary study outcome. We excluded studies that reported only parent- or clinician-proxy measures without including the child's self-reported NVR, and those without specifying the NVR data collection process. The literature search identified twenty-four studies evaluating pediatric nausea, vomiting or retching. In the assessment of NVR, structured surveys were the most commonly used instrument for NVR assessment (75%) and the use of patient diaries (50%). Nine studies (38%) relied solely on self-reports from children as the outcome measure, while fifteen studies (62%) solicited input from parents/ caregivers and healthcare providers in addition to children's self-reports. Almost all the studies reported the frequency (n = 24) and/or severity (n = 23) of NVR symptoms and the use of antiemetic therapy (n = 19). Fewer studies evaluated distress caused by the symptoms (n = 2) and the effects of symptoms on activities of daily living (n = 4). Incorporating NVR measurement tools as part of standard of care for pediatric patients undergoing chemotherapy is strongly advocated. Based on the age group, we recommend the use of such tools comprising Likert scale, pictorial scales and structured scripts to assess various dimensions of a child's NVR experience.

Background sensitivity to chemotherapy-induced nausea and vomiting and response to antiemetics in paediatric patients: a genetic association study

Chemotherapy-induced nausea and vomiting (CINV) remains a common adverse effect for children with cancer. In children, chemotherapy emetogenicity and patient factors such as susceptibility to motion sickness and age group determine a patient's risk of CINV. Besides known risk factors, genetic factors may play a role in interindividual variation in the occurrence of CINV. We investigated the influence of candidate gene polymorphisms on the efficacy of antiemetics and on the background sensitivity to CINV in children. This prospective study included 100 children with cancer (median age 6.4 years, range 0.8-17.9) who received moderately to highly emetogenic chemotherapy. Participants registered nausea and vomiting episodes in a mobile app. Genotypes were determined by whole-genome sequencing (n = 79) or Sanger sequencing (n = 21) for 71 genetic polymorphisms involved in motion sickness and antiemetic pathways. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to estimate associations between acute CINV and genotypes adjusting for susceptibility to motion sickness and age group. Rs3782025 in the 5-hydroxytryptamine type 3 (5-HT3) receptor gene (HTR3B) [minor allele frequency (MAF): 0.48] affected response to 5-HT3 receptor antagonists; acute CINV occurred in 76% of patients with GA/AA genotypes and in 41% of patients with GG genotype (OR 5.59; 95% CI 1.74-17.9, dominant genetic model). Rs2975226 in the dopamine transporter gene (SLC6A3) (MAF: 0.54) was associated with acute CINV (OR 5.79; 95% CI 1.09-30.67, recessive genetic model). Polymorphisms in HTR3B and SLC6A3 may contribute to the variability in response to antiemetic prophylaxis for CINV in children.

Seriously ill pediatric patient, parent, and clinician perspectives on visualizing symptom data

OBJECTIVE

This study examined the perspectives on the use of data visualizations and identified key features seriously ill children, their parents, and clinicians prefer to see when visualizing symptom data obtained from mobile health technologies (an Apple Watch and smartphone symptom app).

MATERIALS AND METHODS

Children with serious illness and their parents were enrolled into a symptom monitoring study then a subset was interviewed for this study. A study team member created symptom data visualizations using the pediatric participant's mobile technology data. Semi-structured interviews were conducted with a convenience sample of participants (n = 14 children; n = 14 parents). In addition, a convenience sample of clinicians (n = 30) completed surveys. Pediatric and parent participants shared their preferences and perspectives on the symptom visualizations.

RESULTS

We identified 3 themes from the pediatric and parent participant interviews: increased symptom awareness, communication, and interpretability of the symptom visualizations. Clinicians preferred pie charts and simple bar charts for their ease of interpretation and ability to be used as communication tools. Most clinicians would prefer to see symptom visualizations in the electronic health record.

DISCUSSION

Mobile health tools offer a unique opportunity to obtain patient-generated health data. Effective, concise symptom visualizations can be used to synthesize key clinical information to inform clinical decisions and promote patient-clinician communication to enhance symptom management.

CONCLUSIONS

Effectively visualizing complex mobile health data can enhance understanding of symptom dynamics and promote patient-clinician communication, leading to tailored personalized symptom management strategies.

Using Biometric Sensor Data to Monitor Cancer Patients During Radiotherapy: Protocol for the OncoWatch Feasibility Study

Background

Patients with head and neck cancer (HNC) experience severe side effects during radiotherapy (RT). Ongoing technological advances in wearable biometric sensors allow for the collection of objective data (eg, physical activity and heart rate), which might, in the future, help detect and counter side effects before they become severe. A smartwatch such as the Apple Watch allows for objective data monitoring outside the hospital with minimal effort from the patient. To determine whether such tools can be implemented in the oncological setting, feasibility studies are needed.

Objective

This protocol describes the design of the OncoWatch 1.0 feasibility study that assesses the adherence of patients with HNC to an Apple Watch during RT.

Methods

A prospective, single-cohort trial will be conducted at the Department of Oncology, Rigshospitalet (Copenhagen, Denmark). Patients aged ≥18 years intended for primary or postoperative curatively intended RT for HNC will be recruited. Consenting patients will be asked to wear an Apple Watch on the wrist during and until 2 weeks after RT. The study will include 10 patients. Data on adherence, data acquisition, and biometric data will be collected. Demographic data, objective toxicity scores, and hospitalizations will be documented.

Results

The primary outcome is to determine if it is feasible for the patients to wear a smartwatch continuously (minimum 12 hours/day) during RT. Furthermore, we will explore how the heart rate and physical activity change over the treatment course.

Conclusions

The study will assess the feasibility of using the Apple Watch for home monitoring of patients with HNC. Our findings may provide novel insights into the patient’s activity levels and variations in heart rate during the treatment course. The knowledge obtained from this study will be essential for further investigating how biometric data can be used as part of symptom monitoring for patients with HNC.

Trial Registration

ClinicalTrials.gov NCT04613232; https://clinicaltrials.gov/ct2/show/NCT04613232

International Registered Report Identifier (IRRID)

PRR1-10.2196/26096

MyPal-Child study protocol: an observational prospective clinical feasibility study of the MyPal ePRO-based early palliative care digital system in paediatric oncology patients

INTRODUCTION

Electronic patient-reported outcomes (ePROs) have tremendous potential to optimise palliative and supportive care for children with cancer, their families and healthcare providers. Particularly, these children and their families are subjected to multiple strains caused by the disease and its treatment. The MyPal digital health platform is designed to address these complex demands by offering pursuant ePRO-based functionalities via two mobile applications, one developed for children and the other for their parents.

METHODS AND ANALYSIS

In this observational prospective feasibility study, 100 paediatric oncology patients aged between 6 and 17 years and at least one of their parents/legal guardians will be recruited at three clinical sites in two European countries (Germany and Czech Republic). They will use the mobile applications which are part of the novel digital health platform. During a 6-month study period, participants will complete various ePROs via the applications addressing quality of life, satisfaction with care and impact of the disease on the family at monthly intervals. Additionally, priority-based symptom reporting is integrated into a serious game for children. Outcomes that will be assessed concern the feasibility and the evaluation of the newly designed digital health platform to contribute to the evidence base of clinical ePRO use in paediatric oncology and palliative care process.

ETHICS AND DISSEMINATION

The MyPal-Child study obtained ethical approval from the Ethics Committee responsible for the University of Saarland, that is, the Ärztekammer des Saarlandes, the Ethics Committee of the Medical School Hannover and the Ethics Committee of the University of Brno. Study results will be disseminated through scientific publications, presentations at international conferences, congresses and a final report to the European Commission. General publicly accessible information can be found on the project website (www.mypal-project.eu) and social media.

TRIAL REGISTRATION NUMBERS

U1111-1251-0043, DRKS00021458, NCT04381221.