Introduction
At the moment in Japan, medical insurance coverage covers using self-monitoring blood glucose (SMBG) just for sufferers on insulin and Glucagon like peptide-1 receptor agonists and pregnant girls with irregular glucose metabolism.1 Even with the widespread use of latest self-monitoring gadgets, comparable to intermittently scanned steady glucose monitoring (isCGM), there are nonetheless many SMBG customers. The American Diabetes Affiliation (ADA) pointers acknowledge even for sufferers utilizing much less frequent insulin injections, SMBG might assist information remedy choices as a part of a broad academic program.2 And it has benefits in not solely checking hypoglycemia and hyperglycemia but additionally assessing bodily exercise and food regimen, motivating self-management, and constructing a detailed relationship with the attending doctor.3 However, the aged, visually impaired, and hypersensitive sufferers might have issue performing SMBG resulting from ache on the time of puncture and the complexity of the measurement operation, and several other assistive gadgets are generally used as equipment in Japan (Figure 1A–C). Nonetheless, there are instances the place SMBG can’t be carried out with present SMBG assistive gadgets, so ample self-care has not but been achieved.
As medical care turns into extra refined and sophisticated, the success or failure of remedy for power ailments, comparable to diabetes, largely will depend on the affected person’s self-care, and sufferers and their households are vital members of the medical group. It’s due to this fact vital to foster affected person and household engagement, whereby the affected person and their relations take part in numerous facets of medical care, performing medical care along with the affected person’s medical doctors.4 As well as, the ADA and European Affiliation for the Research of Diabetes (EASD) revealed a fundamental coverage in regards to the remedy of kind 2 diabetes (T2D) in 2012. It advocates a patient-centered method, which
respects the preferences, wants, and values of the person affected person, offers care that’s conscious of these preferences and wishes, and ensures that affected person values information all medical choices.5,6
As well as, the significance of personalised care that takes into consideration the traits and comorbidities of every affected person are vital within the area of diabetes has been lately reported, as using personalised drugs in sufferers with T2D ought to enhance remedy adherence, affected person satisfaction, and high quality of life, scale back diabetes misery, and enhance bodily well being.7
On this research, we report our views on the significance of affected person and household engagement, the wants for SMBG the necessity for SMBG and its assistive gadgets engagement in diabetes care, utilizing a narrative as a useful resource.
Case Presentation
The affected person was a 47-year-old lady with a chief criticism of imaginative and prescient loss. Concerning her household historical past, her mom had T2D. The affected person was a homemaker. When she had been pregnant together with her first son at 25 years outdated and her second son at 27 years outdated, excessive blood glucose ranges had been famous, however diabetes had not been recognized, and she or he by no means underwent a bodily examination or hospital go to. At 47 years outdated, she turned conscious of decreased visible acuity in her left eye in Might X. In June X, she turned conscious of decreased visible acuity in her proper eye, and in July X, her decreased visible acuity worsened, so her husband beneficial that she go to the Division of Ophthalmology of Tokai College Faculty of Drugs.
On visiting the ophthalmology division, she was recognized with bilateral proliferative diabetic retinopathy and tractional retinal detachment, and she or he was referred to a diabetologist on the similar college on the identical day. She had by no means been weighed each day, so her weight fluctuations have been unknown, and she or he had by no means been on a food regimen. She was not conscious of any signs, comparable to thirst, polydipsia, or polyuria.
On the time of session, her peak was 153 cm, her weight was 66 kg, her physique mass index (BMI) was 28 kg/m2. Her arterial blood strain was 190/103mmHg, pulse price was 83 bpm (common), respiration price was 16/min, physique temperature was 36.0 °C, and consciousness was lucid. A decreased Achilles tendon reflex was noticed.
Laboratory checks at session confirmed a fasting blood glucose degree of 242 mg/dl and HbA1c of 10.3%, indicating poor blood glucose management. Urinary ketone our bodies have been optimistic, however there was no metabolic acidosis, and anti-GAD (glutamic acid decarboxylase) antibodies have been unfavorable. Consequently, the affected person was recognized with hypertension, and diabetic ketosis resulting from T2D.
To handle her diabetic ketosis, SMBG steering and insulin remedy have been began. For her hypertension, salt restriction to six g/day and the antihypertensive drug olmesartan medoxomil have been began. Concerning the attention illness, it was determined that she would bear surgical procedure as soon as her blood glucose ranges stabilized. Because of the affected person’s sturdy request that she couldn’t be hospitalized due to the necessity to care for her cat and the appreciable psychological and bodily burden she would maintain, we determined to deal with her as an outpatient as a substitute of hospitalizing her.
Because it was tough to be taught the SMBG approach resulting from poor imaginative and prescient, we ready ready-made SMBG assistive gadgets fabricated from rubber bands and plastic (Figure 1A–C). Sadly, the ready-made SMBG assistive gadgets have been sophisticated to function and SMBG couldn’t be carried out, making it tough to proceed insulin remedy within the outpatient hospital. We made the advice once more that she be hospitalized, however she nonetheless refused. For diabetic ketosis, SMBG instruction and insulin remedy have been began, however the affected person had issue studying the SMBG with common approach instruction resulting from poor imaginative and prescient and different components, and SMBG couldn’t be carried out nicely, and her blood glucose degree remained unstable. The dearth of outcomes elevated the nervousness and frustration of the affected person and her household daily. Nonetheless, the medical workers tried to create an environment the place the affected person and household might take part within the remedy as a lot as potential whereas giving precedence to the affected person’s requests. The workers continued to deal with the sufferers at outpatient visits each one to 2 weeks, however on the outpatient clinic on week X+4, many readings of blood glucose ranges have been famous within the SMBG notes. This turned out to not be a false studying however as a substitute the results of the affected person’s husband, who labored in manufacturing, making a easier SMBG assist that the affected person might function alone. Thereafter, at any time when the affected person’s husband visited the outpatient hospital with the affected person, the husband introduced the SMBG assistive system with him. Every day, the SMBG assistive gadgets turned extra hygienic, safer, and extra adaptable to varied finger sizes. The primary SMBG assistive system was fabricated from wooden by the producer, the affected person’s husband (Figure 2A). The second SMBG assistive system was fabricated from ABS (acrylonitrile-butadiene-styrene) resin with an antibacterial impact by the affected person’s husband (Figure 2B). The third SMBG assistive system was fabricated from ABS resin with an antibacterial impact for security by the affected person’s husband (Figure 2C). After the third SMBG assistive system, it’s system fabricated from ABS resin with an antibacterial impact continued to enhance, and numerous sorts and sizes of SMBG assistive gadgets have been made (Figure 2D).
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Determine 2 SMBG assistive system created by the affected person’s husband. (A) The primary SMBG assistive system was fabricated from wooden by the producer, the affected person’s husband. (B) The second SMBG assistive system was fabricated from ABS resin with an antibacterial impact by the affected person’s husband. (C) The third SMBG assistive system was additionally fabricated from ABS resin with an antibacterial impact by the affected person’s husband. (D) After (C), the SMBG assistive system fabricated from ABS (acrylonitrile-butadiene-styrene resin) resin with an antibacterial impact continued to enhance, and numerous sorts and sizes of SMBG assistive gadgets have been made. |
On account of having the ability to measure blood glucose ranges easily with the SMBG assistive system, the affected person herself turned extra optimistic concerning the remedy and paid extra consideration to her every day life, together with food regimen, and her blood glucose ranges stabilized. Laser remedy and vitrectomy have been carried out for bilateral proliferative diabetic retinopathy and tractional retinal detachment, and 10 months after the go to, the visible acuity of the proper eye recovered from 0.04 to 0.06 and that of the left eye from 0.01 to 0.4. As well as, the SMBG assistive gadgets created by her husband introduced her, her household, and medical professionals nearer collectively, permitting affected person to keep away from being subjected to extreme bodily and bodily stress. The affected person, household, and medical professionals at the moment are in a position to follow drugs in an excellent relationship. With strict dietary management and elevated every day organic exercise in consideration to her eyes, insulin was not elevated past insulin aspart (2-2-2 models), insulin degludec (4-0-0 models), and good glycemic management may very well be continued.
After one 12 months, the necessity for insulin was eradicated and insulin was discontinued. We beneficial that the affected person discontinue SMBG, as her insurance coverage wouldn’t proceed to cowl the monitoring due her cessation of insulin. Nonetheless, because the affected person and her husband desired to take action, she continued to carry out SMBG at her personal expense. Since withdrawing from insulin, she has maintained her HbA1c degree within the 6% vary for a number of years with no oral remedy, solely food regimen and train remedy. She has stated that she was in a position to proceed self-management of her diabetes by checking her blood glucose ranges through SMBG, which she measures sometimes. Her husband and the medical workers continued to develop SMBG assistive gadgets for sufferers who have been having bother performing SMBG on their very own. Consequently, a medical system firm producing SMBG help gadgets requested for our assist in growing a brand new SMBG help system, and after testing greater than 200 prototypes (Figure 3), a brand new kind of SMBG assistive system is now obtainable for sufferers who want to have it as an adjunct to SMBG (Figure 4).
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Determine 3 A part of the prototype created by the affected person’s husband. These are a number of the greater than 200 prototypes created by the affected person’s husband in response to a request from a medical system firm that was within the course of of manufacturing an SMBG assistive system. |
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Determine 4 SMBG assistive system provided as an adjunct. That is the SMBG assistive system that, after plenty of prototypes, is at the moment being supplied to sufferers who want to have it as an adjunct to SMBG (Roche DC Japan Okay.Okay., Minatoku, Tokyo, Japan). |
Issues with SMBG
Some experiences have described totally different views in regards to the want for SMBG, and help for SMBG is combined.8 Randomized trials of SMBG in non-insulin-treated T2D say that it doesn’t have an effect on glycemic management, that the results of SMBG usually are not long-lasting, and that the cost-effectiveness of decreasing diabetes-related issues could also be low.9–11 It has additionally been reported that the Society of Basic Inner Drugs (SGIM) doesn’t advocate SMBG in such sufferers.12
Moreover, some experiences recommend that clinicians’ attitudes towards SMBG play an vital function within the frequency of monitoring and that the choice for discontinuation ought to be mentioned with the affected person.12,14 Among the many poor, SMBG adherence reportedly doesn’t correlate with attaining glycemic targets, imposing a big value burden on the healthcare system.15 The principle causes for not performing SMBG often embody an absence of time, not remembering, and self-consciousness, underscoring the necessity to enhance help for SMBG implementation and profitable conduct change in sufferers.16,17 In contrast to assisted monitoring of blood glucose (AMBG), which is carried out by healthcare professionals and different caregivers for sufferers with diabetes, SMBG will not be a self-monitoring measure per se however is usually carried out by the affected person.18 Nonetheless, as sufferers age, their relations or residence care givers might must help them, and comparable measures are wanted to forestall infections, which is an issue with AMBG. Though the present common precept of SMBG includes accumulating blood by inserting a needle into the finger, making use of it to a reagent strip, and studying it with an automatic system, new applied sciences at the moment are being evaluated to realize painless and correct next-generation glucose monitoring for diabetes mellitus and to meaningfully form the glucose self-monitoring system market. As well as, plenty of organizations are making makes an attempt to considerably enhance the well being standing of individuals affected by diabetes.19
The standard and value of SMBG gadgets are repeatedly bettering. Nonetheless, as a result of sophisticated operations required, SMBG might not have the ability to be carried out by the aged, visually impaired, or hypersensitive sufferers, as a result of ache throughout puncture and issue performing measurements.
About SMBG Assistive Units
SMBG is crucial for the self-management of diabetes, and the reliability of SMBG measurements relies upon largely on how the measurer prepares and performs the measurement.20,21 Revolutionary applied sciences have led to the emergence of high-quality SMBG techniques with a wide range of user-friendly options, comparable to shorter measurement occasions, smaller blood attracts, and painless lancing gadgets, and have been reported to cut back the chance of mishandling and enhance usability by altering the SMBG working process.22–26
Nonetheless, we now have seen many instances in medical follow the place SMBG is tough to carry out, and though some producers have developed their very own assistive gadgets, we now have not seen many situations the place these gadgets are successfully used.26 As well as, to our information, there are few articles associated to SMBG assistive gadgets, and many of the few that exist are from the identical establishment in Japan regarding aged sufferers with diabetes. The authors developed an SMBG system appropriate for the aged and reported the necessity for SMBG assistive gadgets in an growing old society and the necessity for academic strategies to help the implementation of SMBG in aged diabetic sufferers.27–31 Their report is believed to be the primary describing the difficulties of SMBG implementation primarily based on affected person commentary.31 Nonetheless, their assistive system is exact however advanced, primarily focusing on the aged, and is unlikely to nonetheless be utilized by many sufferers.
Want for SMBG
In Japan, using SMBG continues to be largely managed by medical establishments specializing in diabetes care, however abroad, SMBG is beneficial for main care physicians resulting from its significance in affected person self-management. It has been acknowledged as a vital prerequisite for the profitable administration and remedy of diabetes in numerous pointers.1,7 Moreover, with the widespread use of latest self-monitoring devices, comparable to isCGM, many kind 1 and a pair of diabetic sufferers and their care groups are more likely to depend on isCGM as an vital instrument in diabetes administration.32 Nonetheless, the necessity for continued SMBG testing reportedly stays vital for all isCGM customers.33 Concerning the effectiveness of SMBG, the ADA pointers have reported its usefulness in bettering diabetes self-management and pharmacotherapy. Along with checking for hypoglycemia and hyperglycemia, SMBG has been reported to be efficient in assessing bodily exercise and food regimen, motivating self-management, constructing a detailed relationship with the affected person’s doctor, being efficient in non-insulin customers, influencing the variety of occasions SMBG is carried out on glycemic management, serving as an academic and therapeutic instrument for sufferers, and doubtlessly decreasing annual medical prices.1–3,34–37
Efficient Use of SMBG
Efficient use of SMBG can result in outcomes that promote self-management and empowerment, type an inexpensive foundation for a partnership between the affected person and the healthcare group, and will even allow sufferers to realize good glycemic management and scale back the chance of diabetes-related issues.38–44 With a purpose to use SMBG successfully, it is very important establish how and why SMBG is carried out in follow.42,45,46 A personalised understanding is reportedly wanted to advise diabetic sufferers on how SMBG will be optimized, as sufferers with diabetes who’re receiving insulin remedy don’t essentially self-monitor with the specific aim of bettering their long-term glycemic management.47 Moreover, sufferers with diabetes want to have the ability to carry out clean blood glucose monitoring and have the power and confidence to interpret the outcomes of self-monitored blood glucose ranges; nonetheless, sufferers usually lack formal SMBG coaching.48,49 For these practices to help sufferers’ self-monitoring, it’s essential to develop a affected person and household engagement method to healthcare that features sufferers and their households and is performed in good relationship with healthcare suppliers.
Affected person and Household Engagement with Emphasis on Affected person-Centered and Customized Care
Within the twenty first century, medical care has develop into extra refined and sophisticated, and the variety of sufferers with a number of comorbidities has elevated. With rising specialization, the continuity of remedy and care is fragmented, and the affected person is the one one concerned in your entire remedy course of. When there are a number of remedy choices, it’s tough for physicians to determine which one is finest for the affected person within the midst of diversifying wants. The success or failure of a remedy for a power illness, comparable to diabetes, relies upon largely on the affected person’s self-care. On this context, the concept that “sufferers are vital members of the medical group and are liable for creating medical care collectively” and that involving sufferers and their households in numerous medical processes is crucial for twenty first century drugs has developed.4
There are a number of definitions of patient-centered drugs.50–56 Amongst these, Carman et al’s definition,“patient-centered care is the energetic collaboration of sufferers, households, brokers, and healthcare suppliers at numerous ranges of healthcare, ie direct care, hospital system growth and governance, and well being coverage, to enhance the standard and security of healthcare,” is usually cited.4,50
The significance of patient-centered care is highlighted within the fundamental coverage for the remedy of T2D revealed by the ADA and EASD in 2012. It advocates a patient-centered method, which
respects the preferences, wants, and values of the person affected person, offers care that’s conscious of these preferences and wishes, and ensures that affected person values information all medical choices.5,6
There’s additionally a latest report that using personalised method within the administration of T2D sufferers can scale back the prices and failures related to algorithmic “one-size-fits-all” approaches, predict illness development, enhance response to diabetes medicines, scale back the event of diabetes-related issues, and finally enhance remedy adherence, affected person satisfaction, high quality of life, diabetes misery, and bodily well being through the use of personalised method for T2D sufferers.7 These cares ought to be the fundamental precept of healthcare for sufferers with all power ailments. As well as, relating to affected person decision-making, affected person involvement in medical choice making is reportedly a fundamental precept of evidence-based drugs, and in medical follow, it’s needed to grasp the extent to which sufferers want to be concerned and to think about remedy choices.57,58 Within the shared decision-making method, it’s helpful for clinicians and sufferers to debate the scenario with the intention to attain a consensus relating to the remedy plan.59,60
Affected person engagement is the energetic collaboration of sufferers, their households, their representatives, and healthcare suppliers at numerous ranges of healthcare (ie direct medical care, hospital system growth and governance, and healthcare coverage) to enhance the standard and security of healthcare. Affected person engagement is predicted to not solely enhance the affected person expertise and satisfaction, remedy adherence, and remedy outcomes but additionally to strengthen belief between sufferers and healthcare suppliers, enhance job satisfaction for healthcare suppliers, and scale back burnout and turnover amongst healthcare suppliers.54,61–66 If sufferers proactively take part in their very own remedy, pointless hospitalizations and emergency room visits shall be lowered, the size of hospital keep shall be shortened, and consequently, healthcare prices shall be lowered, which is seen as an vital situation in healthcare coverage.4 As well as, because the inhabitants ages and the variety of sufferers with power ailments will increase, the function of the household will develop into much more vital, so the time period “ affected person and household engagement” is usually used as a substitute of “affected person engagement”.67
Dialogue
The case we introduced here’s a uncommon instance of a affected person who was efficiently handled for extreme diabetes mellitus and diabetic issues with out pointless monetary burden of hospitalization resulting from enhanced self-care by SMBG by way of the follow of patient-centered or personalised care and affected person and household engagement.
As talked about in “Issues with SMBG” above, the necessity to think about cost-effectiveness and sufferers’ intentions has led to a number of points relating to the length of SMBG use, the involvement of healthcare suppliers, and measurement strategies.16–23 One in all them states that,
A survey of sufferers confirmed that lots of those that responded that SMBG improves their QOL would discontinue monitoring if their doctor instructed them it may very well be discontinued. Contemplating the prices related to SMBG, main care physicians ought to reevaluate the advantages of SMBG for sufferers and discontinue it if potential It ought to be discontinued if potential.22
Nonetheless, SMBG has lengthy been confirmed needed for diabetes self-management.1,2,8–14 Moreover, contemplating the significance of affected person and household engagement, a reassessment of the affected person’s self-care standing and the advantages of SMBG shouldn’t be decided solely by the first care doctor however ought to as a substitute contain the affected person, their household, and all collaborating healthcare suppliers.
Within the case introduced right here, though physicians urged the affected person to discontinue SMBG, the affected person and her household continued to have interaction in SMBG at their very own expense, not lined by medical insurance coverage, of their very own volition. The affected person is now doing nicely with self-management because of the results of SMBG. The quantity of out-of-pocket bills for insulin, SMBG tools varies relying on the medical scenario in every nation, so it’s tough to strictly evaluate and consider the cost-effectiveness between Japan and different international locations. In fact, it is very important pay attention to cost-effectiveness in medical remedy. Nonetheless, whether or not or not the price of SMBG is commensurate with its effectiveness shall be judged primarily based on how sufferers really feel concerning the cost-effectiveness and whether or not or not they can preserve good management of their blood glucose ranges, ie the analysis shall be left as much as particular person sufferers, their private emotions, and their administration standing.
As well as, contemplating that self-care is enormously influenced by the affected person’s choice, want, and values, this can be very vital to think about sufferers (and households) with emphasis on patient-centered and personalised care. Such affected person and household engagement with emphasis on patient-centered and personalised care is vital for inducing behavioral modifications in sufferers and producing the next results of SMBG on diabetes administration: 1) correct assessments of the bodily exercise and food regimen, 2) elevated motivation for self-management, 3) institution of a detailed relationship with the attending doctor, 4) improved efficacy in non-insulin customers, 5) elevated influence of the variety of SMBG classes on glycemic management, 6) institution of a job as an academic and therapeutic instrument for sufferers, and seven) elevated potential to cut back annual medical prices.4,8,10–13 The current reported case is an effective instance of those roles of SMBG in motion. Heeding the affected person’s request that she couldn’t be hospitalized as a result of she wanted to care for her cat, the medical workers prioritized the affected person’s needs and tried to create an environment the place the affected person and her household might take part within the remedy as a lot as potential. Consequently, the affected person’s household turned concerned in her medical care by crafting SMBG assistive gadgets, and the affected person was in a position to carry out SMBG by herself. Concerning level 3, the SMBG assistive gadgets made by her husband introduced the affected person, her household, and the medical workers nearer collectively, and relating to factors 5 and 6, frequent blood glucose monitoring confirmed that SMBG is a crucial instrument for adjusting the variety of insulin models. Concerning level 4, the truth that the affected person was in a position to be weaned off insulin and maintained good glycemic management with out remedy for a number of years highlights the effectiveness of SMBG in insulin non-users, and relating to level 7, though the affected person needed to bear the monetary burden of SMBG at her personal expense, this medical value was lower than that of insulin use and thus a worthwhile funding.
We and the affected person’s husband continued to work collectively to create SMBG assistive gadgets for sufferers who have been having bother with SMBG, and consequently, these aids have been distributed as equipment for SMBG (Figure 4). Whereas the standard and ease of use of SMBG tools has improved through the years, the aged, visually impaired, and hypersensitive sufferers should be unable to carry out SMBG resulting from ache on the time of puncture or issue in performing measurements and manipulation, so SMBG assistive gadgets are vital instruments for constructing a secure self-care system with emphasis on patient-centered and personalised care. To make the most of this vital instrument for self-care, it’s needed for medical professionals to acknowledge that SMBG is a crucial instrument to help self-management by creating behavioral modifications in sufferers by way of affected person and household engagement with emphasis on patient-centered and personalised care, considering sufferers’ preferences, wants, and values. Sufferers have to be made conscious that SMBG is a crucial instrument to help self-management. It is usually an vital level that empirical research utilizing isCGM and a number of topics and adopted over time are wanted to indicate that SMBG and SMBG assistive gadgets are certainly really helpful for a lot of sufferers with diabetes. The SMBG assistive system developed on this research, whereas taking hygiene points into consideration, has begun for use successfully for not solely guiding needle puncture but additionally serving to those that are unable to squeeze out sufficient blood from the puncture web site. Nonetheless, there was no particular analysis of the effectiveness of this assist and no verification of its points. The affected person’s husband continues to be engaged on creating a greater SMBG assistive system, and we preserve hope that this system shall be re-evaluated sooner or later, with even higher SMBG assistive gadgets to be developed to fulfill the wants of sufferers.
Conclusion
As medical care turns into extra refined and sophisticated, the success or failure of remedy in diabetes largely will depend on the affected person’s self-care. With a purpose to make SMBG, which is a crucial instrument for sustaining self-care, efficient in diabetes remedy, it is very important foster affected person and household engagement with emphasis on patient-centered and personalised care, ie considering sufferers’ preferences, wants, values, traits, and comorbidities. As well as, SMBG assistive gadgets are vital instruments for aiding the aged, visually impaired, and hypersensitive sufferers in establishing a secure self-care system.
We hope that, primarily based on these findings, many medical professionals concerned in diabetes care shall be reminded of those wants and significance and apply our observations to precise medical follow.
Moral Approval
This case report has been ready in accordance with the moral ideas of the Declaration of Helsinki and conforms to the ICMJE pointers for acceptable anonymization.
Consent
We now have obtained written consent from the affected person to submit this manuscript to a tutorial journal utilizing the Affected person Consent Kind (supplied by the Taylor & Francis Group, of which Dove Medical Press is a member). Our establishment doesn’t require Institutional Assessment Board approval for publication of a case report.
Acknowledgments
We wish to thank Yoritomo Tamura, the affected person’s husband, who performed a central function within the design of the assistive system, and Roche DC Japan Okay.Okay. for his or her cooperation in designing the system and rising its manufacturing, and Hiromi Tsuzukibashi, Masaki Hoshino for his or her sympathy with the necessity to create SMBG assistive gadgets.
Creator Contributions
All authors made a big contribution to the work reported, whether or not that’s within the conception, research design, execution, acquisition of knowledge, evaluation and interpretation, or in all these areas; took half in drafting, revising or critically reviewing the article; gave ultimate approval of the model to be revealed; have agreed on the journal to which the article has been submitted; and comply with be accountable for all facets of the work.
Disclosure
Masafumi Fukagawa experiences grants and/or private charges from Kyowa Kirin and Astra Zeneca, outdoors the submitted work. The authors declare no different conflicts of curiosity on this work.
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