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JACM-D-15-00001
March 4, 2015
17:56
J Ambulatory Care Manage Vol. 38, No. 2, pp. 196–199 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Digital Health Tools for Diabetes Patricia Salber, MD, MBA; Alisa Niksch, MD
Abstract: Digital health tools are providing patients with easier ways to keep track of their blood glucose levels and other key self-reported data, such as carbohydrates ingested, medication administered, and physical activity. Data are often uploaded into the cloud where physicians and other members of the care team can access them. Clinical studies are beginning to demonstrate efficacy of some of these tools, and Food and Drug Administration approval, when present, provides some much-needed validation. It is anticipated that these tools will continue to evolve and patient acceptance will continue to grow. Physician and care teams will need to familiarize themselves with the tools their patients are using and provide guidance and support for their use. Key words: apps for diabetes, care management, diabetes self-management, digital health tools, diabetes logbook apps, population management, self-reported diabetes data, tracking carbs, tracking glucose, tracking physical activity
D
IABETES is a chronic condition that presents relentless challenges to the patients who suffer from it and the clinicians who treat it. The complex regimens, multiple daily decision points involving titration of medication doses and dietary choices, and balancing comorbid conditions require an intense partnership between patients and their caregivers. According to the American Diabetes Association (2013), the cost of navigating diabetes management was $245 billion in 2012,
Author Affiliations: Health Tech Hatch, Larkspur, California (Dr Salber); and Tufts Medical Center, Boston, Massachusetts (Dr Niksch). Dr Salber is CEO of Health Tech Hatch and Host of The Doctor Weighs In. She serves as an advisor to digital health start-ups, including CliniOps, mHealth Solutions (product is CareSmarts), and DoctorBase. Dr Niksch is a pediatric cardiologist and director of Pediatric Electrophysiology at Tufts Medical Center in Boston, Massachusetts. She serves as an advisor to start-up companies Sproutling and Genetesis and has conducted research with Zephyr Technologies (now a subsidiary of Covidien). Correspondence: Patricia Salber, MD, MBA, Health Tech Hatch, 21 Marina Vista Ave, Larkspur, CA 94939 ([email protected]). DOI: 10.1097/JAC.0000000000000080
including $176 billion of direct medical costs and $69 billion in lost productivity. As much of this cost burden is due to inpatient care and medical management of diabetes complications, a movement has been launched to improve systems to enhance patient engagement and diabetes literacy to ultimately reduce treatment costs. Digital health tools have been introduced in an attempt to facilitate many of these goals and improve overall quality of life of patients and their families.
IMPROVING DIABETES SELF-MANAGEMENT Diabetes self-management is viewed as a critical component of better diabetes outcomes. Recent studies have shown that diabetic patients who undergo education on self-management have improvement in multiple metrics, including a 3-fold decrease in hemoglobin A1c levels compared with a control group (Brunisholz et al., 2014). Although not a complete listing, here are some digital health tools that support self-management and also have validation via clinical studies or Food and Drug Administration (FDA) approval, or,
196 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-15-00001
March 4, 2015
17:56
Digital Health Tools for Diabetes absent that, have high ratings in the app stores in which they are offered. WellDoc, Inc (http://www.welldoc.com), is a health care company founded in 2005 that leverages digital technology via its DiabetesManager platform to promote enhanced self-management and long-term medication adherence. The platform includes a diabetes coaching system that uses both mobile phone communication and a physician-patient portal for targeted treatment interventions. Realtime analytics of patient data are designed to formulate personalized therapy recommendations that are communicated to health care providers. WellDoc has both clinical and marketplace validation. The company published the results of 2 pilot studies that documented the positive impact of their multipronged approach to patient support and management (Quinn et al., 2008, 2011) The FDA approved the WellDoc BlueStar app in 2010. Last year the app received approval for reimbursement as a pharmacy benefit for employees of several large companies, including RiteAid, Ford Motor Company, and Dexcom. The BlueStar platform still requires a physician prescription. Physicians who have evaluated the app have been encouraged but are still hesitant about the applicability of the app for patients who are less experienced with technology (Fiore, 2014). Glooko (https://glooko.com/) is an FDAcleared, unified diabetes management system that allows patients to wirelessly transfer glucose readings from more than 30 different glucometers, anytime, anyplace, to a mobile phone logbook. The readings can be contextualized on the go by entering medication use and recording diet and physical activity. A PDF of the last 2 to 4 weeks of the mobile logbook can be shared with the physicians and other caregivers via e-mail or fax. A review of the app by David Ahn, MD, a second-year endocrinology fellow at UC San Diego is available on iMedical Apps (http:// www.imedicalapps.com/2014/12/diabetesdevice-glooko-metersync-blue-review). The app is available for personal purchase or via various payer group coverage arrangements
197
for both iOS and Android phones. Peerreviewed publications of the apps efficacy are not currently available; however, the Glooko system appears in multiple lists of best diabetes management apps. Glooko also offers a Population Tracker that enables clinicians to manage all of their patients with diabetes (population management). Also, the “Joslin HypoMap powered by Glooko” provides real-time and aggregate data maps on hypoglycemic events to help patients and clinicians better understand hypoglycemic unawareness and the events that may have triggered a “low.” As an addition to its wireless continuous glucose monitoring system, Dexcom has added an additional mobile communication system to engage family members in tracking glucose levels, called Dexcom SHARE (http:// dexcom.com/share). The FDA-approved Dexcom glucose sensor is attached to a transmitter worn by the patient that sends data to a handheld receiver where glucose levels are tracked and alarm limits can be customized for high or low glucose levels (Linebaugh, 2014). The Dexcom SHARE feature now adds a Bluetooth-enabled cradle where the receiver can be docked. The cradle can be paired with up to 5 iPhones or iPod Touch with the companion app, allowing for sharing of data with family and other caregivers who can add another layer of protection for patients prone to labile glucose levels. As of this publication, the platform was not available for Android operating systems. In addition, the cradle is not covered by insurance and has a $299 out-ofpocket cost to consumers. Dexcom is already planning its next generation of sensors that will communicate directly with smartphones, obviating the need for intermediary devices. CareSmarts, a product of mHealth Solutions (http://www.mhealth-solutions.com), is an automated text message–based program that takes users through educational modules designed to help improve self-care. The care team provides outreach when user response to text messages suggests they need more help. A recent study of the program, published in Health Affairs, demonstrated statistically significant improvements in glycemic
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-15-00001
198
March 4, 2015
17:56
JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2015
control, patient satisfaction, as well as cost savings (Nundy et al., 2014). Because the program is text-based, it can be used on mobile phones with simple SMS capability, crucial for reaching a significant portion of the population. APPS FOR KIDS MySugr Junior (http://mysugr.com/junior) is a gamified diabetes logbook app designed for kids and their parents. Kids log their blood glucose levels, food intake including carbohydrates estimates, insulin dose, and how they are currently feeling. They get points and feedback from an animated diabetes monster as they make their entries. Entries are automatically sent to the parent’s smartphone so they can provide support and feedback. Although it has not been studied formally, comments from parents and kids in the Android app store suggest that the app is a fun way to get young kids with diabetes engaged in managing their condition. Carb Counting with Lenny (http://www .lenny-diabetes.com/carb-counting-with-lenny .html) is a free educational app game, made by Medtronic, that teaches youngsters about carbs and carb counting through a series of progressively more challenging games. There are versions for the iPhone, iPad, and Android systems. Dexcom also has a continuous glucose monitoring sensor system approved for diabetic patients aged 2 to 17 years. This is also compatible with the Dexcom SHARE system, which has transformed how children with diabetes are monitored in the home and school settings. Testimonials from parents reveal significantly decreased anxiety levels and improved quality of life and independence for children living with this disease. NAVIGATING THE WORLD OF DIABETES APPS The list of digital health tools for diabetes management has exploded recently as a result of more widespread use of mobile phones, greater support for health tech innovation via numerous incubators, accelerators (Suen-
nen, 2014), and challenges. There has also been a greater outcry for improved diabetes technology from increasingly influential patient groups. The developers of digital health tools have clearly seen diabetes as a highimpact market. As a result, the field has become crowded with multiple apps that provide a sometimes confusing array of services and functionalities. Diabetes Mine (www.diabetesmine.com) is a respected patient advocacy site that recognizes the potential benefits of digital health in managing diabetes but understands that patients can easily get frustrated finding the right management tool for them. In addition to its archives of engaged patient reviews of anything from insulin pumps to continuous glucose monitors, the site has added a section for reviewing mobile apps for diabetes. Written and video testimonials (Diabetes Mine Test Kitchen, available at: http://www.diabetesmine.com/ test-kitchen-categories) from volunteer patients with both type I and type II diabetes give practical evaluations regarding the functionality of various mobile platforms. Mobile apps providing lifestyle management, data logging, and activity trackers are specifically featured. Video product reviews are accompanied by an overall rating score. There is a breakdown of pros and cons to each reviewed product, as well as additional links to outside reviews and articles. Recurring themes presented by patient reviewers include ease of navigation within the app, functionality, feedback loops to promote engagement, and ability to track and share data. Another source of information about diabetes apps is iMedicalApps (www .imedicalapps.com), a site affiliated with MedPageToday. The site features reviews of apps and other digital health tools for diabetic patients written by physicians. CONCLUSIONS The quest to transform diabetes care has attracted significant attention from the digital health sector. The recognized potential for improvement in disease management, and
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-15-00001
March 4, 2015
17:56
Digital Health Tools for Diabetes an already engaged patient population, has opened the door for a larger role for digital health. The use of mobile devices as the hub for data storage, coaching and education, and direct communication with clinicians has inspired the development of very sophisticated platforms to improve longer-term outcomes. However, these technologies continue to face the same challenges as many digital health
199
tools: lack of validation for outcomes improvement, interoperability into existing clinical databases, regulatory oversight requirements, and inconsistent reimbursement patterns. As demand for these technologies grows, an accelerated response to these challenges will require more active physician and institutional roles in conducting research and interfacing with payers and regulatory agencies.
REFERENCES American Diabetes Association. (2013). Economic costs of diabetes in the U.S. in 2012. Diabetes Care, 36(4), 1033–1046. Brunisholz, K. D., Briot, P., Hamilton, S., Joy, E. A., Lomax, M., Barton, N., . . . Cannon, W. (2014, November). Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure. Journal of Multidisciplinary Healthcare, 7, 533–542. Fiore, K. (2014, January 16). Will docs write Rx for apps? MedPageToday. Retrieved from http:// www.medpagetoday.com/Endocrinology/ GeneralEndocrinology/43841 Linebaugh, K. (2014, October 20). Dexcom’s remote glucose-monitoring device cleared. Wall Street Journal. http://www.wsj.com/articles/dexcoms-remoteglucose-monitoring-device-cleared-1413828626 Nundy, S., Dick, J. J., Chou, C. H., Nocon, R. S., Chin, M. H., & Peek, M. E. (2014). Mobile phone diabetes project led to improved glycemic control and net
savings for Chicago plan participants. Health Affairs, 33(2), 265–272. Quinn, C. C., Clough, S. S., Minor, J. M., Lender, D., Okafor, M. C., & Gruber-Baldini, A. (2008, June). WellDoc mobile diabetes management randomized controlled trial: Change in clinical and behavioral outcomes and patient and physician satisfaction. Diabetes Technology & Therapeutics, 10(3), 160–168. Quinn, C. C., Shardell, M. D., Terrin, M. L., Barr, E. A., Ballew, S. H., & Gruber-Baldini, A. L. (2011, September). Cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care, 34, 1934–1942. Suennen, L. (2014, October). Survival of the fittest: Health care accelerators evolve toward specialization. Sacramento, CA: California HealthcareHealth Care Foundation. Retrieved from http://www.chcf .org/publications/2014/10/survival-fittest-accelerators #ixzz3MbxRpKDe
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JACM-D-15-00001
March 4, 2015
17:56
J Ambulatory Care Manage Vol. 38, No. 2, pp. 196–199 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Digital Health Tools for Diabetes Patricia Salber, MD, MBA; Alisa Niksch, MD
Abstract: Digital health tools are providing patients with easier ways to keep track of their blood glucose levels and other key self-reported data, such as carbohydrates ingested, medication administered, and physical activity. Data are often uploaded into the cloud where physicians and other members of the care team can access them. Clinical studies are beginning to demonstrate efficacy of some of these tools, and Food and Drug Administration approval, when present, provides some much-needed validation. It is anticipated that these tools will continue to evolve and patient acceptance will continue to grow. Physician and care teams will need to familiarize themselves with the tools their patients are using and provide guidance and support for their use. Key words: apps for diabetes, care management, diabetes self-management, digital health tools, diabetes logbook apps, population management, self-reported diabetes data, tracking carbs, tracking glucose, tracking physical activity
D
IABETES is a chronic condition that presents relentless challenges to the patients who suffer from it and the clinicians who treat it. The complex regimens, multiple daily decision points involving titration of medication doses and dietary choices, and balancing comorbid conditions require an intense partnership between patients and their caregivers. According to the American Diabetes Association (2013), the cost of navigating diabetes management was $245 billion in 2012,
Author Affiliations: Health Tech Hatch, Larkspur, California (Dr Salber); and Tufts Medical Center, Boston, Massachusetts (Dr Niksch). Dr Salber is CEO of Health Tech Hatch and Host of The Doctor Weighs In. She serves as an advisor to digital health start-ups, including CliniOps, mHealth Solutions (product is CareSmarts), and DoctorBase. Dr Niksch is a pediatric cardiologist and director of Pediatric Electrophysiology at Tufts Medical Center in Boston, Massachusetts. She serves as an advisor to start-up companies Sproutling and Genetesis and has conducted research with Zephyr Technologies (now a subsidiary of Covidien). Correspondence: Patricia Salber, MD, MBA, Health Tech Hatch, 21 Marina Vista Ave, Larkspur, CA 94939 ([email protected]). DOI: 10.1097/JAC.0000000000000080
including $176 billion of direct medical costs and $69 billion in lost productivity. As much of this cost burden is due to inpatient care and medical management of diabetes complications, a movement has been launched to improve systems to enhance patient engagement and diabetes literacy to ultimately reduce treatment costs. Digital health tools have been introduced in an attempt to facilitate many of these goals and improve overall quality of life of patients and their families.
IMPROVING DIABETES SELF-MANAGEMENT Diabetes self-management is viewed as a critical component of better diabetes outcomes. Recent studies have shown that diabetic patients who undergo education on self-management have improvement in multiple metrics, including a 3-fold decrease in hemoglobin A1c levels compared with a control group (Brunisholz et al., 2014). Although not a complete listing, here are some digital health tools that support self-management and also have validation via clinical studies or Food and Drug Administration (FDA) approval, or,
196 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-15-00001
March 4, 2015
17:56
Digital Health Tools for Diabetes absent that, have high ratings in the app stores in which they are offered. WellDoc, Inc (http://www.welldoc.com), is a health care company founded in 2005 that leverages digital technology via its DiabetesManager platform to promote enhanced self-management and long-term medication adherence. The platform includes a diabetes coaching system that uses both mobile phone communication and a physician-patient portal for targeted treatment interventions. Realtime analytics of patient data are designed to formulate personalized therapy recommendations that are communicated to health care providers. WellDoc has both clinical and marketplace validation. The company published the results of 2 pilot studies that documented the positive impact of their multipronged approach to patient support and management (Quinn et al., 2008, 2011) The FDA approved the WellDoc BlueStar app in 2010. Last year the app received approval for reimbursement as a pharmacy benefit for employees of several large companies, including RiteAid, Ford Motor Company, and Dexcom. The BlueStar platform still requires a physician prescription. Physicians who have evaluated the app have been encouraged but are still hesitant about the applicability of the app for patients who are less experienced with technology (Fiore, 2014). Glooko (https://glooko.com/) is an FDAcleared, unified diabetes management system that allows patients to wirelessly transfer glucose readings from more than 30 different glucometers, anytime, anyplace, to a mobile phone logbook. The readings can be contextualized on the go by entering medication use and recording diet and physical activity. A PDF of the last 2 to 4 weeks of the mobile logbook can be shared with the physicians and other caregivers via e-mail or fax. A review of the app by David Ahn, MD, a second-year endocrinology fellow at UC San Diego is available on iMedical Apps (http:// www.imedicalapps.com/2014/12/diabetesdevice-glooko-metersync-blue-review). The app is available for personal purchase or via various payer group coverage arrangements
197
for both iOS and Android phones. Peerreviewed publications of the apps efficacy are not currently available; however, the Glooko system appears in multiple lists of best diabetes management apps. Glooko also offers a Population Tracker that enables clinicians to manage all of their patients with diabetes (population management). Also, the “Joslin HypoMap powered by Glooko” provides real-time and aggregate data maps on hypoglycemic events to help patients and clinicians better understand hypoglycemic unawareness and the events that may have triggered a “low.” As an addition to its wireless continuous glucose monitoring system, Dexcom has added an additional mobile communication system to engage family members in tracking glucose levels, called Dexcom SHARE (http:// dexcom.com/share). The FDA-approved Dexcom glucose sensor is attached to a transmitter worn by the patient that sends data to a handheld receiver where glucose levels are tracked and alarm limits can be customized for high or low glucose levels (Linebaugh, 2014). The Dexcom SHARE feature now adds a Bluetooth-enabled cradle where the receiver can be docked. The cradle can be paired with up to 5 iPhones or iPod Touch with the companion app, allowing for sharing of data with family and other caregivers who can add another layer of protection for patients prone to labile glucose levels. As of this publication, the platform was not available for Android operating systems. In addition, the cradle is not covered by insurance and has a $299 out-ofpocket cost to consumers. Dexcom is already planning its next generation of sensors that will communicate directly with smartphones, obviating the need for intermediary devices. CareSmarts, a product of mHealth Solutions (http://www.mhealth-solutions.com), is an automated text message–based program that takes users through educational modules designed to help improve self-care. The care team provides outreach when user response to text messages suggests they need more help. A recent study of the program, published in Health Affairs, demonstrated statistically significant improvements in glycemic
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-15-00001
198
March 4, 2015
17:56
JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2015
control, patient satisfaction, as well as cost savings (Nundy et al., 2014). Because the program is text-based, it can be used on mobile phones with simple SMS capability, crucial for reaching a significant portion of the population. APPS FOR KIDS MySugr Junior (http://mysugr.com/junior) is a gamified diabetes logbook app designed for kids and their parents. Kids log their blood glucose levels, food intake including carbohydrates estimates, insulin dose, and how they are currently feeling. They get points and feedback from an animated diabetes monster as they make their entries. Entries are automatically sent to the parent’s smartphone so they can provide support and feedback. Although it has not been studied formally, comments from parents and kids in the Android app store suggest that the app is a fun way to get young kids with diabetes engaged in managing their condition. Carb Counting with Lenny (http://www .lenny-diabetes.com/carb-counting-with-lenny .html) is a free educational app game, made by Medtronic, that teaches youngsters about carbs and carb counting through a series of progressively more challenging games. There are versions for the iPhone, iPad, and Android systems. Dexcom also has a continuous glucose monitoring sensor system approved for diabetic patients aged 2 to 17 years. This is also compatible with the Dexcom SHARE system, which has transformed how children with diabetes are monitored in the home and school settings. Testimonials from parents reveal significantly decreased anxiety levels and improved quality of life and independence for children living with this disease. NAVIGATING THE WORLD OF DIABETES APPS The list of digital health tools for diabetes management has exploded recently as a result of more widespread use of mobile phones, greater support for health tech innovation via numerous incubators, accelerators (Suen-
nen, 2014), and challenges. There has also been a greater outcry for improved diabetes technology from increasingly influential patient groups. The developers of digital health tools have clearly seen diabetes as a highimpact market. As a result, the field has become crowded with multiple apps that provide a sometimes confusing array of services and functionalities. Diabetes Mine (www.diabetesmine.com) is a respected patient advocacy site that recognizes the potential benefits of digital health in managing diabetes but understands that patients can easily get frustrated finding the right management tool for them. In addition to its archives of engaged patient reviews of anything from insulin pumps to continuous glucose monitors, the site has added a section for reviewing mobile apps for diabetes. Written and video testimonials (Diabetes Mine Test Kitchen, available at: http://www.diabetesmine.com/ test-kitchen-categories) from volunteer patients with both type I and type II diabetes give practical evaluations regarding the functionality of various mobile platforms. Mobile apps providing lifestyle management, data logging, and activity trackers are specifically featured. Video product reviews are accompanied by an overall rating score. There is a breakdown of pros and cons to each reviewed product, as well as additional links to outside reviews and articles. Recurring themes presented by patient reviewers include ease of navigation within the app, functionality, feedback loops to promote engagement, and ability to track and share data. Another source of information about diabetes apps is iMedicalApps (www .imedicalapps.com), a site affiliated with MedPageToday. The site features reviews of apps and other digital health tools for diabetic patients written by physicians. CONCLUSIONS The quest to transform diabetes care has attracted significant attention from the digital health sector. The recognized potential for improvement in disease management, and
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LWW/JACM
JACM-D-15-00001
March 4, 2015
17:56
Digital Health Tools for Diabetes an already engaged patient population, has opened the door for a larger role for digital health. The use of mobile devices as the hub for data storage, coaching and education, and direct communication with clinicians has inspired the development of very sophisticated platforms to improve longer-term outcomes. However, these technologies continue to face the same challenges as many digital health
199
tools: lack of validation for outcomes improvement, interoperability into existing clinical databases, regulatory oversight requirements, and inconsistent reimbursement patterns. As demand for these technologies grows, an accelerated response to these challenges will require more active physician and institutional roles in conducting research and interfacing with payers and regulatory agencies.
REFERENCES American Diabetes Association. (2013). Economic costs of diabetes in the U.S. in 2012. Diabetes Care, 36(4), 1033–1046. Brunisholz, K. D., Briot, P., Hamilton, S., Joy, E. A., Lomax, M., Barton, N., . . . Cannon, W. (2014, November). Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure. Journal of Multidisciplinary Healthcare, 7, 533–542. Fiore, K. (2014, January 16). Will docs write Rx for apps? MedPageToday. Retrieved from http:// www.medpagetoday.com/Endocrinology/ GeneralEndocrinology/43841 Linebaugh, K. (2014, October 20). Dexcom’s remote glucose-monitoring device cleared. Wall Street Journal. http://www.wsj.com/articles/dexcoms-remoteglucose-monitoring-device-cleared-1413828626 Nundy, S., Dick, J. J., Chou, C. H., Nocon, R. S., Chin, M. H., & Peek, M. E. (2014). Mobile phone diabetes project led to improved glycemic control and net
savings for Chicago plan participants. Health Affairs, 33(2), 265–272. Quinn, C. C., Clough, S. S., Minor, J. M., Lender, D., Okafor, M. C., & Gruber-Baldini, A. (2008, June). WellDoc mobile diabetes management randomized controlled trial: Change in clinical and behavioral outcomes and patient and physician satisfaction. Diabetes Technology & Therapeutics, 10(3), 160–168. Quinn, C. C., Shardell, M. D., Terrin, M. L., Barr, E. A., Ballew, S. H., & Gruber-Baldini, A. L. (2011, September). Cluster-randomized trial of a mobile phone personalized behavioral intervention for blood glucose control. Diabetes Care, 34, 1934–1942. Suennen, L. (2014, October). Survival of the fittest: Health care accelerators evolve toward specialization. Sacramento, CA: California HealthcareHealth Care Foundation. Retrieved from http://www.chcf .org/publications/2014/10/survival-fittest-accelerators #ixzz3MbxRpKDe
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
