Patient Contributions Research Articles

The expert patient's contribution to the empowerment of people with diabetes mellitus

Objective: to uncover the contributions of specialist patients to the empowerment of people with diabetes mellitus. Methods: a qualitative study comprising three open virtual communities with public posts in Portuguese, aimed at discussing diabetes mellitus. The nuclei of meaning were identified through a word cloud, with mutual checking between three researchers using content analysis. Results: the interactions showed concern about the clinical dimension of the disease and the welcoming nature of suffering and anguish. It was also observed that living with diabetes provides knowledge about the disease, making these people propagators of knowledge and ensuring their participation in the treatment process. Furthermore, the dialogues provided by the online environment can contribute to health promotion, facilitating understanding of aspects inherent to diabetes. Conclusion: specialist patients are willing to answer questions based on the knowledge they have acquired through the experience of becoming ill, supporting their recommendations in the care and recommendations received during treatment. Contributions to practice: it is hoped that the results can contribute to the recognition and appreciation of new approaches to health promotion and self-care for people with diabetes, such as virtual communities.

Advance in contemporary orthodontics: a systematic review

Introduction: During orthodontic treatment, careful planning is essential for its success, taking into account aspects such as facial harmony, functional occlusion, and esthetics. The anchorage system has been widely used by orthodontists due to its high level of success. In addition to replacing the use of extra and intraoral devices, mini-implants show a simple technique that does not require patient cooperation and less discomfort, enabling more movements predictable and balanced in a short treatment time. Objective: To report the types of mini-implants and their characteristics, addressing their advantages and disadvantages, insertion locations, indications, and contraindications, in order to promote general knowledge of orthodontic treatment with skeletal anchorage. Methods: Clinical studies with qualitative and/or quantitative analysis were included, following the rules of the systematic review-PRISMA. Results: The mini-implants are made in two types, such as self-tapping requires a drill and self-drilling that has a cut. Their use provides advantages such as a set of more agile, simple, and less invasive techniques, with minimal anatomical limitations, less cost, not depending on the patient's contribution, allowing the application of immediate load and increased predictability of movements. Disadvantages are considered when there is movement and loosening of the mini-implant, involvement of nerves and blood vessels during surgery, mucosal irritation, and gingival hyperplasia caused by poor hygiene causing pain and swelling. Conclusion: It is concluded that the mini-implant emerged to revolutionize orthodontic treatment through more precise movements, in a short time, facilitating more complex movements that other devices had difficulty performing. Its main characteristic is a high success rate, in addition to having a reduced size, which allows its insertion in several sites. Consequently, the skeletal anchorage device is an excellent method, as long as it is used according to indications and taking meticulous care from the ideal choice of the device to the moment of its insertion.

Progress in Psychotherapy: The Perspective of Control-Mastery Theory.

In the classical psychoanalytic tradition, the patient is seen as unconsciously governed by forces that are at odds with the healing process. But over the years, the concept of resistance against change has been subjected to modifications, and the patient's contribution to the therapeutic relationship has come to be seen as more oriented to a conscious and unconscious collaboration with the clinician. This article aims to explore a new way of understanding how progress in psychotherapy is achieved and to reframe the therapeutic relationship from the point of view of Control-Mastery Theory (CMT). According to CMT, people are motivated to achieve adaptive goals, to master their traumas, and to feel better; to this purpose, patients unconsciously assume proactive roles in the therapeutic process. Indeed, they work during therapy to disprove their pathogenic beliefs, testing them in the therapeutic relationship, and helping the therapist through coaching behaviors, attitudes, and communications aimed at providing helpful information to understand the components of their own unconscious plan.

Patients Are Knowledge Workers in the Clinical Information Space.

Limited research exists on patient knowledge/cognition or "getting inside patients' heads." Because patients possess unique and privileged knowledge, clinicians need this information to make patient-centered and coordinated treatment planning decisions. To achieve patient-centered care, we characterize patient knowledge and contributions to the clinical information space. In a theoretical overview, we explore the relevance of patient knowledge to care provision, apply historical perspectives of knowledge acquisition to patient knowledge, propose a representation of patient knowledge types across the continuum of care, and include illustrative vignettes about Mr. Jones. We highlight how the field of human factors (a core competency of health informatics) provides a perspective and methods for eliciting and characterizing patient knowledge. Patients play a vital role in the clinical information space by possessing and sharing unique knowledge relevant to the clinical picture. Without a patient's contributions, the clinical picture of the patient is incomplete. A human factors perspective informs patient-centered care and health information technology solutions to support clinical information sharing.

Recommendations on the utilization of telemedicine in cardiology.

The enormous progress made in recent years in the field of information and communication technology and also in sensor and computer technology has affected numerous fields of medicine and is capable of inducing even radical changes in diagnostic and therapeutic processes. This is particularly true for cardiology, where, for example, telemetric monitoring of cardiac and circulatory functions has been in use for many years. Nevertheless, broad application of newer telemedical processes has not yet been achieved to the extent one would expect from the encouraging results of numerous clinical studies in this field and the state of the art of the underlying technology. In the present paper, the Working Group on Rhythmology of the Austrian Cardiological Society aims to provoke acritical discussion of the digital change in cardiology and to make recommendations for the implementation of those telemedical processes that have been shown to exert positive effects on awide variety of medical and economic parameters. The greatest benefit of telecardiological applications is certainly to be found in the long-term care of patients with chronic cardiovascular diseases. Accordingly, follow-up care of patients with cardiological rhythm implants, management of chronic heart failure and secondary prevention following an acute cardiac event during rehabilitation are currently the most important fields of application. Telemedicine is intended to enable high-quality and cost-efficient care for an increasing number of patients, whose care poses one of the greatest challenges to our healthcare system. Not least of all, telemedicine should make adecisive contribution to improving the quality of life of this segment of the population by favorably influencing mortality, morbidity and hospitalization as well as the patient's contribution to treatment.

A democratic program for healing: The Raspail domestic medicine method in 1840s France.

Raspail's domestic medicine method, popularized in 1840s France, has similarities with the practices of nineteenth century non-academic healers. His mass marketing of camphor as a universal treatment echoes the practices of "charlatans" and their circles. But Raspail is also very original in this history of popular care. As a scientist, a popularizer of encyclopedic knowledge and a political activist, he managed to blur traditional distinctions between science and politics and between popular and learned medicine. Raspail was a constant thorn in the side of academic institutions and professional organizations, which were struggling to gain legitimacy. His work took a political turn when he combined, within a single project, his approach to treatment and his call for democratizing medical care. Raspail's method challenged institutional norms by acknowledging the importance of the patient's contribution to the healing process, and recognizing the necessity of thwarting the occasionally deleterious effects of monopolistic medicalization.

Financial contributions made by patients towards dispensed medicines prescribed by Australian dentists from 2006 to 2018: a cost-analysis study.

Objective This cost-analysis study explored Pharmaceutical Benefits Scheme (PBS) data to determine the financial patient contribution (PC) towards dispensed medications prescribed by dentists and temporal trends in cost contributions. Methods For this study we used the PBS online dataset and only included concessional data in the analysis. Data on dental medications dispensed under the PBS from 2006 to 2018 were accessed. For all medicines aggregated to different pharmacological categories (antibiotics, analgesics and opiates, anti-inflammatories, antifungals, benzodiazepines, anticonvulsants and anti-emetics, and emergency medications), a temporal trend was generated using annual PC data. Cumulative patient and mean annual PC data were also generated in a similar manner. Results Cumulative PC over the study period for dental PBS prescriptions was A$28783361 (A$5.55 per dispensing). The mean annual PC for dental PBS was A$2214105 (for the entire concessional population from 2006 to 2018), with a statistically significant and strong correlation between year and PC (Dental PBS, A$59756 per year; r=0.98: P<0.0001). Antibiotics represented the highest proportion of PC (87.8%), whereas the lowest proportion of PC was for emergency medications (e.g. adrenaline, atropine, glucagon, naloxone), which amounted to 0.003%. Conclusions This study highlights the increasing contributions made by patients towards antibiotic prescriptions. What is known about the topic? Australian dentists can independently prescribe subsidised medications as per a set scope for general and specialist dentists, regulated under the PBS with requisite adherence to specific legal requirements. What does this paper add? This is the first study highlighting the increased level of patient financial contributions towards dental medicines, according to different pharmacological categories, dispensed by pharmacists in Australia. What are the implications for practitioners? This study creates a base for future research assessing the appropriateness of the PBS subsidy and the PBS Safety Net threshold, possibly reassessing the out-of-pocket pricing on brand substitution and appropriately reassessing the current dental PBS schedule.

Listen to my story: Contribution of patients to their healthcare through effective communication with doctors.

In the era of patient centered healthcare, patients are educated, more aware and demanding than ever. However, there is a significant misalignment between patients and doctors due to improper communication resulting in broken patient-doctor therapeutic relationships and degraded quality of healthcare. This suggests that patients have a greater and mature role to play in their healthcare. The paper aims to fill this gap by studying the contribution of patients in their healthcare through patientdoctor communication in selected Indian multispeciality hospitals. Qualitative multi-case study was steered and in-depth interviews of thirteen patients, twelve doctors were conducted along with the secondary data analysis of more than 600 pages of the documents from the official websites of the sample hospitals. Grounded theory three level coding revealed the themes of contribution of patients in through effective communication. The results indicate that patients contribute to their healthcare through effective communication by demonstrating association with doctors, reflecting reciprocally, resolving communication challenges and supporting their overall treatment process. The paper extends the literature on patient's contribution in their healthcare. It presents clear and succinct implementable implications and distinctive ways in which patients cooperate with the doctors, work mutually, improves communication and strengthen their overall healthcare process.

Komunikacija u fizioterapeutskoj praksi

Communication is considered to be the most important aspect of the practice of healthcare professionals, and the communication relationship between the health care provider and the patient involves two groups of people who have different positions or roles that determine their interaction and relationship. The communication process between physiotherapist and patient is increasingly recognized as a therapeutic practice. Through communication interactions, physiotherapists can educate, motivate, empower, or release, express empathy or authority, show interest, or build confidence. In physiotherapy, as well as in other patient-oriented, biopsychosocial and related health care professions, a patient-centered communication approach has been established as guides and frameworks for practitioners to communicate with their patients. These communication models are used to share information as well as accountability but also to reduce power disparities between the physiotherapist and the patient. Accordingly, this communication model is specifically aimed at understanding the needs of patients and addressing them in order to maximize the perspective of each patient. Developing active patient-therapist collaboration creates a relationship defined as a "therapeutic alliance" characterized by empathy, trust, and respect. Many forms of treatment performed by physiotherapists cannot be successful without the patient's contribution and motivation to cooperate, both during and outside the communication interaction. communication skills have a positive effect on the patient's psychology and therefore physiology as they are inseparable, and the relationship between the physiotherapist and the patient during the rehabilitation process creates a sense of "companionship" on the path during which the patient is free from his or her physical, social and environmental limitations.

Emergence of the patient-actor in patient safety in France. A narrative review in social sciences and public health

For the last forty years, patients have been encouraged to take part in their care and to participate in improving the quality and safety of care. This phenomenon requires reflection on the conditions of emergence of this new role and its public health implications, particularly in the field of patient safety. A narrative review of the international literature was conducted by searching Medline, Cairn and Persée databases. The database query identified 2,206 documents, 106 of which were included in the analysis. The emergence of the patient-actor is linked to sanitary crises and promoted by patient associations in the field of patient safety such as le Lien. This movement induces a transformation of the patient's role beyond the theme of patient safety: it revolutionizes the patient's contribution to the health system. This narrative review of the literature highlights the way in which health crises have encouraged the emergence of a new actor: the patient-actor, accompanied by new semantics concerning the power of the patient. The patient occupies a specific place in the field of safety of care. In collaboration with healthcare professionals, the patient must constitute a resource to improve patient safety. The various contributions of patients are described and an analysis of the acceptability of patient participation is proposed.

Erratum to: Health-Related Quality of Life in Patients with Multiple Sclerosis: Impact of Disease-Modifying Drugs.

Multiple sclerosis (MS) has a profound impact on health-related quality of life (HRQoL), a comprehensive subjective measure of the patient's health status. Assessment of HRQoL informs on the potential advantages and disadvantages of disease-modifying drugs (DMDs) beyond their effects on observer-based disability and magnetic resonance imaging abnormalities. This article reviews published data from randomized controlled trials and observational studies regarding the effects of currently available DMDs on HRQoL. Data indicate that DMD treatment is associated with prevention of worsening or with improvement of HRQoL, and that, in general, second-line DMDs may have a greater impact on HRQoL than first-line DMDs. In clinical practice, monitoring of HRQoL provides clinicians with unique information regarding disease impact and potential benefits and adverse effects of DMD treatment that may not be obtained otherwise; it might also permit early detection of an unfavorable disease course. It is suggested to assess HRQoL at the time of diagnosis and before starting or switching DMD treatment. Regular HRQoL measurements contribute to a comprehensive clinical evaluation, and may help to elucidate and quantify the patient's contribution to shared decision making regarding DMD treatment. Further studies are needed to better determine the role of HRQoL assessments in daily MS care.

Impact on personal growth and environment conservation self-perception in a volunteering program with adults with severe mental illness (SMI)

Introduction“Viaje del Parnaso” is a volunteering project developed at the Day Center Aranjuez2 (CD2) for helping adults with SMI to get a satisfactory and responsible occupation through their implication in a volunteering work in the community, while involved in the maintenance of a green area in the city of Aranjuez.Objectives/aimsThe aim of this study was to evaluate the impact of the project on the volunteers’ lives in terms of personal growth and environment conservation and compare its results with non-volunteers also attended at the CD2.MethodsThe project was carried once a week during 45 weeks. 11 volunteers participated on the project, plus 5 non-volunteers were considered as cuasi-control group. The instruments applied were an item on “environment conservation” and 2 subscale items of “Personal Growth” from the Ryff Scales of psychological well-being. Measures were applied at baseline, 6 and 12 months after.ResultsSignificant differences were found on the environment conservation item between volunteers at baseline and 6 months after (P &lt; 0.05). Results also revealed a significant difference (P &lt; 0.05) between volunteers and non-volunteers at both variables (“environment conservation” and “Personal Growth”) in baseline and 6 months after treatment.ConclusionsThe data from this study suggest that a volunteering program seems to be an effective intervention for bringing about improvements in well-being of people with SMI, and also for increasing their environmental awareness. These improvements may also help to change the stigma of SMI reinforcing mental health patient's contributions to society.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Therapist-reported alliance: Is it really a predictor of outcome?

Most of the literature on the alliance-outcome association is based exclusively on differences between patient reports on alliance. Much less is known about the unique contribution of the therapist's report to this association across treatment, that is, the association between therapist-reported alliance and outcome over the course of treatment, after controlling for the patient's contribution. The present study is the first to examine the unique contribution of the therapist-reported alliance to outcome, accounting for reverse causation (symptomatic levels predicting alliance), at several time points in the course of treatment. Of 156 patients randomized to dynamic supportive-expressive psychotherapy, antidepressant medication with clinical management, and placebo with clinical management, 149 were included in the present study. Alliance was assessed from the perspective of both the patient and the therapist. Outcome measures included the patients' self-reported and diagnostician-rated depressive symptoms. Overall, the findings demonstrate that the therapists' contribution to the alliance-outcome association was explained mainly by prior symptomatic levels. However, when a time lag of several sessions was introduced between alliance and symptoms, a positive association emerged between alliance at 1 time point and symptomatic distress assessed several sessions later in the treatment, controlling for previous symptomatic level. The findings were similar whether or not we controlled for the patient's perspective on the alliance. Taken together, the findings attest to the importance of improving therapists' ability to detect deterioration in the alliance.

The impact of age and gender on resource utilization and profitability in ED patients seen and released

ObjectiveTo determine how age and gender impact resource utilization and profitability in patients seen and released from an Emergency Department (ED). MethodsBilling data for patients seen and released from an Emergency Department (ED) with >100,000 annual visits between 2003 and 2009 were collected. Resource utilization was measured by length of stay (placement in ED bed to leaving the bed) and direct clinical costs (e.g., ED nursing salary and benefits, pharmacy and supply costs, etc.) estimated using relative value unit cost accounting. The primary outcome of profitability was defined as contribution margin per hour. A patient's contribution margin by insurance type (excluding self-pay) was determined by subtracting direct clinical costs from facility contractual revenue. Results are expressed as medians and US dollars. ResultsIn 523 882 outpatient ED encounters, as patients' aged, length of stay and direct clinical cost increased while the contribution margin and contribution margin by hour decreased. Women of childbearing age (15-44) had higher median length of stay (2.1 hours), direct clinical cost ($149), and contribution margin per hour ($103/hour) than men of same age (1.7, $131, $85/hour, respectively). Resource utilization and profitability by gender were similar in children and adults over 45. ConclusionResource utilization increased and profitability decreased with increasing age in patients seen and released from an ED. The care of women of childbearing age resulted in higher resource utilization and higher profitability than men of the same age. No differences in resource utilization or profitability by gender were observed in children and adults over 45.

Patient and Therapist Perspectives on Alliance Development: Therapists' Practice Experiences as Predictors

Research has shown that the therapist's contribution to the alliance is more important for the outcome than the patient's contribution (e.g., Baldwin, Wampold, & Imel, 2007); however, knowledge is lacking about which therapist characteristics are relevant for alliance building and development. The objective of this study was to explore the development of the working alliance (using the Working Alliance Inventory), rated by both patients and therapists as a function of therapist in-session experiences. The therapist experiences were gathered by means of the Development of Psychotherapists Common Core Questionnaire (Orlinsky & Rønnestad, 2005). Data from the Norwegian Multisite Study of the Process and Outcome of Psychotherapy (Havik et al., 1995) were used. Multilevel growth curve analyses of alliance scores from Sessions 3, 12, 20 and 40 showed that the therapist factors predicted working alliance levels or growths differently, depending on whether the alliance was rated by patients or by therapists. For example, it emerged that therapists' negative reactions to patients and their in-session anxiety affected patient-rated alliance but not therapist-rated alliance, whereas therapist experiences of flow (Csikszentmihalyi, 1990) during sessions impacted only the therapist-rated alliance. The patterns observed in this study imply that therapists should be particularly aware that their negative experiences of therapy are noticed by, and seem to influence, their clients when they evaluate the working alliance through the course of treatment. The findings of this study suggest that the working alliance is influenced by therapists' self-reported practice experiences, which presumably are communicated through the therapists' in-session behaviours. The study found a notable divergence between practice experiences that influenced the therapists and those that influenced the patients when evaluating the working alliance. Specifically, practitioners' self-reported difficulties in practice, such as their negative reactions to patients and their in-session anxiety, affected patient-rated alliance but not therapist-rated alliance, whereas therapist experiences of 'flow' during sessions impacted only the therapist-rated alliance. Practitioners should note that patient alliance ratings were more likely to be influenced by therapists' negative practice experiences than by positive ones. The divergence in the patient and therapist viewpoints has potential implications for therapist training and supervision and everyday self-reflection.

Tuberculosis management time: an alternative parameter for measuring the tuberculosis infectious pool

To demonstrate the application of TB management time as an alternative parameter to estimate the size of the tuberculosis infectious pool in West Gojjam Zone of Amhara Region, Ethiopia. In this study, we used the TB management time, i.e. the number of days from start of cough until start of treatment, to determine the infectious period. Patients with sputum smear-positive and smear-negative pulmonary TB, retreatment and an estimated number of undetected cases were included. The infectious pool was then estimated as the annual number of infectious person days in a defined population. The TB management time of presently undiagnosed TB cases and sputum smear-positive patients contributed significantly to the infectious pool with 151,840 and 128,750 infectious person days per year, respectively. The total infectious pool including sputum smear-negative TB cases and retreatment patients in the study area was estimated at 325,410 person days or 15,447 person days per 100,000 population during the study year. Recording TB management time may be used to estimate the infectious pool of TB and to monitor programme performance in the community.

Therapist effects and the outcome–alliance correlation in cognitive behavioral therapy for panic disorder with agoraphobia

Although the alliance–outcome correlation is well established, no published studies to date have separated between therapists' and patients' contributions while controlling for early symptom change. In this study, we examined therapist effects in two trials of CBT for panic disorder with agoraphobia (PDA) and the impact of therapists' and patients' contribution to the alliance on outcome and attrition in one trial. Alliance ratings were obtained from patients and therapists early and late in treatment (n = 133). Data were analyzed using multi-level modeling controlling for early symptom change. No therapist effects were found. The patients' contribution to the alliance predicted outcome (in both panic severity and anxiety sensitivity) and attrition. The therapists' contribution to the alliance predicted attrition but not outcome. Results suggest that the patient's contribution to the alliance plays an important role in CBT for PDA and that including common factors into research on CBT may help elucidate treatment processes.

Quantification of patient compliance with Hawley retainers and removable functional appliances during the retention phase

The success of retention with removable retainers is highly dependent on efficient patient compliance. The aim of this study was to quantify patient compliance with removable retainers using microelectronic wear-time documentation during the retention phase. One hundred patients, between 13 and 20 years of age, were retained with removable Hawley retainers and functional appliance retainers after successful multibracket treatment at the University Hospital of Tübingen, Germany, and in 4 private practices in Germany. Microsensors were incorporated into the orthodontic retainers by polymerization, and daily wear time was documented in 15-minute intervals during the retention phase for up to 15 months. Patient compliance was quantified with wear-time documentation. Additionally, the influences of age, sex, place of treatment, device type, and health insurance status on compliance were determined and statistically evaluated. Most study participants complied with the prescribed wear time of 8 hours or more per day. Combined patient data indicated a median wear time of 7.0 hours per day over the evaluation period. Wear-time documentation showed either regular or irregular patterns of compliance. Initial compliance did not usually alter over the retention phase. Compliance was not influenced by device type, but age, sex, place of treatment, and insurance status produced changes in the median wear time of up to 50%. Electronic wear-time documentation of patients' compliance is an easily comprehensible measurement that allows orthodontists to examine the patient's contribution to the success of retention and personalize treatment accordingly. Place of treatment and health insurance status are more closely associated with compliance than are basic patient demographics.

Estimating the patient�s contribution during robot-assisted therapy

Robot-assisted therapy has become increasingly common in neurorehabilitation. Sophisticated controllers have been developed for robots to assist and cooperate with the patient. It is difficult for the patient to judge to what extent the robot contributes to the execution of a movement. Therefore, methods to comprehensively quantify the patient's contribution and provide feedback are of key importance. We developed a method comprehensively to estimate the patient's contribution by combining kinematic measures and the motor assistance applied. Inverse dynamic models of the robot and the passive human arm calculate the required torques to move the robot and the arm and build, together with the recorded motor torque, a metric (in percentage) that represents the patient's contribution to the movement. To evaluate the developed metric, 12 nondisabled subjects and 7 patients with neurological problems simulated instructed movement contributions. The results are compared with a common performance metric. The estimation shows very satisfying results for both groups, even though the arm model used was strongly simplified. Displaying this metric to patients during therapy can potentially motivate them to actively participate in the training.

Practical perspectives of personalized healthcare in oncology

There is an increasing prevalence of drug-diagnostic combinations in oncology. This has placed diagnostic stakeholders directly into the complex benefit-risk, cost, value and uncertainty-driven development paradigm traditionally the preserve of the drug development community. In this review we focus on the delivery of the clinical data required to advance such drug-diagnostic combination development programmes and ultimately satisfy regulators and payors of the value of contemporaneous changes in diagnostic and treatment practice. Ideally all stakeholders would like to initially estimate, and ultimately specify, the comparative benefit-risk for a new treatment option with and without changing diagnostic practice. Hence, in an ideal world clinical trial design is focused on acquiring biomarker treatment interaction data. In this review we describe the key scientific and feasibility inputs required to design and deliver such trials and the drivers, advantages and disadvantages associated with departing from this model. We do not discuss the discovery of new biomarkers nor the analytical validation and marketing of diagnostic products. Following on from trial design we describe how subsequent success then depends upon the concepts that guide trial design being driven into the complex world of large, multinational clinical trial delivery. For every aspect of a traditional clinical drug trial such as supply, recruitment and adherence, there is a corresponding concept for the diagnostic element. In practice, this means that each patient's contribution to the decision making data-set is subject to double jeopardy (attrition on clinical outcome and biomarker status). Historically, this has led to significantly reduced power for detecting biomarker-treatment interactions, reduced decision making confidence and a waste of valuable human and financial resources. We describe recent practice changes and experience that have led to the successful delivery of such trials focusing on both pre- and on trial aspects. The former includes the pivotal role of tissue banks in accurate estimation of evaluability and prevalence for biomarker assays and the latter several practices designed to engage and incentivize key stakeholders particularly CRAs and pathologists. The result is that in the new world of developing personalized treatments for cancer patients the real-time acquisition and monitoring of biomarker data receives similar support to that traditionally reserved for clinical outcome data and far more patients contribute to the testing of personalized medicine hypotheses.