Category: Clinical Trial

Effects of Cacao Flavonoids in Long COVID-19 Patients with Chronic Fatigue: FLALOC, a Placebo-Controlled Randomized Clinical Trial

Abstract:

Background: In the context of long COVID, persistent fatigue is among the most prevalent symptoms that can develop after SARS-CoV-2 infection. Mitochondrial myopathy and endothelial dysfunction, which are triggers of inflammation, have emerged as prominent causes of long COVID-induced fatigue. Interestingly, the intake of flavanols, particularly (−)-epicatechin (EC), has been associated with the positive modulation of endothelial and mitochondrial structure and function.
Methods: In this work, we conducted a randomized, double-blind, placebo-controlled clinical trial to determine whether an EC-enriched supplement (ECES) improves plasma markers of inflammation, endothelial structure, and fatigue-related endpoints in patients with long COVID-19.
Results: The study included 46 subjects (mean age 52 years) who were instructed to consume two capsules/day for 90 days of either ECES (n = 23) or placebo (n = 23). Endpoints assessed included mean changes in plasma inflammatory markers (IL-1β, IL-6, and TNF-α) and endothelial dysfunction markers (syndecan-1), handgrip strength, fatigue scale, and quality of life (QoL). The results showed significant improvements in the ECES group for inflammatory markers, syndecan-1, and fatigue compared with the placebo group.
Conclusions: The results yield intriguing positive findings for EC and open a new avenue for treating long COVID.
Source: Munguía L, Silva S, Villarreal F, Nájera N, Ceballos G. Effects of Cacao Flavonoids in Long COVID-19 Patients with Chronic Fatigue: FLALOC, a Placebo-Controlled Randomized Clinical Trial. Journal of Clinical Medicine. 2026; 15(4):1468. https://doi.org/10.3390/jcm15041468 https://www.mdpi.com/2077-0383/15/4/1468 (Full text)

Vitamin D in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome After COVID-19 or Vaccination: A Randomized Controlled Trial

Abstract:

Background: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) can develop as post-vaccination syndrome (PVS) or Post-Acute Sequelae of SARS-CoV-2 infection (PASC). In our prior retrospective study, most patients with PVS who developed ME/CFS had vitamin D insufficiency or deficiency. We evaluated the efficacy of vitamin D replacement therapy guidance for ME/CFS symptom improvement in patients with vitamin D insufficiency or deficiency.

Methods: This open-label randomized controlled trial enrolled 91 participants with ME/CFS as PVS or PASC and serum 25(OH) vitamin D < 30 ng/mL across five clinical sites. Participants were randomized 1:1 to intervention (active vitamin D preparation plus vitamin D replacement therapy guidance: 25 μg daily supplementation, dietary counseling, sun exposure, and exercise) or control (active vitamin D preparation alone) for 12 weeks. The primary endpoint was the change in ME/CFS symptom count from screening to Week 12.

Results: Mean symptom change was -6.7 in the intervention group versus -1.2 in the control group (between-group difference -5.6; 95% CI: -7.2, -3.9; p < 0.001). Serum 25(OH) vitamin D improved from 18.6 to 27.1 ng/mL in the intervention group, while the control group showed a decreasing trend (between-group difference 10.2 ng/mL; 95% CI: 7.9, 12.5). Achievement of <8 symptoms (i.e., no longer meeting ME/CFS diagnostic criteria) was significantly higher in the intervention group, with 16 participants achieving this threshold compared to 1 in the control group (p < 0.001). Subgroup analyses showed consistent benefit in both PVS (n = 56) and PASC (n = 29) cohorts.

Conclusions: Vitamin D replacement therapy guidance significantly reduced ME/CFS symptoms along with improvement of serum 25(OH) vitamin D levels in patients with vitamin D insufficiency or deficiency who developed ME/CFS as PVS or PASC.

Source: Kodama S, Nakata M, Konishi N, Yoshino M, Fujisawa A, Naganuma M, Kobayashi Y, Hirai Y, Kitagawa A, Miyokawa M, Mishima R, Teramukai S, Fukushima M. Vitamin D in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome After COVID-19 or Vaccination: A Randomized Controlled Trial. Nutrients. 2026 Feb 3;18(3):521. doi: 10.3390/nu18030521. PMID: 41683343. https://www.mdpi.com/2072-6643/18/3/521 (Full text)

Effects of recumbent isometric yoga on the daily functioning level of patients with myalgic encephalomyelitis/chronic fatigue syndrome: a randomized, controlled trial

Abstract:

Background: Although seated isometric yoga has been shown to reduce the fatigue and pain of patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), some patients who are for the most part bedridden have difficulty practicing it. Many patients with this disease also suffer from fibromyalgia (FM). We developed a recumbent isometric yoga program for patients who were for the most part bedridden, including patients with comorbid FM. The aim of this study was to investigate the effect of this recumbent isometric yoga intervention with such patients.

Methods: This was a randomized, controlled trial of 48 adult patients (7 male, 41 female, age 20-70 years) with ME/CFS without satisfactory improvement after ≥ 3 months of conventional therapy. They were divided randomly into a yoga group (n = 24) and a control group (n = 24). The yoga group received conventional therapy with recumbent isometric yoga practice for ~ 12 weeks (25-min sessions with a yoga instructor at hospital visits and daily in-home sessions). The control group received conventional therapy alone. The effect of recumbent isometric yoga on the level of functioning was assessed by measuring Performance Status (PS). Fatigue was assessed with self-rated questionnaires, including the Chalder Fatigue Scale (FS) and Profile of Mood States (POMS). Adverse events and benefits were recorded for the yoga group.

Results: After the intervention period, the PS score of the yoga group was significantly lower than that of the control group (P < 0.001), suggesting an improvement in functioning level. The Chalder FS score decreased in both groups, but the decrease was greater in the yoga group than in the control group (P < 0.01). Subgroup analysis showed that the Chalder FS score was reduced significantly only in the yoga group in patients with severe disease (P < 0.001) and those with comorbid FM (P < 0.01), although the PS scores did not differ significantly. In the yoga group, a single practice session with a yoga instructor significantly reduced fatigue and increased vigor in patients with severe disease and patients with comorbid FM. Patients reported no serious adverse effects and many benefits of recumbent isometric yoga, including improvements in physical symptoms and brain fog, enhanced awareness of their limits to activities that cause post-exertional malaise, and promotion of behavioral changes to live better within their limits.

Conclusions: Recumbent isometric yoga is an effective adjunctive therapy for patients with ME/CFS, including those for the most part bedridden and those who have FM.

Trial registration: University Hospital Medical Information Network (UMIN CTR) UMIN000023472 (Registered Aug. 4, 2016) and UMIN000030051 (Registered Nov. 20, 2017).

Source: Oka T, Lkhagvasuren B, Yamada Y. Effects of recumbent isometric yoga on the daily functioning level of patients with myalgic encephalomyelitis/chronic fatigue syndrome: a randomized, controlled trial. Biopsychosoc Med. 2025 Oct 10;19(1):19. doi: 10.1186/s13030-025-00339-7. PMID: 41074089; PMCID: PMC12512564. https://pmc.ncbi.nlm.nih.gov/articles/PMC12512564/ (Full text)

Pacing with a heart rate monitor for people with myalgic encephalomyelitis/chronic fatigue syndrome and long COVID: a feasibility study

Abstract:

Background: People living with ME/CFS and LC frequently live with post-exertional malaise (PEM), which is associated with impairments in aerobic metabolism. They often use pacing with a heart rate monitor (HRM) to minimize time spent above the anaerobic threshold; however, there is limited research on the feasibility and efficacy.

Objective: To establish the acceptability, adherence, outcomes, and adverse events associated with pacing with an HRM for a future definitive study.

Methods: After informed consent and baseline measurements (including 10 min stand test, 5 questionnaires, accelerometry, heart rate variability, and lactate), participants were randomized into a control or intervention group using simple randomization and sealed envelopes. The intervention group used a heart rate monitor with weekly online HRM pacing advice (how to use the HRM, problem solving), and the control group received weekly online pacing advice (how to pace, problem solving). Follow-up measures were repeated, and semi-structured interviews were conducted at two and six months post-enrolment.

Results: 47 participants were recruited; however, recruiting people with LC was difficult due to wanting to use/already using HR monitoring. The interviews identified that the procedure was acceptable, and the majority of the participants completed the outcome measures. There were some changes from baseline to follow-up in all the outcome measures except the 10-minute stand test and accelerometry. There were no serious adverse events. Follow-up interviews identified 89% continued using HRM at 8 weeks and 66% after 6 months.

Conclusions: Studies of HRM are feasible and acceptable for ME/CFS and LC, although recruitment strategies should be reviewed for LC.

Clinical Trial registration number: ISRCTN10554129.

Source: Clague-Baker, N., Davenport, T. E., Wickens, B., Leeming, H., Dickinson, K., McBurney, E., … Hilliard, N. (2025). Pacing with a heart rate monitor for people with myalgic encephalomyelitis/chronic fatigue syndrome and long COVID: a feasibility study. Fatigue: Biomedicine, Health &amp; Behavior, 1–23. https://doi.org/10.1080/21641846.2025.2565103 https://www.tandfonline.com/doi/full/10.1080/21641846.2025.2565103#abstract (Full text)

Relationships between fatigue, cognitive function, and upright activity in a randomized trial of oxaloacetate for myalgic encephalomyelitis/chronic fatigue syndrome

Abstract:

Background: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a debilitating condition characterized by fatigue, cognitive impairment, and reduced physical function. Oxaloacetate (OAA), a metabolic compound with potential mitochondrial and neuroprotective effects, has shown promise in reducing fatigue symptoms in ME/CFS. However, the interrelationships between fatigue, cognitive performance, and physical activity and their responsiveness to treatment remain poorly understood in ME/CFS.

Methods: This 90-day randomized, double-blind, controlled trial evaluated the effects of 2,000 mg/day OAA or a control of 2,000 mg rice flour in 82 adults with ME/CFS. Self-reported fatigue (Chalder Fatigue Questionnaire), cognitive function (DANA Brain Vital), and upright activity time (UP Time) were assessed at baseline and three follow-up visits. Linear mixed-effects models examined associations between fatigue severity and cognitive/physical function, with treatment group interactions. Responder status at the last visit (Visit 4) was classified based on ≥15% fatigue reduction and/or ≥10% cognitive improvement.

Results: The OAA group showed greater cognitive improvement over time, with a significant between-group difference at Visit 3, 60 days into the trial, (p = 0.034) and trends at other visits. Higher fatigue was significantly associated with reduced cognitive gains in the OAA group (β = −0.34, p < 0.0001), but not in controls. UP Time increased modestly in the OAA group, reaching significance at Visit 2, day 30 (p = 0.044), though fatigue was not a strong predictor of UP Time in either group. At Visit 4, day 90, Global and Fatigue Only Responders were more frequent in the OAA group, while Cognitive Only Responders were more frequent in controls, though group differences did not reach statistical significance (p = 0.10).

Conclusion: OAA supplementation was associated with improved cognitive performance and small improvement in UP Time in ME/CFS participants receiving OAA. Fatigue–cognition coupling was particularly strong in OAA-treated participants, suggesting a potentially targetable phenotype. These findings underscore the importance of multidimensional outcome measures in ME/CFS clinical trials and support the need for more research and trials of metabolic interventions in ME/CFS.

Source: Vernon Suzanne D. , Rond Candace , Sun Yifei , Roundy Shad , Bell Jennifer , Rond Bella , Kaufman David L. , Cash Alan B. , Yellman Brayden , Bateman Lucinda. Relationships between fatigue, cognitive function, and upright activity in a randomized trial of oxaloacetate for myalgic encephalomyelitis/chronic fatigue syndrome. Frontiers in Neurology, Volume 16 – 2025. DOI=10.3389/fneur.2025.1691147 ISSN=1664-2295 https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2025.1691147/full (Full text)

Solriamfetol improves daily fatigue symptoms in adults with myalgic encephalomyelitis/chronic fatigue syndrome after 8 weeks of treatment

Abstract:

Background: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a long-term illness with no treatment options that address the disease directly. Solriamfetol is a selective dual norepinephrine-dopamine reuptake inhibitor that promotes wakefulness in obstructive sleep apnea and narcolepsy.

Aims: This study evaluated the efficacy and safety of solriamfetol for fatigue symptoms in adults with ME/CFS over 8 weeks of treatment.

Methods: This was a phase 4, double-blind, randomized, placebo-controlled trial of solriamfetol in adults with ME/CFS. Eligible participants (N = 38) were randomly assigned to receive 75 mg (titrated to 150 mg as needed) solriamfetol or placebo. Participants completed a battery of assessments at weekly visits. The primary outcome was Fatigue Symptom Inventory (FSI) scores, and the secondary outcome measure was Behavioral Rating Inventory of Executive Function for Adults (BRIEF-A), at Weeks 6 and 8. T-tests assessed the differences in mean change from baseline between solriamfetol and placebo. Adverse events were monitored throughout the study.

Results: At Week 8 (p = 0.039), but not Week 6 (p = 0.270), solriamfetol improved FSI severity compared to placebo. On the BRIEF-A global executive composite, solriamfetol improved more than placebo at Week 8 (p = 0.012), driven by improved metacognition index (p = 0.004), but not behavioral regulation index (p = 0.574). Solriamfetol was well tolerated, with most common AEs being sleep loss and headaches.

Conclusions: Solriamfetol demonstrated good safety and efficacy in improving fatigue and executive functioning in patients with ME/CFS. As a dual norepinephrine-dopamine reuptake inhibitor and wakefulness-promoting factors, solriamfetol has the potential to improve fatigue symptoms of ME/CFS.

Clinical trial number: NCT04622293.

Source: Young JL, Powell RN, Powell A, Welling LLM, Granata L, Saal J. Solriamfetol improves daily fatigue symptoms in adults with myalgic encephalomyelitis/chronic fatigue syndrome after 8 weeks of treatment. J Psychopharmacol. 2025 Sep 16:2698811251368371. doi: 10.1177/02698811251368371. Epub ahead of print. PMID: 40958377. https://journals.sagepub.com/doi/10.1177/02698811251368371

Pyridostigmine and low-dose naltrexone for ME/CFS: study protocol for the Life Improvement Trial (LIFT), a randomized, double-blind, placebo-controlled clinical trial

Abstract:

Background: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, chronic disease with no FDA-approved treatments. This report describes a protocol for the Life Improvement Trial (LIFT), a randomized, double-blind, placebo-controlled clinical trial investigating the impact of low-dose naltrexone (LDN) and pyridostigmine (Mestinon) on physiological response, symptoms, and functionality of ME/CFS patients.

Methods: Participants (target n = 160) are recruited through clinics at Massachusetts General Hospital and Brigham and Women’s Hospital, and through Open Medicine Foundation’s StudyME registry. They are then randomized into one of four arms: LDN/pyridostigmine, LDN/placebo, placebo/pyridostigmine, placebo/placebo. Treatment is administered for 13 weeks after an initial screening period of up to 4 weeks. Primary outcomes are FUNCAP-55 score, peak oxygen utilization, heart rate recovery, and oxygen uptake efficiency slope. Secondary outcomes are scores from DSQ-PEM and PROMIS-29 surveys, DANA Brain Vital score, step count, heart rate, and heart rate variability.

Discussion: The results of this trial will provide novel insights into the efficacy of and predictors of response to LDN and pyridostigmine in ME/CFS. This may inform future treatment strategies for ME/CFS. The trial will also validate what primary and secondary outcomes to use in similar clinical trials.

Source: Danielle Meadows, Johanna Squires, Joshua Dibble et al. Pyridostigmine and low-dose naltrexone for ME/CFS: study protocol for the Life Improvement Trial (LIFT), a randomized, double-blind, placebo-controlled clinical trial, 04 March 2025, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-5626167/v1]

Beneficial effects of intermittent intravenous saline infusion in dysautonomic patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: a caseseries

Abstract:

Purpose. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a debilitating condition with no single, uniformly effective pharmacologic therapy. Dysautonomic features like orthostatic intolerance and postural tachycardia syndrome are common features in ME/CFS, severely affecting the patient´s quality-of-life. Intermittent saline infusion may reduce symptoms associated with dysautonomia, but this has not been tested scientifically in patients with ME/CFS.

In this case-series, 22 patients with ME/CFS and signs of dysautonomia and/or hypovolemia were treated every third week over 9 weeks with intravenous saline (9 mg/mL NaCl), using standard aseptic technique. Symptoms were monitored throughout the treatment regime, and a follow-up evaluation was conducted.

Results. At treatment start, patients were predominantly female (95%), at mean age 46 ± 10 years, and with a mean body hydration percentage of 48 ± 6. Self-reported health status revealed an overall symptom score of 47 ± 13 on a 0-96 scale, a median POTS score of 64 (IQR 16) on a 0-120 scale, and poor measures of quality-of-life (median 25 IQR 25, on a 0-100 scale) and abilityto-work (median 0, IQR 26, on a 0-100 scale). Following 9 weeks of intermittent saline infusion (mean volume 1600 ± 360 mL), self-reported composite symptom score, quality-of-life and POTS-related symptoms improved significantly (all p<0.001), as did ability-to-work (p<0.05).

Our data derived from a non-controlled case-series indicate health benefits from volume loading with intermittent infusion of saline among patients with ME/CFS, which may stimulate further studies on various forms of intravenous volume loading to patients with ME/CFS and dysautonomia.

Source: Per Sjogren, Helena Huhmar, Bo Christer Bertilson, Björn A Bragée, Olli Polo. Beneficial effects of intermittent intravenous saline infusion in dysautonomic patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: a caseseries. Front. Neurol., Sec. Autonomic Disorders, Volume 16 – 2025 | doi: 10.3389/fneur.2025.1601599 https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2025.1601599/abstract

Plasma cell targeting with the anti-CD38 antibody daratumumab in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) -a clinical pilot study

Abstract:

Background: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) entails low quality of life for patients and massive societal costs. There is an urgent need for elucidation of disease mechanisms and for rational treatment. Our working hypothesis is that ME/CFS in a subgroup of patients is associated with functional autoantibodies emerging after an infection, and that plasma-cell depletion with transient reductions in serum immunoglobulins will have a beneficial effect on symptoms.

Objective: To evaluate feasibility and toxicity of plasma-cell targeting treatment using subcutaneous anti-CD38 antibody daratumumab (Darzalex) in moderate to severe ME/CFS, and to assess the clinical course through 12-24 months follow-up. Methods: We performed an open-label pilot trial (EudraCT 2022-000281-18). Ten female patients were enrolled. Following 12 weeks run-in, six patients received four daratumumab injections. The next four patients received four, followed by three additional injections from week 20.

Results: All planned treatments were administered, and there were no serious adverse events. Four patients had no significant clinical changes. Six patients experienced marked improvement. For all ten patients, mean SF-36 Physical Function (SF-36 PF) increased from 25.9 to 55.0 at eight to nine months (p=0.002). In six responders, mean SF-36 PF increased from 32.2 to 78.3. Five of these had major and sustained improvement with a mean SF-36 PF of 88 (range 80 to 95) toward end of follow-up. Mean steps per 24 hours was 3359 (range 1493 to 6277) at baseline. At eight to nine months, the mean number of steps was 5862, and 7392 in the six responders. All five patients with sustained improvement reached a mean step count above 10000/24h for some weeks, and above 15000 on individual days. Relative reduction of serum IgG levels was 54% in patients with clinical improvement, and 40% in those with no benefit. Low baseline NK-cell count in blood was associated with lack of clinical response.

Conclusion: Subcutaneous daratumumab was well tolerated. In six ME/CFS patients, treatment was associated with clinical improvement and concurrent transient reduction of serum IgG levels, indicating pathomechanistic roles for long-lived plasma cells and functional autoantibodies. No definite conclusions should be drawn before a randomized study has been performed.

See: Correction

Source: Øystein Fluge, Ingrid Gurvin Rekeland, Kari Sørland, Kine Alme. Kristin Risa, Ove Bruland, Karl Johan Tronstad, Olav Mella. Plasma cell targeting with the anti-CD38 antibody daratumumab in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) -a clinical pilot study.
Front. Med., Sec. Infectious Diseases: Pathogenesis and Therapy, Volume 12 – 2025 | doi: 10.3389/fmed.2025.1607353  https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2025.1607353/abstract

Multimodal Web-Based Telerehabilitation for Patients With Post-COVID-19 Condition: Protocol for a Randomized Controlled Trial

Abstract:

Background: Patients with post-COVID-19 condition (PCC) experience persistent, long-term health consequences following SARS-CoV-2 infection, including fatigue, hyperventilation, cognitive impairment, and limitations in daily activities. There is emerging evidence suggesting that exercise and respiratory therapy-based telerehabilitation is safe and could potentially improve physical capacity while reducing health care costs.

Objective: This study aims to evaluate the superiority of a multimodal, symptom-titrated telerehabilitation program over standard care in patients with PCC who are severely affected, using the highest oxygen uptake rate (VO2peak [mL/min/kg]) achieved during the cardiopulmonary exercise test (CPET) and minute ventilation/carbon dioxide production slope (VE/VCO2 [full slope]) as primary outcomes. In addition, this study seeks to provide novel insights into the clinical and physiological adaptations associated with PCC, informing future rehabilitation strategies.

Methods: This prospective, randomized, waitlist-controlled trial was approved by the Rhineland-Palatinate Medical Association ethics committee. All procedures comply with the Declaration of Helsinki. This study comprises 3 examination time points, which include patient-reported outcomes, clinical assessments, and a CPET. It is structured into an 8-week intervention phase followed by an 8-week follow-up phase. Following baseline assessment, patients will be randomly assigned to either the intervention group (IG) or the control group (CG). During the intervention phase, IG participants will receive a web-based, multimodal, symptom-titrated telerehabilitation program consisting of sports medicine consultations, weekly teleconsultations, a structured pacing approach, and exercise and respiratory therapy. In contrast, CG participants will receive treatment as usual, which includes a single sports medicine consultation on healthy habits and a self-directed pacing approach for managing symptoms and daily activities. During the follow-up phase, IG participants will continue training independently without teleconsultations, whereas CG participants will undergo the same telerehabilitation intervention as the IG. A follow-up assessment will be conducted for both groups to evaluate long-term effects. This study adheres to the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guidelines and follows the Consensus on Exercise Reporting Template.

Results: Recruitment began in August 2023 and was extended until March 2025. As of March 2025, 80 participants have been recruited, and data analysis is ongoing. Final results are expected by December 2025, with a cross-sectional analysis of baseline data anticipated by July 2025.

Conclusions: This study is the first randomized controlled trial investigating the effectiveness of multimodal and symptom-titrated telerehabilitation in patients with PCC who are severely affected. The integration of various objective diagnostic systems will provide valuable insights into emerging postviral fatigue syndromes, supporting the development of CPET-based diagnostics, personalized rehabilitation strategies, and future research on long-term telerehabilitation effectiveness. The findings will be disseminated through peer-reviewed publications, professional networks, and patient advocacy groups to ensure scientific, clinical, and public impact.

Trial registration: German Clinical Trials Register (DRKS) DRKS00032394; https://drks.de/search/de/trial/DRKS00032394.

Source: Tomaskovic A, Weber V, Ochmann DT, Neuberger EW, Lachtermann E, Brahmer A, Haller N, Hillen B, Enders K, Eggert V, Zeier P, Lieb K, Simon P. Multimodal Web-Based Telerehabilitation for Patients With Post-COVID-19 Condition: Protocol for a Randomized Controlled Trial. JMIR Res Protoc. 2025 May 21;14:e65044. doi: 10.2196/65044. PMID: 40397936. https://www.researchprotocols.org/2025/1/e65044 (Full text)