Precision rehabilitation for aphasia by patient age, sex, aphasia severity, and time since stroke? A prespecified, systematic review-based, individual participant data, network, subgroup meta-analysis

BACKGROUND

Stroke rehabilitation interventions are routinely personalized to address individuals' needs, goals, and challenges based on evidence from aggregated randomized controlled trials (RCT) data and meta-syntheses. Individual participant data (IPD) meta-analyses may better inform the development of precision rehabilitation approaches, quantifying treatment responses while adjusting for confounders and reducing ecological bias.

AIM

We explored associations between speech and language therapy (SLT) interventions frequency (days/week), intensity (h/week), and dosage (total SLT-hours) and language outcomes for different age, sex, aphasia severity, and chronicity subgroups by undertaking prespecified subgroup network meta-analyses of the RELEASE database.

METHODS

MEDLINE, EMBASE, and trial registrations were systematically searched (inception-Sept2015) for RCTs, including ⩾ 10 IPD on stroke-related aphasia. We extracted demographic, stroke, aphasia, SLT, and risk of bias data. Overall-language ability, auditory comprehension, and functional communication outcomes were standardized. A one-stage, random effects, network meta-analysis approach filtered IPD into a single optimal model, examining SLT regimen and language recovery from baseline to first post-intervention follow-up, adjusting for covariates identified a-priori. Data were dichotomized by age (⩽/> 65 years), aphasia severity (mild-moderate/ moderate-severe based on language outcomes' median value), chronicity (⩽/> 3 months), and sex subgroups. We reported estimates of means and 95% confidence intervals. Where relative variance was high (> 50%), results were reported for completeness.

RESULTS

959 IPD (25 RCTs) were analyzed. For working-age participants, greatest language gains from baseline occurred alongside moderate to high-intensity SLT (functional communication 3-to-4 h/week; overall-language and comprehension > 9 h/week); older participants' greatest gains occurred alongside low-intensity SLT (⩽ 2 h/week) except for auditory comprehension (> 9 h/week). For both age-groups, SLT-frequency and dosage associated with best language gains were similar. Participants ⩽ 3 months post-onset demonstrated greatest overall-language gains for SLT at low intensity/moderate dosage (⩽ 2 SLT-h/week; 20-to-50 h); for those > 3 months, post-stroke greatest gains were associated with moderate-intensity/high-dosage SLT (3-4 SLT-h/week; ⩾ 50 hours). For moderate-severe participants, 4 SLT-days/week conferred the greatest language gains across outcomes, with auditory comprehension gains only observed for ⩾ 4 SLT-days/week; mild-moderate participants' greatest functional communication gains were associated with similar frequency (⩾ 4 SLT-days/week) and greatest overall-language gains with higher frequency SLT (⩾ 6 days/weekly). Males' greatest gains were associated with SLT of moderate (functional communication; 3-to-4 h/weekly) or high intensity (overall-language and auditory comprehension; (> 9 h/weekly) compared to females for whom the greatest gains were associated with lower-intensity SLT (< 2 SLT-h/weekly). Consistencies across subgroups were also evident; greatest overall-language gains were associated with 20-to-50 SLT-h in total; auditory comprehension gains were generally observed when SLT > 9 h over ⩾ 4 days/week.

CONCLUSIONS

We observed a treatment response in most subgroups' overall-language, auditory comprehension, and functional communication language gains. For some, the maximum treatment response varied in association with different SLT-frequency, intensity, and dosage. Where differences were observed, working-aged, chronic, mild-moderate, and male subgroups experienced their greatest language gains alongside high-frequency/intensity SLT. In contrast, older, moderate-severely impaired, and female subgroups within 3 months of aphasia onset made their greatest gains for lower-intensity SLT. The acceptability, clinical, and cost effectiveness of precision aphasia rehabilitation approaches based on age, sex, aphasia severity, and chronicity should be evaluated in future clinical RCTs.

RELEASE: a protocol for a systematic review based, individual participant data, meta- and network meta-analysis, of complex speech-language therapy interventions for stroke-related aphasia

BACKGROUND

Speech and language therapy (SLT) benefits people with aphasia following stroke. Group level summary statistics from randomised controlled trials hinder exploration of highly complex SLT interventions and a clinically relevant heterogeneous population. Creating a database of individual participant data (IPD) for people with aphasia aims to allow exploration of individual and therapy-related predictors of recovery and prognosis.

AIM

To explore the contribution that individual participant characteristics (including stroke and aphasia profiles) and SLT intervention components make to language recovery following stroke.

METHODS AND PROCEDURES

We will identify eligible IPD datasets (including randomised controlled trials, non-randomised comparison studies, observational studies and registries) and invite their contribution to the database. Where possible, we will use meta- and network meta-analysis to explore language performance after stroke and predictors of recovery as it relates to participants who had no SLT, historical SLT or SLT in the primary research study. We will also examine the components of effective SLT interventions.

OUTCOMES AND RESULTS

Outcomes include changes in measures of functional communication, overall severity of language impairment, auditory comprehension, spoken language (including naming), reading and writing from baseline. Data captured on assessment tools will be collated and transformed to a standardised measure for each of the outcome domains.

CONCLUSION

Our planned systematic-review-based IPD meta- and network meta-analysis is a large scale, international, multidisciplinary and methodologically complex endeavour. It will enable hypotheses to be generated and tested to optimise and inform development of interventions for people with aphasia after stroke.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42018110947).

Chronic exposure to inorganic mercury induces biochemical and morphological changes in the salivary glands of rats

Mercury exposure is considered to be a public health problem due to the generation of toxic effects on human health as a result of environmental and occupational conditions. The inorganic form of mercury (HgCl₂) can cause several biological changes in cells and tissues through its cumulative toxic potential, but little has been experimentally proven about the effects of inorganic mercury on salivary glands, an important modulator organ of oral health. This study analyzes the effects of prolonged low dose exposure to HgCl₂ on the salivary glands of rats. Adult animals received a dose of 0.375 mg kg^-1 day^-1 over a period of 45 days. The parotid and submandibular glands were collected for analysis of the mercury levels and evaluation of oxidative stress, histological parameters and immunomodulation for metallothionein I and II (MT-I/II). In this investigation, biochemical and tissue changes in the salivary glands were verified due to the mercury levels, causing reduction in antioxidant capacity against peroxyl radicals, with consequent cellular lipid peroxidation and an increase in nitrite levels, volumetric changes and cytoskeletal damage in the submandibular glands, with less severe damage to the parotid glands. The results also have shown the occurrence of a cytoprotection mechanism due to increased MT-I/II expression, but not enough to avoid the morphology and oxidative damage. This evidence highlights, for the first time, that inorganic mercury is able to alter the morphology and oxidative biochemistry in salivary glands when exposed for a long time in low doses.

Evaluation of genome similarities using the non-decimated wavelet transform

The wavelets have become increasingly popular in the field of bioinformatics due to their capacity in multiresolution analysis and space-frequency localization; the latter particularity is acquired due to a moving window that runs through the analyzed space. As a feature, they have a better ability to capture hidden components of biological data and an efficient link between biological systems and the mathematical objects used to describe them. The decomposition of signals/sequences at different levels of resolution allows obtaining distinct characteristics in each level. The energy (variance) obtained at each level provides a new set of information that can be used to search similarities between sequences. We show that the behavior of GC-content sequence can be succinctly described regarding the non-decimated wavelet transform, and we indicate how this characterization can be used to improve clustering of the similar strains of the genome of the Mycobacterium tuberculosis, having a very efficient level of detail. The clustering analysis using the energy obtained at each level of the analyzed sequences was essential to verify the dissimilarity of the sequences.

Addition of insulin-like growth factor I to the maturation medium of bovine oocytes subjected to heat shock: effects on the production of reactive oxygen species, mitochondrial activity and oocyte competence

This study was performed to investigate the effects of insulin-like growth factor-I (IGF-I) addition to in vitro maturation (IVM) medium on apoptosis, mitochondrial membrane potential, ROS production, and developmental competence of bovine oocytes subjected to heat shock. Two temperatures (conventional: 24 h at 38.5°C, or heat shock: 12 h at 41°C followed by 12 h at 38.5°C) and 3 IGF-I concentrations (0, 25, and 100 ng/mL) were tested during IVM. The oocytes were then fertilized in vitro, and the presumptive zygotes were cultured until reaching the blastocyst stage. There was no interaction between temperature and IGF-I concentration for any variable evaluated (P > 0.05). The addition of IGF-I did not alter the proportion of nuclear maturation, TUNEL-positive oocytes and caspase-3 activity, or blastocyst proportion on Days 7 and 8 post-fertilization. Furthermore, the total number of cells and the number of cells in the inner cell mass (ICM) in the blastocyst were not altered (P > 0.05). However, IGF-I increased (P < 0.05) the mitochondrial membrane potential and the production of ROS in oocytes and decreased (P < 0.05) the proportion of apoptotic cells in the ICM in blastocysts. Heat shock increased (P < 0.05) the proportion of TUNEL-positive oocytes and ROS production and reduced (P < 0.05) the mitochondrial membrane potential. Moreover, heat shock increased (P < 0.05) the apoptosis proportion in the ICM cells. In conclusion, supplementing IVM medium with IGF-I may increase the mitochondrial membrane potential and ROS production in oocytes and decrease apoptosis in the ICM in blastocysts. Heat shock for 12 h compromised oocyte developmental competence and increased apoptosis within the ICM cells of the blastocysts.

Factor analysis using mixed models of multi-environment trials with different levels of unbalancing

This study aimed to analyze the robustness of mixed models for the study of genotype-environment interactions (G x E). Simulated unbalancing of real data was used to determine if the method could predict missing genotypes and select stable genotypes. Data from multi-environment trials containing 55 maize hybrids, collected during the 2005-2006 harvest season, were used in this study. Analyses were performed in two steps: the variance components were estimated by restricted maximum likelihood, using the expectation-maximization (EM) algorithm, and factor analysis (FA) was used to calculate the factor scores and relative position of each genotype in the biplot. Random unbalancing of the data was performed by removing 10, 30, and 50% of the plots; the scores were then re-estimated using the FA model. It was observed that 10, 30, and 50% unbalancing exhibited mean correlation values of 0.7, 0.6, and 0.56, respectively. Overall, the genotypes classified as stable in the biplot had smaller prediction error sum of squares (PRESS) value and prediction amplitude of ellipses. Therefore, our results revealed the applicability of the PRESS statistic to evaluate the performance of stable genotypes in the biplot. This result was confirmed by the sizes of the prediction ellipses, which were smaller for the stable genotypes. Therefore, mixed models can confidently be used to evaluate stability in plant breeding programs, even with highly unbalanced data.

Colostrum composition of Santa Inês sheep and passive transfer of immunity to lambs

This study aimed to analyze the chemical composition and the IgG concentration of the colostrum, transitional milk, and mature milk of Santa Inês ewes as well as the transfer of passive immunity to lambs. Thirty-two pregnant ewes and 38 lambs were used. Ewes were milked immediately after lambing and at 12, 24, 36 h and 10 d postpartum. Colostrum was provided to the lambs at 40±15 min (mean±SE) after birth and then at 30-min intervals for obtaining the intake closest to 10% of body weight, and transitional milk was provided ad libitum. Blood from the lambs was collected 36 h after birth for measuring the serum concentrations of IgG, total protein, albumin, and gamma-globulin. The production was lower in primiparous than in multiparous ewes with body condition score (BCS)<2.75, but did not differ between primiparous and multiparous with BCS≥2.75 (interaction parity and BCS). The IgG concentration and fat, protein, lactose, and defatted dry extract percentages were not affected by the BCS of the ewe at lambing or by the parity. The total solids percentage in the colostrum was higher in ewes with BCS<2.75 (interaction BCS and time). The production and the protein, total solid, and defatted dry extract percentages showed quadratic behavior, the fat percentage decreased linearly, and the lactose percentage increased linearly with time postpartum. The IgG concentration in the colostrum was not correlated with the ewe's weight or BCS at the time of lambing. Moreover, the parity, the BCS, the ewe's type of gestation, and the lamb's sex did not influence the serum concentrations of IgG, total protein, albumin, and gamma-globulin in lambs. Adequate passive immune transfer (PIT) was observed in lambs for which the IgG intake was higher than 30 g. Failure in PIT was observed in 39.5% of lambs when considering a serum IgG concentration lower than 15 mg/mL and in 21% when considering a serum total protein concentration lower than 45 mg/mL. The mean apparent efficiency of absorption was 38.10%, with values between 0.02% and 98.80%. The serum IgG concentration was correlated with the total protein concentration (according to the enzymatic colorimetric method), the gamma-globulin concentration, and the absorption efficiency. The extreme variation on apparent efficiency of absorption may have an effect on the success of PIT. Lambs should consume at least 30 g of IgG in the first 24 h of life to ensure adequate PIT.

Validation of prediction equations to estimate the energy values of feedstuffs for broilers: performance and carcass yield

The objective was to evaluate the use of prediction equations based on the chemical composition of feedstuffs to estimate the values of apparent metabolisable energy corrected for nitrogen balance (AMEn) of corn and soybean meal for broilers. For performance and carcass characteristics, 1,200 one-d-old birds (male and female) were allotted to a completely randomised factorial 2×8 (two genders and eight experimental diets) with three replicates of each sex with 25 birds. In the metabolism trial, 240 eight-d-old birds were distributed in the same design, but with a split plot in time (age of evaluation) with five, four and three birds per plot, respectively, in stages 8 to 21, 22 to 35, and 36 to 42 d of age. The treatments consisted of the use of six equations systems to predict the AMEn content of feedstuffs, tables of food composition and AMEn values obtained by in vivo assay, totalling eight treatments. Means were compared by Scott-Knott test at 5% probability and a confidence interval of 95% was used to check the fit of the energy values of the diets to the requirements of the birds. As a result of this study, the use of prediction equations resulted in better adjustment to the broiler requirements, resulting in better performance and carcass characteristics compared to the use of tables, however, the use of energy values of feedstuffs obtained by in vivo assay is still the most effective. The best equations were: AMEn = 4,021.8–227.55 Ash (for corn) combined with AMEn = −822.33+69.54 CP-45.26 ADF+90.81 EE (for soybean meal); AMEn = 36.21 CP+85.44 EE+37.26 NFE (nitrogen-free extract) (for corn) combined with AMEn = 37.5 CP+46.39 EE+14.9 NFE (for soybean); and AMEn = 4,164.187+51.006 EE-197.663 Ash-35.689 CF-20.593 NDF (for corn and soybean meal).

Metabolic parameters in rats receiving different levels of oral glycerol supplementation

The use of glycerol in the diets for animals is of interest because it is a residue of biodiesel production and rich in energy. Thus, this study aimed to evaluate metabolic and physiological parameters of rats receiving supplemental pure glycerol by gavage. We used 30 Wistar rats (initial weight 202.7 ± 29.98 g) receiving 0 (control/saline), 200, 400, 800 and 1600 mg glycerol/kg of body weight (bidistilled glycerine, 99.85% glycerol) beside food and water ad libitum for 28 days. We used a completely randomised design with five treatments and six replicates. At the end of the experiment, the animals were killed, and the results showed that there was no change (p > 0.05) in the intake and excretion of water, the average daily weight gain, dry matter, ash and crude protein in the carcass or plasma triacylglycerols. There was a beneficial effect (p < 0.05) up to a dose of 800 mg/kg glycerol on feed intake, percentage of carcass fat, plasma levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), high-density lipoprotein (HDLc) and low-/very low-density lipoprotein (LDLc + VLDLc). The levels of total cholesterol and glucose were increased with up to a dose of 800 mg/kg glycerol (but remained within the normal range); they were reduced with the dose of 1600 mg/kg. The total leucocyte count tended to be reduced, although it was within the reference values for rats. There were no renal or pancreatic lesions. In conclusion, glycerol presented as a safe supplement at the studied doses, even having some beneficial effects in a dose-dependent manner in rats.

Nursing regimens: effects on body condition, return to postpartum ovarian cyclicity in Santa Ines ewes, and performance of lambs

The effects of nursing regimens on the body condition, onset of ovarian cyclicity postpartum and weaning weight of lambs were assessed in Santa Ines ewes. Thirty-two ewes were blocked according to parity, number of lambs, and body weight at lambing and within each block randomly allocated to treatments: continuous nursing (CN), controlled nursing (CN2) with two daily feedings for an hour after the 10th day postpartum, or early weaning (EW) with total separation from the lambs after the 10th day. The animals were evaluated from the 12th day postpartum until the first estrus or until 60th day. The dry matter and nutrients intake did not differ among treatments (P>0.05) but did differ over time (P<0.01). The weight, body condition score, serum concentrations of non-esterified fatty acids and prolactin, the percentages of ewes in estrus, of ewes that ovulated within 60th day and had ovulation silent, the period from lambing to estrus, ovulation and follicle with a diameter ≥5mm and the maximum follicular diameter did not differ (P>0.05) among the treatments. The percentage of ovulation until 30th day was greater (P<0.05) in the EW group. The percentage of short luteal phases was higher in the CN2 and EW groups (P=0.07) and normal luteal phases were higher in the CN group (P=0.01). Lamb weight weaning was lower in the EW group (P<0.05). It is possible to use CN to obtain lambing periods less than eight months in Santa Ines ewes, with the advantages of simpler management and higher lamb weaning weights.

Optical transition radiation used in the diagnostic of low energy and low current electron beams in particle accelerators

Optical transition radiation (OTR) plays an important role in beam diagnostics for high energy particle accelerators. Its linear intensity with beam current is a great advantage as compared to fluorescent screens, which are subject to saturation. Moreover, the measurement of the angular distribution of the emitted radiation enables the determination of many beam parameters in a single observation point. However, few works deals with the application of OTR to monitor low energy beams. In this work we describe the design of an OTR based beam monitor used to measure the transverse beam charge distribution of the 1.9-MeV electron beam of the linac injector of the IFUSP microtron using a standard vision machine camera. The average beam current in pulsed operation mode is of the order of tens of nano-Amps. Low energy and low beam current make OTR observation difficult. To improve sensitivity, the beam incidence angle on the target was chosen to maximize the photon flux in the camera field-of-view. Measurements that assess OTR observation (linearity with beam current, polarization, and spectrum shape) are presented, as well as a typical 1.9-MeV electron beam charge distribution obtained from OTR. Some aspects of emittance measurement using this device are also discussed.

The energy value of biodiesel glycerine products fed to broilers at different ages

The objective of this study was to determine the apparent metabolisable energy corrected for nitrogen balance (AMEn) of some products containing glycerine from soybean oil (GOIL), a mixture of frying oil and lard (GMIX) and a semi-purified process (GSP) in broilers of different ages (10, 20, 30 and 40 days post-hatching), using two methodologies. In trial 1, the basal diets were replaced with 100 g/kg of each studied glycerine product and the diets were supplied ad libitum. Three hundred broilers were used in five replicates, with five, four, three and three animals per cage in each age group, respectively. The AMEn was calculated for each experimental unit. In trial 2, dietary treatments included the addition of glycerine at 0, 40, 80 or 120 g/kg for each crude glycerine product, with 900 broilers in six replicates, using the same number of animals per cage as described in trial 1. Depending on the experimental unit, the feeding was restricted in 88%, 92%, 96% and 100% of estimated intake according to the Cobb guide. The AMEn was determined using linear regression between the feed intake and the AMEn of each diet. In both trials, the total excreta collection method was used. Because of the chemical composition, GMIX was not considered crude glycerine. The mean AMEn values of the products were 20.55 MJ/kg, 15.80 MJ/kg and 15.05 MJ/kg for GMIX, GSP and GOIL, respectively. There was a linear decrease (p < 0.01) in the AMEn values with the increasing age of the broilers. Numerically, it was observed that the AMEn values decreased until 28-30 day post-hatching and then remained constant until the finishing phase. It is concluded that products containing glycerine can be used as an energy source for broilers, but that AMEn values can vary according to age. Younger broilers have a higher capacity of energy utilisation from these feedstuffs.

[Mechanisms of secondary degeneration in the central nervous system during acute neural disorders and white matter damage]

INTRODUCTION

Acute neurodegenerative diseases, including stroke and traumatic brain and spinal cord injury, possess an elevated worldwide incidence. Two distinct lesive patterns can be identified after these destructive events: primary damage, an early consequence of the primary pathological event, and secondary neural degeneration (SND), a group of pathological events inducing late degeneration in cells not or even only partially affected by the primary damage. This pathological mechanism is an important contributing factor for functional deficits and target for therapeutic approaches. Several factors are involved on the SND etiology, including excitotoxicity, inflammation, and oxidative stress.

AIM

To review the main mechanisms underlying the SND occurring after acute neural disorders.

DEVELOPMENT

The more recent findings about the eliciting processes of SND degeneration are discussed, as well as their significance to degeneration of white matter tracts.

CONCLUSIONS

The characterization of the events underlying SND is of fundamental importance for the development of new therapeutic approaches effective enough to decrease the functional deficits, contributing to the improvement of the quality of life of people suffering neurological diseases. These therapeutic approaches must be validated in experimental models of both brain and spinal cord diseases, which effectively simulate human neural disorders protecting both gray and white matters for a better neuroprotective efficacy.