The aim of this study was to use the scientific literature to identify interdisciplinary interventions for rehabilitation during the perioperative period for cancer patients who underwent total laryngectomy. We systematically researched controlled descriptors: laryngectomy, patient care team/education, patient care team/manpower, patient care team/methods, patient care team/utilization and rehabilitation. We performed a qualitative narrative synthesis and identified 549 articles. Of these, 113 were duplicates, 398 were excluded during the analysis of the title and abstract, 1 was excluded for unfeasibility of access, and 4 were excluded after reading the article in full, resulting in 33 included articles. The articles addressed different types of interdisciplinary actions, such as vocal, olfactory, pulmonary and alimentary rehabilitation; comparisons of prosthetic devices; and descriptions of practices for total laryngectomized patient rehabilitation. Although the interventions found in the literature were effective in the rehabilitation of the total laryngectomized patient, their interdisciplinarity was not evidenced but was highlighted in these studies as a factor for improvement in terms of practical assistance and quality of life. The treatment of laryngeal cancer is differentiated according to the disease stage. For stages I and II, maintenance of functionality, with the objective of guaranteeing voice quality and swallowing capacity, is prioritized. Thus, the treatments indicated are radiotherapy and surgery, which result in a 5-year patient survival rate of more than 90%. However, radiotherapy is more often indicated because it presents better results in the maintenance of functionality For stages III and IV, the chosen treatment is related to the modality that allows a longer disease-free time and/or the absence of orotracheal interventions (tracheostomy or tube feeding) for two years or more. Therefore, the choice of treatment depends more on the patient's ability to participate actively in rehabilitation than on the chosen treatment modality The surgical treatment takes into account the different portions and extent of involvement of the laryngeal tumor and is basically divided into partial and total laryngectomy, which differ mainly in terms of the anatomical alteration performed because when the structures that allow the recovery of breathing and phonation are maintained, a better quality of life for the patient and return to social activities is enabled In the total laryngectomy procedure, the three laryngeal  portions of the cartilaginous skeleton, the pre-epiglottic space and the laryngeal musculature are removed. As a consequence, a definitive tracheostoma is necessary, since there is no further communication between the lungs and upper airways, making phonation impossible At the same time, late side effects of treatment may occur, such as dental and oral health complications , recurrent laryngeal nerve palsy, chronic pain, ototoxicity, peripheral neuropathy, autonomic dysfunction, musculoskeletal complications, damage to the carotid arteries, nephrotoxicity and psychosocial issues Complications can be minimized during rehabilitation, which can be defined as a set of therapeutic measures aimed at the individual reaching the maximum of his physical, psychological and social capacity, using preventive, therapeutic, adaptive and palliative measures In this context, an interdisciplinary approach is necessary because the treatment depends on the extent and location of the tumor; the patient's age, performance status, comorbidities, and psychosocial support; and the availability of a rehabilitation service. The main objective of the rehabilitation service is to perform an evaluation that is integral to the needs of the patient, in addition to providing the rehabilitation care line and addressing specific issues of each of the specialties, with the richness of effective interdisciplinarity The interdisciplinary approach in vocal rehabilitation after laryngectomy should cover the perioperative period to produce the best speech results. The vocal restoration of the post-laryngectomy patient is a complex task and usually occurs throughout the patient's lifetime. The best results are found with pre-operative interdisciplinary planning, which includes robust pre-operative educational efforts, a meticulous and safe surgical technique that supports hospital care, postoperative follow-up that includes permanent education and speech therapy Thus, adherence to rehabilitation is a fundamental factor in the treatment of laryngeal cancer patients, where each professional performs specific rehabilitation interventions aiming at a better quality of life for the patient and family In view of the above, this study aimed to evaluate the scientific knowledge produced on the subject, seeking to identify the interdisciplinary interventions for the perioperative rehabilitation of cancer patients who underwent total laryngectomy.Therefore, the objective of this study was to identify, through the scientific literature, interdisciplinary rehabilitation interventions during the perioperative period for cancer patients who underwent total laryngectomy.This is an integrative review, which uses the acronym PICO, where P indicates population, I indicates intervention, and CO indicates context The inclusion criteria were studies in the Spanish, English and Portuguese languages, studies performed from 2010 to 2015, and studies with adult oncology patients and/or elderly patients undergoing perioperative rehabilitation after total laryngectomy who participated in rehabilitation interventions performed by a multiprofessional team. We excluded studies performed on animals, children and patients with partial or subtotal laryngectomy.Medical Subject Heading (MeSH), Health Sciences Descriptors (DeCS) and terms related to the research problem (cancer rehabilitation) combined with Boolean operators (AND e OR) and truncation symbols. The selection of articles for the review occurred in 4 steps: identification, screening, eligibility and inclusion. The identification stage comprised the bibliographic search that occurred from November 2015 to January 2016, and the studies were identified with the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL) from The Cochrane Library, National Library of Medicine/NLM (MEDLINE)/PubMed and Biomedical Database (EMBASE). A manual search was also carried out, through a reference consultation of articles related to the topic and contact with researchers working in the area of rehabilitation. The search strategies were formulated according to the criteria and manuals of each database. The following descriptors were used: For the screening stage, the studies were evaluated by title and summary independently by two reviewers, who applied the eligibility criteria and selected the relevant studies. For the subsequent eligibility stage, the selected studies were evaluated in full with the application of the inclusion and exclusion criteria, and in the last step, namely, the inclusion stage, the studies that were included and excluded from the review were defined.To extract the data, the authors used an Excel spreadsheet, which included the numerical identification of the publication, title, authors, journal title and year of publication, objectives, method used, and results, namely, the interventions of the multiprofessional team in the rehabilitation of patients and conclusions/recommendations and level of evidence. The level of evidence  of the sA total of 549 articles were found. Of these, 113 were duplicates, 398 were excluded in the title and abstract analysis, 1 was excluded for unfeasibility of access, and 4 were excluded after reading the article in full, bringing the total number of articles for analysis in the review to 33 .Regarding the methodological quality of the studies, most of them were descriptive or qualitative and were classified as having a level of evidence VI, which is considered weak .Regarding the objective of this review, i.e., interdisciplinary rehabilitation interventions in cancer patients during the perioperative period of total laryngectomy, actions were identified in relation to vocal rehabilitation (8 studies), olfactory methods (6 studies), pulmonary methods (5 study) (1 study), comparisons of prosthetic devices (3 studies) and descriptions of total laryngectomy rehabilitation practices (10 studies).Most of the articles were written by physicians The vocal rehabilitation interventions found in the review of the literature were voice by tracheoesophageal prosthesis, esophageal voice and voice by electrolarynx. Additionally, we found interventions that contribute to the improvement of voice quality in previous models.Voice restoration with the tracheoesophageal prosthesis is performed by surgical implantation of a device between the trachea and the esophagus, a mechanism that is basically a unidirectional valve, which allows the passage of the pulmonary airflow into the esophagus through the digital occlusion of the prosthesis. The new sound source is the pharyngoesophageal segment, which consists of the constricting pharynx and cricopharyngeal muscles and the upper portion of the esophagus, which vibrates and produce the sound The implantation of the tracheoesophageal prosthesis for vocal rehabilitation may occur soon after total laryngectomy or late because of the risk of serious postoperative complications, such as fistula formation or wound failure. However, regardless of the time of implantation, the results of voice rehabilitation are similar Digital occlusion of the prosthesis during speech is still regarded as a major drawback of the tracheoesophageal prosthesis. The development of a valve with automatic tracheostomy closure facilitates hands-free speech, which presents better results when fixed with a silicone adhesive and external cervical collar The esophageal voice is characterized by the momentary introduction of air into the esophagus and its ejection, causing the vibration of the pharyngoesophageal segment, a segment that becomes the new sound source, to produce the voice The pharyngoesophageal segment may present spasms resulting from surgery, being one of the causes of apophony and poor quality of the esophageal voice and tracheoesophageal prosthesis. The botulinum toxin type A technique, which involves injecting the toxin into the pharyngoesophageal segment, blocks the presynaptic release of acetylcholine at the neuromuscular junction, preventing hyperactive nerve impulses that trigger excessive muscle contractions, allowing better vibration of the segment and better voice quality The electrolaryngeal voice has the hypopharynx as the sound source. The electrolaryngeal voice produces the sound through the oscillator device that is placed on the wall of the neck and captures the vibration of the hypopharynx walls, producing the sound Regardless of the type of vocal rehabilitation, patients who were trained at admission or in the outpatient clinic presented better results than those who did not perform any training Two olfactory rehabilitation interventions were found: a) the laryngeal shunt device and b) the polite yawning technique The laryngeal bypass device uses a flexible tube with a sealing lip around the stoma, with the other end held between the lips, temporarily connecting the mouth and nose to the lower airway. Thus, the natural pulmonary inspiration draws air through the nose before passing it through the mouth, tube and trachea. The patient should learn to relax the soft palate so that it does not obstruct the nasopharynx The polite yawning technique or nasal airflow-inducing maneuver utilizes the orofacial musculature to develop the means of generating nasal flow. It consists of a prolonged yawning movement with a simultaneous reduction in the mandible, floor of the mouth, tongue, base of the tongue and soft palate, keeping the lips tightly closed, producing nasal flow Olfactory rehabilitation with the polite yawning technique presents effective results both with the training by the professional and at home without support, but in the short term, the result is better when assisted by the professional Disconnection of the upper lower limb pathway prevents the heating, humidification and filtration of inhaled air, which can lead to lung problems. These can be compensated with the use of a heat exchanger and humidity In the case report of a patient with uncorrected pharyngocutaneous fistula in the various repair attempts with skin grafts, the bilateral major pectoralis muscle and deltopectoral myocutaneous flaps affected alimentary dependence via the gastric feeding tube. For alimentary rehabilitation, the salivary tube technique was used, which is the insertion of a bypass tube that connects the remaining funnel of the base of the tongue to the distal tube of the esophagus. This process transfers the saliva from the oral cavity to the esophagus, controlling salivary secretion and preventing the occurrence of aspiration, even with general diet consumption Current Opinion in Otolaryngology & Head & Neck Surgery provides an enlightened and innovative method for rehabilitation of laryngectomized patients in several countries, and all of these studies emphasize the importance of the interdisciplinary approach.In the field of oncology, there are many studies on the treatment of neoplasias, but few of them describe rehabilitation in an interdisciplinary way. The evidence-based practice is broad in terms of new techniques and the performance of each professional independently In this series, interestingly, the need of each patient varies with culture, and with this variation, the quality of life assessment also has certain distortions. In the United States, the onset of preoperative rehabilitation is a distinctive feature that educates, informs, and empowers the patient through figures and illustrations and simple explanations of injury and treatment Studies related to the perioperative rehabilitation of total laryngectomies emphasize vocal, olfactory, pulmonary and alimentary restoration, as well as resources with technology to promote better adaptability to daily functional activities, social integration and autonomy for quality of life. To do this, these approaches rely on speech-language pathology, which depends on the conditions of each country, and can result in the addition of other professionals to the team In India, a study evaluated the impact of laryngectomy according to the country's socioeconomic conditions and observed the lack of specialized staff and centers for this type of rehabilitation The studies with the best levels of evidence (II and III) that were found in this review emphasize the importance of vocal rehabilitation, the maintenance of pulmonary health  and olfactory rehabilitation. For the reestablishment of oral communication, tracheoesophageal prosthesis with or without the use of a heat and moisture exchanger is recommended by a large number of reports A review that analyzed the practice of laryngectomized rehabilitation in Hong Kong highlights the conclusion that alaryngeal speech modalities do not satisfy the demand of the population that speak Cantonese because the approach does not allow changes in tones during speech, which are important for proper expression in this language The voice through the electrolarynx presents greater ease of rehabilitation but with lower patient satisfaction. In contrast, the esophageal voice is the most used in developing countries due to the low cost but has a lower success rate. Voice restoration with the tracheoesophageal prosthesis results in better satisfaction and self-confidence and minimizes the patient's social constraints, generating positive effects on quality of life, in addition to being more heavily used in developed countries A study comparing healthy people to people who underwent vocal rehabilitation with a prosthesis or esophageal speech identified a statistically significant difference in quality of life after their analysis of social function At the Cancer Institute of the State of São Paulo (ICESP), the continuity of vocal rehabilitation is stimulated with a choir group guided by a speech therapist for patients with an esophageal voice, a tracheoesophageal prosthesis or an electrolaryngeal voice. During the sessions, the presented difficulties are addressed individually but with the common goal of acquiring greater intelligibility, rhythm and greater respiratory control during esophageal speech The tracheoesophageal prosthesis and heat and moisture exchanger for voice restoration are presented as better resources in vocal and pulmonary rehabilitation, respectively; however, both are associated with a high cost that makes their incorporation into public health units difficult For olfactory rehabilitation, the polite yawning technique appears to be a good option because it is easily taught and learned and because it has a low cost, requiring only the professional specialized in the education of the patient. An important part of functional recovery that is most frequently mentioned in studies that assess quality of life is the olfactory capacity of the patient Failure to perceive bodily odor increases social insecurity, decreasing appetite, libido, sexual activity and the quality of the patient's mood, so olfactory rehabilitation with the polite yawning technique as an integral part of the post-laryngectomy rehabilitation program improves the quality of life of patients Olfactory rehabilitation is performed for the restoration of nasal flow, which is interrupted by the disconnection of the upper inferior pathway, preventing retronasal stimulation of olfactory receptors Loss of nasal function leads to thickening and desquamation of the mucosa due to irritation, excessive secretions and lack of air, and the use of a heat exchanger and humidity helps to significantly decrease the frequency of coughing, forced sputum and lung symptoms Nutritional support is also a concern for these patients, as several studies have observed that adequate nutrition is a quality-of-life factor In general, the interdisciplinary team acts in a manner that optimizes treatment and rehabilitation, in addition to improving quality of life mainly in terms of the functionality of the patient with total laryngectomy, and addresses several aspects of the patient, depending on the individual demand of each This study enabled a characterization of the scientific research on interdisciplinary interventions in the perioperative rehabilitation of patients who underwent total laryngectomy. In total, 33 articles met the inclusion criteria and were part of this integrative review.The evidence found pointed to more multidisciplinary interventions for postoperative rehabilitation.A shortage of intervention studies that portrayed strong evidence was observed, since the majority of the studies found were descriptive, with level-of-evidence classifications of III, IV and VI, which are considered to be weak. We also observed a lack of scientific research both in Brazil and in Latin America, making a reflection on the subject necessary so that new research is developed and disseminated.Although the interventions found in the literature are effective in the rehabilitation of the total laryngectomized patient, interdisciplinarity is not evidenced; however, interdisciplinarity is emphasized in these studies as a factor for improvement in terms of practical assistance and the quality of life of patients. Thus, health professionals should focus more on both the practical assistance of patients and the generation of research studies that address the perioperative rehabilitation of laryngectomized patients, namely, intervention studies that can be applied in clinical practice and that enable improvements to patient quality of life.Baia WRM and Nogueira PC designed the research. Fores JML, Rosa VM, Silva EPF, Guterres EO and Marcelino A performed the research and analyzed the data. Fores JML, Rosa VM and Kulcsar MAV wrote the manuscript.


N = 109) suggest that VR is more immersive and engaging through the mechanism of spatial presence. However, AR seems to be a more effective medium for conveying auditory information through the pathway of spatial presence, possibly because of increased cognitive demands associated with immersive experiences. Thus, an important implication for design is that educational content should be integrated into visual modalities when the experience will be consumed in VR, but into auditory modalities when it will be consumed in AR.The propagation of augmented reality (AR) and virtual reality (VR) applications that leverage smartphone technology has increased along with the ubiquity of smartphone adoption. Although AR and VR technologies have been widely utilized in the educational domain, there remains a dearth of empirical research examining the differences in educational impact across AR and VR technologies. The purpose of our exploratory study was to address this gap in the literature by comparing AR and VR technologies with regard to their impact on learning outcomes, such as retention of science information. Specifically, we use a two-condition (AR vs. VR) between-subjects' design to test college students' science-knowledge retention in response to both auditory and visual information presented on a Samsung S4 smartphone app. Our results ( VR and AR have been implemented in educational settings for years and empirical evidence demonstrates that both technologies help improve student's learning outcomes and enjoyment in different contexts and across various subjects.4With the increasing popularity and adoption of smartphones, we have seen a subsequent rise in augmented reality (AR) and virtual reality (VR) applications that leverage smartphone technology. Low-cost consumer VR headsets such as the Samsung Gear VR, Google Cardboard, and Google Daydream have made digital realities more accessible than ever before.5 In contrast, VR involves real-time immersive simulations completely through digital graphics.6 Therefore, AR integrates virtual objects into a physical space, whereas VR blocks out information from the physical environment that subsequently transports users to a fully virtual world. In other words, VR provides users with a feeling of being psychologically immersed in a virtual environment,7 and AR allows users to interact with both virtual items and objects in the real world. Consequently, the affordances of AR and VR are fundamentally different.AR and VR have been widely applied to teaching, learning, and instructional design. However, there is currently a lack of research that empirically compares the educational effects of AR and VR technologies. AR is a technology that blends digital information with the information from physical-world environments, enabling users to interact with virtual objects and view the physical environment  simultaneously.8 and Ibáñez et al.9). Furthermore, this study sheds light on how to best implement these emerging technologies in educational settings.To our knowledge, no studies have compared the impacts of smartphone-based AR and VR technologies in the context of information retention. Comparisons of AR and VR have tended to focus on visual/graphical aspects of these technologies with little if any attention to auditory information. This exploratory study aims to fill this gap in the literature by empirically comparing AR and VR technologies with regard to their effects on science-learning outcomes. Specifically, this experiment compares the effects of AR and VR technologies on college students' retention of science knowledge presented through auditory and visual information. The goal of this research was to provide insights into the possible psychological and theoretical mechanisms with a focus on the role of presence that has been used to account for the impacts of educational technologies on learning outcomes , that is, the subjective experience of physically being in a virtual or mediated environment.10 When media users allocate their attention to spatial information from the mediated environment, they form a mental representation of the environment.11 After they accept the mental representation and treat the virtual environment as a physical world, they begin to experience the sense of presence that has been positively associated with enjoyment of media use.12 In contrast, AR provides users with additional digital information integrated into existing physical environments.13 Because AR technologies focus on the physical environment and do not transport users to an artificial world like VR,14 AR technologies are less likely to elicit feelings of presence. Based on this reasoning, we hypothesize:H1: Individuals who experience a VR environment—compared to an AR environment with the same digital content—will report a) higher levels of attention to the mediated environment, b) presence, and c) enjoyment.VR technology-based instruction may improve students' learning outcomes in various subjects and contexts,4 However, digital instructional technologies often involve visual and auditory information and thereby force learners to divide their attention between different modalities simultaneously. Perceptual load theory suggests that attentional capacity is shared across vision and hearing. Therefore, the high perceptual load of attention during a visual task may lead to a lower level of sensitivity in auditory detection because of divided attention, which is regarded as load-induced deafness.15 In this sense, the high perceptual load of attention during an immersive visual experience in VR may lead to a higher level of presence that may overload perceptual  resources, thereby limiting individuals' ability to retain auditory-related information. Therefore, we propose the following hypotheses:H2: Individuals who consume visual and auditory content in VR compared to AR will a) exhibit greater retention of visual information but b) lower retention of auditory information.H3: Differences between VR and AR for a) visual and b) auditory learning outcomes will be mediated by the level of presence such that more presence will enhance visual outcomes and hinder auditory outcomes.The enhanced spatial representation, as well as representational fidelity  in VR, can potentially improve learning outcomes.n = 81, 74.3 percent) and the average age was 20.5 years old (standard deviation [SD] = 1.61). There were no significant differences in gender, age, and race between participants across the conditions.To test the proposed hypotheses, this study used a two-condition (AR vs. VR) between-subjects design with participants randomly assigned to each condition. A total of 109 participants (57 in the AR condition and 52 in the VR condition) were recruited from an interdepartmental research subject pool at a large university in the United States. In exchange for participation in the institutional review board-approved study, participants received a small amount of extra credit . Almost 75 percent of the participants were women  in either AR or VR mode  and 2. TTo maintain consistency in participants' experiences across both conditions, participants were required to hold the mobile device in their hands while using the app . In the AR mode, participants held the smartphone in front of their faces and viewed the digital content displayed as a noninteractive layer on top of an image of the physical environment fed from the phone's front-facing camera. In the VR mode, participants held a Mattel VR Viewmaster mobile phone-based VR headset to their eyes and viewed the digital content displayed in front of a white background . In bothUpon arrival at the laboratory, participants were first asked to complete a pretest questionnaire with questions measuring their science  knowledge. As part of a larger study, participants were randomly presented with one of two articles related to gender disparity and digital technologies, one that said women and men are equally skilled in their use of technologies and another that said men outperform women. This manipulation was not found to have an effect on this study's outcome variables and thus is not reported in our results. A future article will analyze whether the manipulation influenced belongingness and acceptance of gender stereotypes in STEM fields.Afterward, participants were instructed on how to use the AR or VR application (depending on condition). Participants then received visual and auditory information from the mobile app for 5 minutes. This was enough time for each participant to hear and visually see all the solar system content presented in the application. Participants then answered a posttest questionnaire with questions about their psychological and cognitive feelings of spatial presence and a new set of science  knowledge questions.16 that assesses the level of attention allocation to a mediated environment . Spatial presence was measured with a revised scale on immersive virtual technologies (α = 0.90)17 . Enjoyment was also measured using an existing scale (α = 0.91)18 . For all measures, participants were asked to indicate their agreement on a seven-point scale . The survey items for each scale were summed and averaged to create overall variable scores.Attention to the mediated environment was measured with an existing scale (α = 0.93)19 or VR20 environments. The pretest contained 10 questions related to general knowledge taken from basic information provided in the app . The posttest contained 10 questions regarding planets and our solar system. Of these questions, five were derived from the auditory information presented in the mobile app  and five from the visual information presented . To ensure that participants' preexisting knowledge did not influence the results of the experiment, knowledge at the pretest was compared. There was no significant difference in the score between VR  and AR  conditions  = −2.06, p < 0.05, 95 percent confidence interval (−0.88 to −0.02). In other words, participants in the VR condition reported higher levels of spatial presence that accounted for the lower scores on auditory information. However, interestingly, the impact of VR on participants' scores on visual information retention was not mediated by spatial presence. Therefore, the third hypothesis was partially supported. For the results of the mediation analysis see Finally, to test the third hypothesis, a mediation test was conducted using the PROCESS path-analysis macro (Model 4). The results showed that being in the VR and AR conditions influenced participants' feelings of spatial presence differently, which later impacted their science-learning outcomes differently. Specifically, the relationship between AR and VR and participants' scores on auditory-related information was mediated by spatial presence at a significant level, This study compared the impacts of AR and VR on knowledge retention when using a mobile phone platform. Participants in the VR condition allocated more attention to the mediated environment, perceived higher feelings of spatial presence, and reported more enjoyment than those in the AR condition. In other words, being in the VR condition resulted in more psychological and cognitive responses to the media compared with the AR condition. Furthermore, those psychological and cognitive responses to the media helped participants retain more knowledge that was presented visually in the mobile app.15 In contrast, participants in the AR condition had weaker cognitive and psychological responses  to the virtual environment, allowing them to dedicate more cognitive and attentional resources toward retaining the auditory information. The level of spatial presence explained the impacts of VR and AR technologies on participants' scores on auditory information, but not on visual information. This unexpected finding indicates the need for more research on the relationship between spatial presence and learning across these two media modalities.However, although participants in the AR condition retained less visual-related science information, they retained more auditory-related science information compared with those in the VR condition. Participants' feelings of spatial presence played a mediating role in the relationship between modality and science learning. To be more specific, when participants were in the VR condition, they paid more visual attention to the mediated environment so they received more information of the same modality  and less in the different modality . This finding is consistent with previous research on shared attentional capacity across visual and auditory perception.This study has important theoretical implications for the literature on AR and VR, namely, that these two modalities place different cognitive demands on users. In particular, VR seems to be more immersive and engaging through the psychological mechanism of spatial presence. However, the cognitive demands of such immersive experiences may make AR a more effective medium for conveying auditory  information. Researchers should continue to explore the psychological and cognitive differences between these two media modalities.These findings also have important implications for educators and designers/developers of interactive media and technologies. For educators who wish to emphasize content that is communicated visually, VR (compared with AR) seems to be a better technology because it draws attention to the visual information presented in the environment. However, if the digital learning technologies include important information conveyed through auditory channels, AR seems to be more effective because it frees up attentional/cognitive resources otherwise dedicated to visual channels, allowing the auditory information to be processed more thoroughly. Designers of VR and AR applications for educational purposes should consider the cognitive demands and modalities that are best suited for specific types of content. When designing VR experiences, it may be best to embed relevant information visually into the environment. Likewise, when designing AR experiences, it may be best to communicate relevant information in an auditory format.in situ measures  to reliably confirm influence on participants' feelings of presence. This study primarily focused on attentional resources and did not directly measure the participants' cognitive load, and the measure of attention does not necessary reflect their perceptual load despite the link between the two variables.15 Future research should further examine the role of cognitive or perceptual load while using these two technologies and how cognitive or perceptual load influences participants' feelings and presence as well as learning outcomes. The auditory information presented in the application was arguably less concrete  than the visually presented information , so future research should control for information concreteness as a potential confound between modalities. The study did not control for participants' previous experience using AR and VR technologies that were likely novel for many participants. Future research should investigate whether previous experience using these technologies might have an impact on the efficacy of AR and VR for education. Furthermore, future research should explore whether the consistency of auditory and video information  or types of auditory outputs  influence or even optimize learning outcomes across modes.This study has various limitations. The study utilized a mostly female, college-age sample. Future researchers should expand the generalizability of their findings by expanding the representativeness of population samples used. The study only included self-reported questions when measuring participants' feelings of spatial presence. Future research should incorporate nondisruptive Cost-effective and portable AR and VR technologies provided by smartphone-based mobile applications provide tremendous potential for education. The ability to transport students to the stars with VR or to create a scale solar system on students' desks with AR has the potential to change the way students interact with science information. This study has shown that AR and VR can both be used effectively to teach science-based information. However, AR and VR have their own set of strengths and weaknesses that should be considered while integrating these technologies into learning environments. In the end, both technologies provide students with an exciting new educational reality.


The prosurvival protein kinase CK2, androgen receptor (AR), and nuclear factor kappa B (NFκB) interact in the function of prostate cells, and there is evidence of crosstalk between these signals in the pathobiology of prostate cancer (PCa). As CK2 is elevated in PCa, and AR and NFκB are involved in the development and progression of prostate cancer, we investigated their interaction in benign and malignant prostate cells in the presence of altered CK2 expression. Our results show that elevation of CK2 levels caused increased levels of AR and NFκB p65 in prostate cells of different phenotypes. Analysis of TCGA PCa data indicated that AR and CK2α RNA expression are strongly correlated. Small molecule inhibition or molecular down-regulation of CK2 caused reduction in AR mRNA expression and protein levels in PCa cells and in orthotopic xenograft tumors by various pathways. Among these, regulation of AR protein stability plays a unifying role in CK2 maintenance of AR protein levels. Our results show induction of various endoplasmic reticulum stress signals after CK2 inhibition, which may play a role in the PCa cell death response. Of note, CK2 inhibition caused loss of cell viability in both parental and enzalutamide-resistant castrate-resistant PCa cells. The present work elucidates the specific link of CK2 to the pathogenesis of PCa in association with AR and NFκB expression; further, the observation that inhibition of CK2 can exert a growth inhibitory effect on therapy-resistant PCa cells emphasizes the potential utility of CK2 inhibition in patients who are on enzalutamide treatment for advanced cancer. The continued availability of androgens functioning through their cognate receptor  is essential for the development and growth of the prostate throughout the lifetime of the individual; likewise, the initial development of prostate cancer (PCa) also involves androgen-dependent AR function ,2. In ouProtein kinase CK2 (formerly casein kinase 2 or II) is a highly conserved and ubiquitous protein serine/threonine kinase broadly localized in both the cytoplasmic and nuclear compartments. It engages in many functions, including roles in normal and disease-associated cell growth and proliferation. Its heterotetrameric structure includes two catalytic subunits (42 kDa α and 38 kDa α′) linked by two regulatory subunits (28 kDa β). CK2 appears to be constitutively active; however, one regulatory mechanism of CK2 signaling relates to its dynamic shuttling in response to altered growth signals . CK2 medOur early work hinted at a direct crosstalk between AR function and CK2 . A numbeNFκB p65 is among the well-established substrates of CK2; CK2 phosphorylates p65 at S529, and this event is associated with NFκB p65 nuclear translocation . AbnormaIn the present work, we demonstrate inter-connection of CK2 expression with NFκB p65 and AR in non-transformed prostate cells, unifying aspects of our previous work. We further examined AR and NFκB p65 dynamics in response to altered CK2 expression and activity in various PCa cell lines representing AR-expressing androgen-sensitive and CRPC phenotypes. Our results suggest that modulation of CK2 by molecular and chemical means has distinct effects on AR protein and mRNA expression. CK2 signaling promotes prostate and PCa cell survival via regulation of NFκB p65 and AR protein levels whereas anti-CK2 strategies can cause PCa cell death via multiple mechanisms regardless of the AR-driven nature of the disease. Importantly, CRPC cells that are resistant to enzalutamide (a current therapy for advanced CRPC) exhibit a cell death response to anti-CK2 treatment. Together, these observations have implications for PCa therapy, suggesting a significantly improved response by targeting both AR and CK2. As CK2 protein levels are elevated in PCa, we wanted to determine the effect of CK2 overexpression in non-malignant and malignant prostate cells with respect to the expression of AR and NFκB p65. First, a non-transformed prostate cell line stably expressing FLAG-CK2α using RWPE-1 cells was generated. Immunoblot analysis A shows tThese observations were confirmed by transient transfection of the same FLAG-CK2α expression construct into RWPE-1 as well as two PCa cell lines, C4-2B and LNCaP. Transient FLAG-CK2α expression increased 2.9 to 4.4-fold, with higher CK2α’ and CK2β levels again observed over control cells . In all CSNK2A1 and AR mRNA levels in PCa patient samples from The Cancer Genome Atlas (TCGA) was performed . The analysis was performed using cBioPortal with a Z-score cut-off set at 1.5, and the result demonstrates a significant positive correlation of the two genes in PCa patient samples  or 10 µM CX-4945 in cell culture for varying periods of time. To determine whether reducing CK2 activity or expression level had any effect on the AR transcript, we measured AR mRNA levels following treatment of 22Rv1, C4-2, and LNCaP cells with CK2 inhibitor or siCK2 targeting CK2αα΄ . The resWe examined the impact on NFκB p65 protein levels and activation level in LNCaP cells after transfecting with siRNA targeting the CK2α and α´ catalytic subunits. Reduced activation of NFκB p65 at the CK2 phosphorylation site S529 is evident and equivalent at 48 and 72 h; whereas, loss of total NFκB p65 protein is not notable until 72 h post-transfection A. We alsTo establish that the results in cell culture models were also observed in vivo for PCa, we employed orthotopic xenograft 22Rv1 tumors generated in NOD SCID gamma castrated male mice. Treatment of the mice with RNAi-CK2 delivered via a malignant cell-targeted nanocapsule (TBG-RNA-CK2 ) resulteTo test if the presence of androgen had any effect on response of AR to CK2 modulation in prostate tumor cells, we examined the effect of 80 µM TBB on C4-2B and 22Rv1 cells cultured in androgen-free media for a total of 72 h and treated with TBB for 48 h. The results in We also examined the effects of siRNA- and TBB-mediated reduction in CK2 levels or activity in non-malignant RWPE-1 prostate cells on AR protein expression. The results shown in To investigate possible mechanisms of the effects of altered CK2 status on AR abundance, we determined the half-life of AR protein. PCa cells were treated with 80 µM TBB and cycloheximide simultaneously, and cells were collected at various time points as indicated in Reducing CK2 expression and activity is known to induce changes in the endoplasmic reticulum (ER) stress pathway in cancer cells ,49,50. WProstate cancer C4-2B cells represent the lethal CRPC phenotype. Among the final modes of therapy is treatment with enzalutamide, which blocks the activity of AR in CRPC cells; however, drug resistance emerges with ensuing loss of therapeutic response. We tested the effect of inhibiting CK2 activity in enzalutamide-resistant C4-2B cells to determine their response. The results in CSNK2A1 and AR mRNA levels in PCa patient samples representing localized disease using TCGA data is reported here. A phosphoproteomics study using metastatic CRPC specimens found CK2 to be among the top seven enriched kinase activities in metastatic CRPC by kinase substrate enrichment analysis (KSEA) [CSNK2A1 (CK2α) as an inferred activated kinase [We initiated this work to determine if elevated CK2 levels promote increased levels of AR and NFκB p65 proteins in prostate cells in general as well as PCa cells of different phenotypes. Interaction of CK2 and androgen signaling in prostate cell growth has been known for a long time ,7. Likews (KSEA) . In a sud kinase . Our celd kinase ,9. Thus,Our results demonstrate that both parallel and divergent pathways regulating AR protein levels are activated following chemical inhibition of CK2 or its molecular down-regulation. Both modes of blocking CK2 function caused AR protein loss with reduced AR protein stability. Disparately, inhibition of CK2 activity by small molecules caused a notable loss of AR mRNA, whereas siRNA-mediated CK2 down-regulation only modestly reduced AR mRNA levels in LNCaP cells and increased AR transcripts in C4-2 cells. Regardless of its impact on AR transcript abundance, CK2 clearly plays a role in maintaining AR protein levels in prostate cells, in part through AR protein stability. Involvement of CK2 in AR function has been observed in other studies that suggested that CK2 inhibition causes altered nuclear translocation of AR and modulates AR-dependent transcription ,23. In cWe show an increase in various forms of ER stress signals when CK2 is inhibited; the increased BiP, CHOP and IRE1α proteins suggest marked ER stress under these conditions, and increased SQSTM1 p62 suggests involvement of autophagy in response to CK2 inhibition by TBB. The data also suggested that response may vary with the inhibitor of CK2 employed as some of the proteins showed better response with TBB than CX-4945, possibly reflecting differences in their in vivo interaction with CK2. In previous work, inhibition or molecular down-regulation of CK2 was shown to induce apoptosis in PCa cells regardless of their androgen-sensitive and -insensitive status . HoweverCrosstalk between AR and classical NFκB pathway signaling in PCa has been described in many publications, and NFκB is known to activate transcription of the AR gene ,62. Incrc release from mitochondria [In summary, we have presented new data on the function of protein kinase CK2 in PCa survival. These results document new information on the effects of elevated CK2 levels in prostate cells that caused an increase in AR and NFκB p65 protein levels and enhanced activation of NFκB p65 in diverse PCa cell types. Further, we demonstrated pathways leading to cell death after blocking CK2 function in PCa cells of different phenotypes—these include an overarching impact on AR protein stability. The data are broadly summarized in 2. All cells had undetectable levels of mycoplasma when thawed, and were maintained in culture for up to 2 months, with the exception of the RWPE-1 stably transfected cell lines which were kept in culture for up to 84 days. For androgen-deprivation growth conditions, cells were grown in phenol-free RPMI 1640  with 10% charcoal dextran-treated fetal bovine serum .PC3-LN4 and C4-2 cells were obtained as described ,67. LNCaStandard chemistry siRNAs were obtained from Dharmacon . The siCK2 guide strand sequence is 5′-auacaacccaaacuccacauuu-3′ . The conTransfections of plasmid DNA were performed using Lipofectamine 3000 (Thermo Fisher Scientific); for a 60 mm plate of cells, 7.5 µL of Lipofectamine 300, 10 µL of P3000, and from 4 to 6 µg of plasmid DNA were combined in a total volume of 0.5 mL per manufacturer instructions. For transient expression studies, 4 µg of FLAG-CK2α or empty donor plasmid were used, and cell pellets were collected, flash frozen on dry ice, and stored at −80 °C until processed for immunoblot analysis as described above.The FLAG-CK2α construct for CRISPR-mediated insertion into the AAVS1 genomic site was constructed using AAVS1-SA-puro-EF1-MCS donor plasmid . The full length open reading frame for CK2α  was amplified by standard PCR according to recommendation of the manufacturer  using a 5′ primer that inserted the BsrGI site and the FLAG tag in frame at the amino-terminal end (5′-gcgcctactctagatgtacagccctcgccatggactacaagg-3′) and a 3′ primer that inserted the MluI site at the 3′ end (aataaccgcggaatacgcgtttactgctgagcgccagcgg). The targeting vector used was AAVS1-gRNA/Cas9 SMartNuclease . Cloning into the donor vector was performed according to manufacturer instructions using the Cold Fusion cloning kit . Positive clones were sequenced fully on both strands. For RWPE-1 FLAG-CK2α and empty vector stable cell line construction, 4 µg of FLAG-CK2α or empty donor plasmid combined with 2 µg of Cas9/gRNA plasmid were transfected into cells at 70% confluence. The next day, cells were split 1:5 into 5 each 60 mm plates. Six days later, each 60 mm dish was split into a 10 cm dish. On day 8 after transfection, puromycin selection began at 1 µg/mL  and continued for 7 days. Pooled cells were frozen back in 10% DMSO with 40% FBS after an additional 3 days of puromycin selection. Matching cell pellets  were collected at various time points and stored at −80 °C until processed for immunoblot analysis.® Aqueous One Assay  was used to assess cell viability following treatments. Cells were plated in 96-well plates  and allowed to attach overnight; enzalutamide selection was removed the days that cells were plated into 96 well plates. For TBB and CX-4945, concentrations from 100 μM to 3.1 μM were added to cells by 1:2 dilutions, and fresh drug in media was added every 24 h. DMSO was added to cells at equivalent concentrations. Aqueous One assays were performed at 24, 48, and 72 h of treatment as described [CellTiter 96escribed .Cell pellets from cultured cells were processed in radioimmunoprecipitation assay (RIPA) buffer as previously described . Tumor l(-∆∆Ct) method. RPLP0 and B2M were used as the reference gene for normalization. All results are reported as the average of reactions from two independent experiments with each sample run in duplicate. Total RNA was isolated from frozen cell pellets using the RNeasy mini kit (Qiagen), including the on-column DNase digestion according to the manufacturer’s protocol, and quantitated using a NanoDrop spectrophotometer. The High-capacity cDNA Reverse Transcription Kit (Thermo Fisher Scientific) was used to synthesize cDNA from total RNA (1.5 µg) using oligo-dT primers according to the manufacturer’s protocol and with the following conditions: 10 min 25 °C; 120 min 37 °C, 5 min 85 °C. Pre-designed primers were obtained from Integrated DNA Technologies, Assay Ids: AR Hs.PT.56a.20244349; RPLP0 Hs.PT.58.20222060; B2M Hs.PT.58v.18759587. Reactions were run according to manufacturer’s specification using 96 well FAST plates on an ABI 7900HT machine. Analyses were performed using the SDS 2.3 ABI software and changes calculated according to the 2Cycloheximide  was added at a concentration of 50 µM for all experiments. DMSO and ethanol were added to control cells at concentrations to match the addition of TBB or cycloheximide. SiRNA transfections were performed as described above, and cycloheximide was added 22 h post-transfection. Cycloheximide and TBB were added to cells simultaneously using cells at 70% confluence. Cells were collected as PBS-washed pellets, which were stored at −80 °C, at the timepoints indicated in the figure. Cell pellets were processed for immunoblot analysis as described above.JC-1 FACS analyses were performed as previously described . Three iAnalysis of co-expression of CSNK2A1 and AR mRNA levels in PCa patient samples was performed using cBioPortal with a Z-score cut-off set at 1.5 and using the PanCancer Atlas data set from The Cancer Genome Atlas (n = 494 samples). NOD SCID gamma mice were obtained from an in-house colony. Mice were castrated under isoflurane anesthesia . Seven dData were summarized and analyzed using GraphPad Prism 5. Cell viabilities (ratio of CK2i to DMSO) were compared to 1 using one sample, two-sided t-tests for three independent experiments. Means and 95% confidence intervals were presented for immunoblot data. Means and standard deviations were presented for q-RT-PCR and FACS data. JC-1 FACS data for TBB compared to DMSO was analyzed by unpaired two-tailed t-test with Welch’s correction. AR protein half-lives were calculated by regression using Excel. Correlation coefficients and significance calculations for PCa patient TCGA mRNA data presented in


Dormancy is the mechanism that allows seeds to become temporally quiescent in order to select the right time and place to germinate. Like in other species, in barley, grain dormancy is gradually reduced during after-ripening. Phosphosignaling networks in barley grains were investigated by a large-scale analysis of phosphoproteins to examine potential changes in response pathways to after-ripening. We used freshly harvested (FH) and after-ripened (AR) barley grains which showed different dormancy levels. The LC-MS/MS analysis identified 2346 phosphopeptides in barley embryos, with 269 and 97 of them being up- or downregulated during imbibition, respectively. A number of phosphopeptides were differentially regulated between FH and AR samples, suggesting that phosphoproteomic profiles were quite different between FH and AR grains. Motif analysis suggested multiple protein kinases including SnRK2 and MAPK could be involved in such a difference between FH and AR samples. Taken together, our results revealed phosphosignaling pathways in barley grains during the water imbibition process. The switch from dormancy to germination is one of important transition steps in the life cycle of plants, because it will be the first and most fundamental factor determining their survivability. During the evolutionary process, seeds have evolved to germinate only in favorable seasons or places and dormancy is the mechanism that inhibits germination . Seed doTo study seed dormancy, we can dissect this trait into three stages: acquisition, maintenance and decay ,9. It isTo understand the germination process, previous studies have performed a large-scale gene expression analyses of FH and AR seeds in Arabidopsis or barley during imbibition ,14,15,16Taking advantage of the barley model system using FH and AR grains with contrasting dormancy levels, we have performed a large-scale phosphoproteomic analysis which allowed us to analyze phosphoproteins in vivo and to evaluate their phosphorylation sites and phosphorylation levels. In this study, we have identified nearly 2500 phosphopeptides in barley grains when being exposed to water, and analyzed their differential regulations between the dormant and the AR states.To understand the phosphosignaling pathways that operate during the imbibition of matured FH and AR grains, phosphoproteomic analysis was performed in this study. In our phosphoproteomic analysis, we have used barley half-grains in which husk-based dormancy is broken and only embryo-based dormancy is present. In addition, the embryo was dissected and used for phosphoproteomic analysis, to remove a large amount of storage proteins contained in the endosperm.Physcomitrella patens, found a similar distribution of phosphorylated residues  and [-pS/T-P-] were identified in FH and AR grains B. ActualVarious approaches have been performed to investigate the differences between FH and AR grains in cereals ,47,48,49The influence of DELAY OF GERMINATION1 (DOG1) is one possible to alter ABA signaling between FH and AR grains. DOG1 is expressed in fresh/dormant and also in AR Arabidopsis seeds, but DOG1 proteins are less abundant or downregulated in AR seeds ,54. InteWe identified the ortholog of AREB3 and other ABA-responsive proteins were downregulated in AR grains during water imbibition. AREB3 belongs to group A bZIP transcription factors, which are responsible for ABA-responsive element -dependent gene expression ,58. ThesTaken together, this study performed phosphoproteomic analyses of FH and AR embryos in barley during imbibition and demonstrated differential phosphosignals in FH and AR barley grains. We have identified numerous phosphopeptides and 365 of them significantly altered phosphorylation levels during imbibition. These phosphopeptides are possibly involved in control of dormancy and germination, and some of them could be involved in the regulation of ABA signaling. Further studies will be required for understanding the role of these responsive phosphoproteins and the upstream elements that regulate the activity of various protein kinases during after-ripening.Hordeum vulgare cv. Golden Promise) plants were grown in a phytotron glasshouse  under sunlight and temperature set at 17/9 °C day/night [Barley  in plastic petri dishes. After adding 5 mL double-distilled HFollowing imbibition, embryos were dissected from barley half grains and stored at −80 °C as previously described ,72. Fiftw/w) for 3 h. After 4-fold dilution with NH4HCO3, proteins were digested with trypsin  overnight at room temperature.The phosphoproteomic analyses were performed as previously described ,30,59,60After enzymatic digestion, an equivalent volume of 2% trifluoroacetic acid (TFA) was added to the digested samples, and then they were desalted using SDB-XC Empore disk membranes  as described previously . To enri−1 with a four-step gradient, 0.5% acetic acid: 0.5% and 80% acetic acid = 98:2 (0 min), 60:40 (300 min), 10:90 (20 min) and 98:2 (40 min). The eluate was sprayed into mass spectrometer by electrospray ionization (ESI). The mass spectrometry (MS) scan range was 400–1250 m/z and the MS/MS scan range was 100–1600 m/z.Cleaned-up samples were analyzed with TripleTOF 5600 system  equipped with Autosampler-2 1D plus  and NanoLC Ultra  using MonoCap C18 High Resolution 2000 column  and PicoTip emitter SilicaTip . Peptides were eluted at 500 nL minhttps://www.helmholtz-muenchen.de/pgsb) using Mascot version 2.4.0 . Search settings were applied: a precursor mass tolerance of 3 ppm, a fragment ion mass tolerance of 0.8 Da, and cut-off value of 0.95, allowing for up to two miss cleavages, with the enzyme designated as trypsin. A fixed modification of carbamidomethylation of cysteine and variable modifications of oxidation of methionine and phosphorylation of serine, threonine and tyrosine were used. All raw data files were deposited in the Japan Proteome Standard Repository/Database .Peak lists were generated using Protein pilot version 5.0.0.4769 . Raw spectrum files were matched with the barley gene database published on 23 March 2012  was used for phosphopeptide quantification from peak areas [t test (p < 0.05).Skyline software version 4.2 (ak areas . The seahttps://david.ncifcrf.gov) and REViGO (http://revigo.irb.hr). Annotated data with Arabidopsis by BLAST (https://blast.ncbi.nlm.nih.gov/Blast.cgi) was loaded to DAVID, and background database was set as the TAIR 10 Arabidopsis dataset. Outputted GO terms in DAVID were visualized with REViGO. Settings used for REViGO were: medium (0.7) similarity, UniProt Arabidopsis database (https://www.uniprot.org) and simRel semantic measure. Phosphorylation motifs were predicted by the motif-x program (http://motif-x.med.harvard.edu) [Each phosphoproteomic sample including FH and AR grains was compared by PCA ,77,78. Sard.edu) . For motard.edu) .To understand the phosphosignaling that take place during the after-ripening of barley grains and that produce a decay in dormancy, phosphoproteomic profiles were obtained from FH and AR embryos during imbibition. As a result, 2,346 phosphopeptides were identified, with 365 of them responded to imbibition. Our data indicate that multiple protein kinases, such as SnRK2, CDPK, CIPK, or MAPK, can actively participate in the differential phosphorylation of peptides in barley FH or AR grains, and point to some key kinases that could be manipulated for regulating germination in cereals.


There is compelling evidence of beneficial effects of non-immersive virtual reality (VR)-based intervention in the rehabilitation of patients with stroke, whereby patients experience both the real world and the virtual environment. However, to date, research on immersive VR-based rehabilitation is minimal. This study aims to design a randomized controlled trial to assess the effectiveness of immersive VR-based upper extremity rehabilitation in patients with subacute stroke and explore the underlying brain mechanisms of immersive VR-based rehabilitation.n = 60) with subacute stroke (defined as more than 1 week and less than 12 weeks after stroke onset) will be recruited to participate in a single-blinded, randomized controlled trial. Subjects will be randomized 1:1 to either (1) an experimental intervention group, or (2) a conventional group (control). Over a 3-week time period immediately following baseline assessments and randomization, subjects in the experimental group will receive both immersive VR and conventional rehabilitation, while those in the control group will receive conventional rehabilitation only. During the rehabilitation period and over the following 12 weeks, upper extremity function, cognitive function, mental status, and daily living activity performance will be evaluated in the form of questionnaires. To trace brain reorganization in which upper extremity functions previously performed by ischemic-related brain areas are assumed by other brain areas, subjects will have brain scans immediately following enrollment but before randomization, immediately following the conclusion of rehabilitation, and 12 weeks after rehabilitation has concluded.Subjects (Effectiveness is assessed by evaluating motor improvement using the arm motor section of the Fugl-Meyer assessment. The study utilizes a cutting-edge brain neuroimaging approach to longitudinally trace the effectiveness of both VR-based and conventional training on stroke rehabilitation, which will hopefully describe the effects of the brain mechanisms of the intervention on recovery from stroke. Findings from the trial will greatly contribute to evidence on the use of immersive-VR-based training for stroke rehabilitation.NCT03086889. Registered on March 22, 2017.ClinicalTrials.gov,  Stroke is a major cause of death and long-term disability across the globe , 2 and iVirtual reality (VR)-based training might be one of the solutions. VR systems are classified as either immersive or non-immersive VR systems , 11. In Non-immersive VR systems have been widely used in stroke rehabilitation for several years, with the aim of improving motor function , 20. MosThere are two reasons for choosing subjects with subacute stoke rather than other stages post-stroke in the clinic trial. First, in this subacute stage, patients have been shown to have the best and most rapid functional recovery , which bIn summary, in this study we will use immersive VR training in post-stroke rehabilitation and assess the effectiveness in eliciting upper-limb motor recovery post-stroke compared to traditional rehabilitation training. Additionally, we will investigate the underlying brain mechanisms of immersive VR-based rehabilitation using MRI techniques.The aim of the study is to assess the effectiveness of immersive VR-based upper extremity rehabilitation on patients with subacute stroke and explore the underlying brain mechanisms of immersive VR-based rehabilitation. The arm motor section of the Fugl-Meyer assessment (FMA) , 33 willThe Institutional Review Board of the Second Affiliated Hospital and Yuying’s Children Hospital, Wenzhou Medical University, China, approved this study. Prior to inclusion, all subjects will be informed about the objectives and procedures of the study. Subjects who meet the inclusion criteria must provide informed consent before entering into the study.n = 60) diagnosed with stoke in its subacute stage (defined as more than 1 week and less than 12 weeks after stroke onset) from an in-patient stroke rehabilitation unit in China will be enrolled in a single-blinded randomized controlled trial for 15 weeks. They will be randomized in a 1:1 fashion into (1) a new 3-week rehabilitation training program with an immersive VR system, (2) a 3-week conventional rehabilitation program. The random allocation will follow a covariate-adaptive randomization procedure [Subjects , immediately following conclusion of the randomized rehabilitation program (week 3) and follow up 12 weeks after conclusion of the rehabilitation program (week 15). The assessment includes inclusion and exclusion of subjects, clinician-filled questionnaires and MRI scans. To avoid assessment bias, all inclusion and exclusion assessments and clinician-filled questionnaires will be completed by physiotherapists who are blinded to this study and with at least 2-years of experience in physical therapy. The flow chart for the study is shown in Fig. The inclusion criteria are as follows: to be eligible, subjects must (1) be over 30 but less than 85 years old; (2) have had their first stroke within the past month; (3) have a diagnosis of acute stroke confirmed by a neuroimaging neurological assessment (computed tomography or MRI); (4) have a starting upper-limb function of Brunnstrom  stage IIThe exclusion criteria are as follows: (1) history of transient ischemic attack (TIA); (2) failure of critical organs, such as heart, lung, liver, and kidney; (3) previous history of brain neurosurgery or epilepsy; (4) severe cognitive impairments or aphasia (incapable of understanding the instructions given by therapists); (5) not suitable for an MRI scan  cardiac pacemakers, cardiac defibrillators, cochlea implants or nerve stimulators; surgery on the blood vessels of brain or the valves of the heart; claustrophobia; or brain or skull abnormalities); (6) life expectancy < 3 months; and (7) enrollment in another clinical trial involving physical therapy or an investigational drug.This randomized controlled trial is a two-group independent design examining the effects of immersive VR on rehabilitation of subjects with subacute stroke. We assumed a two-tailed comparison and set the type I error rate at 0.05 with 80% power. We plan to screen approximately 100 individuals with subacute stroke. After screening, 80 subjects will be recruited and randomized to the experimental group or the control group. As a conservative estimate (dropout rate = 25%), we presume that 60 subjects will complete the study. To reduce the dropout rate, we will employ two strategies to keep participants engaged: regular communication via phone or social media and clinician visits. After conducting a power analysis based on the aforementioned statistical parameters using the software GPower3.1.9.2 , the effSubjects in the control group will receive 60-min conventional rehabilitation training per day, 5 days per week for 3 weeks. This conventional rehabilitation delivered by a therapist at the hospital includes physical and occupational therapy (upper extremities flexion and extension training) which comprise task-related practice for gross movements and dexterity, including different grips and selective finger movements, strength training, stretching, and training in daily life activities. Conventional rehabilitation will be designed with similar intensity and complexity to simulate the skills required in the immersive VR group. Researchers in the study will supervise and encourage all participant to fully participate in the training to guarantee the quality of the training. In contrast, subjects in the experimental group will receive 30 min of conventional rehabilitation and 30 min of immersive VR rehabilitation training per day, 5 days per week for 3 weeks conducted by a therapist at the hospital. The details will be discussed in the section “VR training protocol”.Shown in Fig. During the daily 30-min VR rehabilitation, subjects in the experimental group will be required to complete the six programs  shown and described in Fig. This is close to a realistic experience and provides a high level of immersion. In the early stages of rehabilitation, due to the poor function of the upper limb on the hemiplegic side, subjects will have to complete the VR programs with the help of the limb on the unaffected side. With the recovery of upper limb function on the hemiplegic side, the subjects will then independently complete the six games using the limb on the hemiplegic side.The arm motor section of the Fugl-Meyer assessment (FMA) , 33, higWe will apply MRI techniques to assess the performance of immersive VR-based rehabilitation and to investigate the brain mechanisms of rehabilitation, particularly in regions related to motor learning and motor control. Three different MRI modalities will be acquired: (1) high-resolution anatomical MRI (T1-MRI) for estimating anatomical parameters of cortex, subcortex, and structural connectivity; (2) resting-state functional MRI (RS-fMRI) for estimating the functional connectivity of brain regions; and (3) diffusion tensor imaging (DTI) for estimating tractographic parameters of white matter and the microstructure of gray matter. Each subject will be scanned three times . The brain parameters obtained by MRI will be assessed and correlation with the clinical outcome measures will be tested.Other secondary outcome measures include: (1) Brunnstrom stage scores, which will be obtained for assessment of motor recovery of the upper extremities; (2) assessment of the subject’s’ mental state, which will be determined using the Hamilton Depression Scale (HAMD)  and the All questionnaires will be collected on an electronic tablet on which the questionnaire software, Research Electronic Data Capture (REDCap), will be installed . REDCap 3, in-plane resolution = 64 × 64, number of volumes = 230, and flip angle = 90°; and for DTI data, TR/TE = 8000/80 ms, flip angle = 90°, FOV = 256 mm × 256 mm, resolution = 128 × 128, slice thickness = 2 mm, slices per volume = 75, 23 volumes with b = 1000 s/mm2 and 49 volumes with b = 2000 s/mm2.Subjects will be scanned on a 3-T GE-Discovery 750 scanner at Wenzhou Medical University (WMU), China, equipped with the following: for anatomical T1-MRI data, repetition time (TR)TR/echo time (TE) = 7.7/3.4 ms, flip angle = 12°, field of view (FOV) = 256 mm × 256 mm, resolution = 256 × 256, slice per volume = 176, slice thickness = 1 mm; for RS-fMRI data, TE/TR = 30/2500 ms, voxel size = 3.4375 × 3.4375 × 3.5 mmData quality control: each imaging modality  will undergo quality control and data with excessive motion or bad signal-to-noise ratio will be excluded . Three dThe subjects’ structural T1 images will be analyzed using the FSL subcortical segmentation tool “FIRST”  and withThe subject’s RS-fMRI will be analyzed using FSL tools. First, we will use an independent component analysis (ICA)-based strategy for automatic removal of motion artifacts (AROMA)  to pre-pThe subject’s DTI will be analyzed using FSL tools. We will use the diffusion toolbox “FDT”  to pre-pt test will be used to compare the within-group changes when ANOVA reveals a significant difference. Statistical significance is determined by a two-sided p value of less than 0.05. In addition, if any demographic or clinical characteristics are significantly imbalanced, analysis of covariance will be performed to adjust the imbalance. To help prevent missing data, all questionnaires are user friendly and collected electronically, and all personnel related to the study are trained to identify and engage the subjects who are at the greatest risk of dropout during follow up. In cases of missing data, the method of baseline observation carried forward [We will use the IBM SPSS Statistics 24  and R 5 to perfo forward  will be Study oversight will be under the direction of an Independent Safety Monitoring Board (ISM), who is composed of experts in clinical trials, medical ethics, statistics, and data management. The ISM is independent of the study and the sponsor, and is responsible for monitoring data and participant safety.We are committed to respecting participant privacy and to keep personal information confidential. All participants’ personal and health information and brain imaging data will be maintained on a secure server. Access to these data are password protected, and all data are anonymized and coded prior to uploading to the server.This clinical trial aims to evaluate the effectiveness of immersive VR-based rehabilitation in upper-limb motor recovery post-stroke compared to traditional rehabilitation through questionnaires and evaluation of brain mechanisms via MRI. Previous studies have shown that non-immersive VR is safe but not significantly more beneficial compared with conventional rehabilitation . It was To avoid creating an imbalance between the two groups in rehabilitation time, which may introduce additional variables to explain the resultant improvement in upper extremity motor function, the total rehabilitation time is set to be identical for the two groups. Moreover, in order to observe the long-term outcomes of immersive VR-based rehabilitation in terms of upper limb motor function, the trial will follow up all subjects 12 weeks after they have finished rehabilitation.The main limitation in this trial is its single-center design and the limited sample size. There is clearly a need for multicenter, large-scale trials to determine the benefits of immersive VR-based rehabilitation, but before launching these it is important to demonstrate feasibility and effectiveness. Another limitation is that current immersive VR technology is still unable to simulate all rehabilitation training. As a compromise, the subjects in the experimental group will experience a combination of 30-min normal rehabilitation and 30-min immersive VR rehabilitation.In conclusion, this study aims to explore the immediate and longer-term effects of immersive VR-based rehabilitation in subjects in the early stage of stroke, and to discuss the mechanism of its impact on the brain’s anatomical and functional reorganization. The results of the trial will be of benefit to future patients with stroke and may provide a new and better method of stroke rehabilitation.Subject recruitment is underway.


Perioperative hyperglycemia and its associated increase in morbidity and mortality have been well studied in the critical care and cardiac surgery literature. However, there is little data regarding the impact of intraoperative hyperglycemia on post-operative infectious complications in non-cardiac surgery.All National Surgery Quality Improvement Program patients undergoing general, vascular, and urological surgery at our tertiary care center were reviewed. After integrating intraoperative glucose measurements from our intraoperative electronic health record, we categorized patients as experiencing mild (8.3–11.0 mmol/L), moderate (11.1–16.6 mmol/L), and severe (≥ 16.7 mmol/L) intraoperative hyperglycemia. Using multiple logistic regression to adjust for patient comorbidities and surgical factors, we evaluated the association of hyperglycemia with the primary outcome of postoperative surgical site infection, pneumonia, urinary tract infection, or sepsis within 30 days.n = 1531) of patients experienced hyperglycemia and 15% (n = 482) patients experienced an infectious complication. Patients with mild  and moderate hyperglycemia  had a statistically significant risk-adjusted increase in infectious complications. The model c-statistic was 0.72 [95% confidence interval 0.69–0.74].Of 13,954 patients reviewed, 3150 patients met inclusion criteria and had an intraoperative glucose measurement. 49%  contains supplementary material, which is available to authorized users. Postoperative hyperglycemia has been associated with increased risks of complications among patients undergoing cardiac surgery and critically ill patients –5. In paThere is a paucity of intraoperative data regarding patients undergoing non-cardiac surgery with no compelling data guiding the optimal glucose target during or after the operation. Most observational or interventional studies evaluating hyperglycemia and non-cardiac surgery have focused on preoperative or postoperative glucose measurements due to challenges in obtaining intraoperative measurements manually entered into paper or electronic anesthesia records –15. PracThe purpose of the current study was to evaluate the relationship between intraoperative glucose levels and postoperative outcomes in non-cardiac surgery. In particular, evaluating the impact on infectious complications may drive a more specific analysis based upon the pathophysiology of hyperglycemia –15. We hInstitutional review board approval  was obtained for this retrospective observational study at a single academic medical center. As there were no care interventions involved and protected health information were removed after the dataset was created, patient consent was waived as part of the approval.All adult patients (age ≥ 18 years) with or without a diagnosis of diabetes mellitus undergoing elective and emergency general, vascular, or urologic procedure were included in this study. Data was extracted from NSQIP data collection process and intraoperative electronic health records at our center from 2005 to 2010.Patients with a scheduled outpatient procedure were excluded due to low expected infectious complication rate. Additional exclusion criteria were: American Society of Anesthesiologists Physical Status classification (ASA) 5 or 6, a preoperative systemic inflammatory response syndrome, sepsis, septic shock, pneumonia, preoperative wound classification of dirty, and confirmed pregnancy. Finally, patients without any glucose measurements during the intraoperative period were also excluded.Data were collected by integrating the local NSQIP database with the departmental perioperative EHR, Centricity® . The NSQIP methodology has been described previously , 21. ForIntraoperative glucose measurements were obtained from the EHR. This included data from the enterprise laboratory information system and values entered manually by the anesthesiology provider using point of care testing which includes, testing using Accu-Check® , point of care blood gas analysis RapidPoint 400® , and formal laboratory testing values. The Accu-Check® point of care device has previously been shown to have an acceptable accuracy over a wide range of hematocrit values in critically ill patients . The EHRGiven the lack of substantial evidence regarding intraoperative hyperglycemia and outcomes in non-cardiac surgery, no existing definitions of elevated glucose levels during surgery were available in the peer-reviewed literature. For the purposes of this analysis, normoglycemia was defined as a maximum glucose of less than 8.3 mol/L. Using the Delphi Method, mild, moderate, and severe hyperglycemia was defined as a maximum glucose measurement of between 8.3–11.0, between 11.1–16.6, and greater than or equal to 16.7 mmol/L, respectively . These vThe primary outcome was the occurrence of one or more of the following infectious morbidity events as defined by NSQIP criteria: surgical site infection (SSI), pneumonia, urinary tract infection, or sepsis. Surgical site infections included superficial SSI, deep incisional SSI, organ space SSI, and wound disruption. The standard NSQIP definitions for each of the complications exclude patients with pre-existing infection of that type. , male sex, emergency surgery, prolonged operative duration, dyspnea at rest, dyspnea at exertion, new or worsening congestive heart failure, ASA physical status , partially dependent functional status, totally dependent functional status, present of ascites, diabetes mellitus requiring oral hypoglycemic therapy, diabetes mellitus requiring insulin therapy, chronic obstructive pulmonary disease, hypertension, angina, history of cardiac surgery, history of percutaneous coronary intervention, cerebrovascular accident, history of transient ischemic attacks, steroid use for a chronic condition, and preoperative serum albumin. All covariates were based upon NSQIP data and dataset definitions  were established as independent predictors of an infectious complication. Measures of effect size were reported using the adjusted odds ratio calculated by the logistic regression full model fit , p-value< 0.001. The Hosmer and Lemeshow Test resulted in a chi-square of 3.0, 8 degrees of freedom, and a p-value of 0.93.When studying the subset of patients without diabetes, mild hyperglycemia, moderate hyperglycemia, severe hyperglycemia, glucose standard deviation, and GLI did not demonstrate a significant independent relationship. The model’s c-statistic was 0.71 [95% CI 0.69–0.74] and the omnibus test of model coefficients resulted in a chi-square of 195.9, 27 degrees of freedom, and a Classification of hyperglycemia defined as a glucose value ≥10 mmol/L did not demonstrate a statistically significant risk adjusted increase in postoperative infectious complications (AOR 1.06 [95% CI 0.80–1.40]). Our sensitivity analysis on the use of RBC intraoperatively demonstrated similar measures of effect sizes for the hyperglycemia groupings (data not shown) and in addition a statistically significant measure of effect size for the number of RBC units administered [[AOR 1.04 (95% CI 1.00–1.07)].Our data demonstrate that among a broad range of patients undergoing major non-cardiac surgery, intraoperative glucose levels above 8.3 mmol/L are associated with a significantly increased risk of postoperative infections. This effect is independent of underlying patient comorbidities, surgical procedure complexity, and surgical duration. A dose-response curve was observed, with mild hyperglycemia resulting in an AOR of 1.30 [95% CI of 1.01–1.68] and moderate hyperglycemia resulting in an AOR of 1.57 [95% CI of 1.08–2.28]. Although the data were underpowered to detect a statistically significant increase among patients with severe hyperglycemia, an AOR of 1.70 [95% CI of 0.67–4.35] was observed. This analysis of 3150 patients is the largest published dataset of intraoperative glucose management and serves to inform future prospective interventional studies.There are very limited prospective data evaluating the impact of intraoperative hyperglycemia and postoperative outcomes in the non-cardiac surgery population . A recenEven observational trials struggle to offer insight into associations between intraoperative glucose values and postoperative outcomes. Of the many observational studies evaluating glucose control and postoperative outcomes, few have been in the non-cardiac literature, –15, 30 aOur data demonstrate that the risk-adjusted association between hyperglycemia and postoperative infections is present with increasing severity of hyperglycemia resulting in an increased risk of infectious complications after adjusting for surgical complexity and patient pre-existing comorbidities. From a pathophysiologic viewpoint, hyperglycemia is associated with increased inflammation, impaired chemotaxis and phagocytosis, and vulnerability to infections , 6. The There is a lack of published guidelines regarding intraoperative glucose management in the diabetic or non-diabetic patient undergoing non-cardiac surgeries. The results of this study highlights the significance of intraoperative glucose levels and in addition questions the practice pattern of casually dismissing an intraoperative glucose measurement of 10 mmol/L as some medical societies have recommended , 32. We There are several limitations to this study. As an observational study, an association between intraoperative hyperglycemia and postoperative infection was demonstrated, but causal relationship could not be established. Despite adjusting for a variety of comorbidities and surgical factors, residual confounding may be present. Several factors that impact infectious complications, such as antibiotic choice, normothermia, and pre-existing immunity deficient states (HIV/AIDS and disseminated cancer) were not incorporated into the analysis. In our database, only 4 patients were diagnosed with HIV/AIDS. This sample size is very small and will not affect the measures of effect sizes on mild and moderate hyperglycemia demonstrated in our primary analysis. We also have 155 patients (4.9%) with a preoperative diagnosis of disseminated cancer. Hyperglycemia, like a suppressed immune system, are only modifiers of susceptibility to infections. Therefore, we did not exclude those patients from the database. Next, the analysis does not address the effect of hyperglycemia treatment. Although many patients did receive intraoperative insulin treatment and these data are reported, the logistic regression did not include insulin treatment as a covariate because insulin treatment is a marker of hyperglycemia itself. Larger observational studies are needed to compare patients with similar hyperglycemia profiles with and without insulin treatment to ascertain an insulin treatment effect. Until then the real risks of hyperglycemia must be weighed against the independent relationship that we observed between intraoperative hyperglycemia and postoperative infection. The point estimates for hyperglycemia may demonstrate a dose response curve, however the wide confidence interval for severe hyperglycemia may indicate it’s not. In addition, the NSQIP definitions of SIRS, sepsis, and septic shock have been enhanced recently. Unfortunately, we do not have the specific data elements available  that are included in the new definition to adequately perform a sensitivity analysis. At our institution, there are no differences in rates of prophylactic antibiotic administration. These data were collected using internal quality assurance metrics and are unable to be linked to this database to allow a propensity score matched analysis to address any potential confounding between prophylactic antibiotic administration and infectious outcomes. It is feasible, that our sample size in the study cohort would be reduced and the dose response curve in intraoperative hyperglycemia and postoperative infectious complications may differ. Although these data add to the non-cardiac literature, the patient population is limited to major general, vascular, and urologic surgery; other common procedures warrant further investigation. The single-center nature of the dataset also limits the generalizability of the conclusions. The data, due to low sample size, were also underpowered to detect a difference among patients experiencing severe hyperglycemia and a sensitivity analysis focused on diabetic patients only was not feasible. Therefore, future clinical trials are needed to focus on diabetic patients. We also acknowledge that the overall composite infection rate is high (15%) in relation to previously published research. However, the individual infection outcomes Table  have an Despite these limitations, these data are impactful and novel. More than 3000 patients undergoing a variety of major non-cardiac surgeries were studied, representing the largest observational dataset regarding intraoperative hyperglycemia in non-cardiac surgery to date. The data clearly demonstrate a dose-dependent relationship between intraoperative hyperglycemia and postoperative infectious complications after risk adjustment for major comorbidities. Intraoperative hyperglycemia is an independent predictor of infectious complications among both diabetic and non-diabetic patients and must become a focus among practicing anesthesiologists. These data demand further exploration beyond infectious complication via larger, multicenter observational datasets and prospective, randomized control trials to establish whether treatment of hyperglycemia may alter outcomes. Non diabetic patients and impact of glucose variability is worth exploring including the value of commercially available continuous glucose monitoring.Additional file 1: Appendix 1.American College of Surgeons - National Surgery Quality Improvement Program Data Element Definitions. (DOC 44 kb)Additional file 2: Appendix 2.American College of Surgeons – National Surgery Quality Improvement Program Data Outcome Definitions. (DOC 58 kb)Additional file 3: Appendix 3.Frequency and Infectious Complication Data by Procedure Description. (DOCX 18 kb)Additional file 4: Appendix 4.Abbreviations: SSI = Surgical Site Infection, UTI = Urinary Tract Infection. (TIF 381 kb)Intraoperative Maximum Glucose Distribution for Patients With and Without Postoperative Infectious Complications. Box and whisker plots for maximum intraoperative blood glucose value (mmol/L) by overall complication infectious complication as well as individual infectious complications.


An estimated 20 million of the 135 million people who need humanitarian assistance globally are living with some form of disability and require access to rehabilitation services and assistive technology.While two important World Health Organization (WHO) initiatives on rehabilitation were launched in the past years, they do not fully capture the challenges of protracted crises. One such action was the Emergency Medical Teams Initiative, focusing on sudden onset disasters, which differ in nature and response from protracted crises.Rehabilitation for persons with permanent impairment and disability is demanding in any given context, because it involves long-term interventions and requires financial resources and care-providers with specialized skills. In protracted crises, however, rehabilitation is particularly challenging.The overall situation may be characterized by political uncertainty, poverty and corruption. The infrastructure may be destroyed or degraded, affecting communication, access to buildings and roads, and procurement of rehabilitation products. The security situation may be volatile and unpredictable. The education system may be weak, complicating professional training. The health system may be overwhelmed or dysfunctional. The needs for rehabilitation will be increased, urgent and complex. Therefore, clinical presentations requiring rehabilitation will be pre-existing conditions that were deteriorating or further developing, plus multiple physical and psychological trauma accumulated at different points in time. Cultural concepts and beliefs around disability may be stigmatizing, hindering the development of rehabilitation policies. Accordingly, the most vulnerable, including women and children with disabilities, may get further marginalized, exploited and exposed to violence. Rehabilitation professionals, if existent, may have left the country, or been killed in conflict,Given this complexity and magnitude of needs, specific approaches are required.First, greater awareness of the rehabilitation needs in countries of protracted crisis is needed. Raising awareness is done best by including persons concerned and their rehabilitation providers. In 2019, the International Committee of the Red Cross (ICRC) sponsored over 50 individuals from 26 countries to participate in the World Confederation for Physical Therapy congressSecond, rehabilitation programmes should be designed and managed to get users ready for social reintegration. Organizations active in these settings could make their employment system as inclusive as possible and proactively offer perspectives for persons with disabilities, by engaging in team diversity and ensuring accessibility for persons with various forms of disabilities to allow them to advance in their career paths.Third, sustainability should be strengthened by capacity building of staff, through advocacy with relevant civil society organizations and authorities, and the creation of structures in the absence of a state system. Moreover, employing former rehabilitation users with disabilities in rehabilitation structures contributes to sustainability.–Fourth, guidelines on clinical work in challenging settings, such as those by the World Confederation for Physical Therapy, the ICRC and partner organizations are crucial.Fifth, mainstreaming rehabilitation in protracted crises requires close collaboration with international rehabilitation or medical associations and WHO, especially on the use and context-adaptation of documents developed within the Rehab 2030 initiative. In crisis settings, collaborating with aid organizations to systematically raise awareness on rehabilitation needs, is vital.Sixth, data and research are needed on demographics and clinical presentations, on the impact of rehabilitation interventions and on workforce. Equally important is qualitative, participatory research that includes the views and needs of affected populations.If the strategies above are considered, health for all as the priority towards achieving SDG 3 can also be accomplished with regards to rehabilitation needs of people in protracted crises.