There is a trend toward formalization of the rehabilitation process for olderrehabilitants in a Challenging Rehabilitation Environment (CRE). This conceptinvolves the comprehensive organization of care, support, and environment inrehabilitation wards. So far, literature about the principles of CRE is scarce.This study aims to explore the opinions of rehabilitants and informal caregiversregarding CRE, through a qualitative study between 2019 and 2020. Threetelephone interviews were conducted with informal caregivers, and also 3 focusgroups with 15 rehabilitants and 3 informal caregivers, all with recentexperience in rehabilitation. Nine themes emerged regarding the rehabilitationprocess: (1) rehabilitant , (2) rehabilitant centered , (3) informal caregivers (involving andattention for resilience and relation), (4) communication , (5) exercise , (6)peer support (learning experiences and recognition), (7) daily schedule(influence on the planning and activities outside therapy), (8) nutrition(energy for rehabilitation), and (9) eHealth . Regarding organizational processes, 4 themes wereidentified: (1) environmental aspects , (2) staff aspects , (3) organizational aspects(organized in an efficient way), and (4) return home (the discharge processshould be well prepared for instance with home visits). Organizing excellentrehabilitation care requires a thorough understanding of the concept of CRE, asit is a complex and comprehensive concept that concerns the whole rehabilitationprocess. Its effectiveness and efficiency should be researched in prospectivestudies. The demand for Geriatric Rehabilitation (GR) in Europe increases with the aging ofthe population . AfterhGR is defined as “a multidimensional approach of diagnostic and therapeuticinterventions, the purpose of which is to optimize functional capacity, promoteactivity and preserve functional reserve and social participation in older peoplewith disabling impairments .”Persons who are rehabilitating are trying to adapt and self-manage their currentcondition. In line with the ideas on positive health of Huber et al, we have chosennot to label persons during their rehabilitation as patients, but to use the term“rehabilitants” when referring to them .A Challenging Rehabilitation Environment (CRE) is a relatively new concept whichinvolves the comprehensive organization of care and support by the rehabilitationteam, as well as the environment in which the rehabilitation takes place ,8. KnowlIn a review, 7 main components for modeling CRE were identified: (1) therapy time,(2) group training, (3) patient-regulated exercise, (4) family participation, (5)task-oriented training, (6) enriched environment, and (7) team dynamics .Because there is no official definition of CRE, there are considerable differencesbetween wards in the interpretation and execution of CRE. Therefore, it is notcertain that the beforementioned components cover all aspects of CRE. In addition,it is unknown which components rehabilitants and their informal caregivers considerrelevant for a CRE. The aim of rehabilitation is to optimize the level offunctioning of a rehabilitant. The availability of an informal caregiver during andafter the rehabilitation is beneficial for the rehabilitation outcomes . TherefoThe aim of the CREATE study  is tosubstantiate the added value of the concept of CRE . In thisA qualitative study, consisting of focus groups and telephone interviews, wasperformed between September 2019 and October 2020. The aim of this research wasto explore the perspectives of (older) rehabilitants and informal caregivers onthe concept of CRE. Qualitative research attains to gain a better understandingof a phenomenon through the experiences of those involved .Supplemental Table)  for improving the quality of reporting qualitative research (seel Table) .Organizations affiliated with the 6 scientific networks (living labs) for elderlycare in the Netherlands demonstrate an interest in scientific research.Therefore, these organizations were approached by email with information aboutthis study .They weRehabilitants and informal caregivers were included if they were currentlyparticipating or had recently participated in a (geriatric) rehabilitationprocess. Rehabilitants and informal caregivers were excluded if they werediagnosed with dementia, were  unable to give informed consent, or werenot proficient in the Dutch language.If rehabilitants and/or their caregivers were interested in the study, theyreceived an information leaflet. If they remained interested or had additionalquestions, they were put in contact with the primary researcher (LT). Questionswere answered, and the informed consent form was signed by the participant andLT. If an informal caregiver participated without the rehabilitant, therehabilitant was asked for permission to interview the informal caregiver. Anappointment was then made for a focus group or telephone interview.We aimed for data saturation, and after each focus group or interview, theauthors discussed whether any new topics had emerged. Inclusion stopped when nonew topics emerged.In preparation for the data collection, a topic list was established based on theabove-mentioned review (Appendix 1) . This toThe focus group interviews were chaired by BB and LT. Female nursing seniorresearcher in the field of rehabilitation BB has experience in qualitativeresearch and chairing discussion groups. Physical therapist LT is a female PhDstudent with formal training in interview techniques and qualitative researchand 10 years of experience in geriatric rehabilitation.The focus groups were held on rehabilitation wards in various regions in theNetherlands. All focus groups were performed in meeting rooms and only theparticipants and researchers were present.Due to COVID-19, we switched from focus group meetings to individual,semi-structured, telephone interviews with informal caregivers during the datacollection. These interviews were conducted by LT, using the same topiclist.Each focus group and telephone interview began with a brief introduction by theresearchers on the topic of the focus group, followed by an introduction of theparticipants. The participants were then asked to share their perspectives onCRE. The chair used open-ended questions based on the topic list and furtherexplored the answers that were given. To increase the internal validity,participants were also asked to share their perspectives on subjects notmentioned in the topic list, but which they considered important regarding CRE.During each focus group and interview, LT made field notes.On average the focus groups lasted 90 min and the telephone interviews 45 min.Both were audio recorded and transcribed verbatim by LT. Transcripts were notreturned to participants, but at the end of every interview, the chair verifieda verbal summary with the participants.Simultaneous with the data collection, thematic analysis was performed toidentify, analyze, and report patterns in the data ,14. ATLALT read and re-read the data to become familiar with the data, after whichinitial themes were identified while reading through the transcript using anopen-coding approach. These initial themes were checked by BB and ED todetermine inter-rater comparisons. ED is a female nursing senior researcher withexperience in qualitative research.Differences in the coding were discussed by LT, ED, and BB until an agreement wasreached. Each initial theme was described in a memo.The identified initial themes were combined into main themes with associatedsubthemes. The connections and contradictions between the initial themes weredescribed per the main theme, and connections between main themes weredescribed.Each main theme was assessed for data saturation, after which the research teamdiscussed the contents of the main themes. After the agreement was reached withthe research team, each main theme was meticulously described, and relevantquotes were identified and translated from Dutch into English.The approached rehabilitants (15) and informal caregivers (6) all agreed toparticipate. In September and October 2019, a total of 3 focus group interviewswere conducted, and in September and October 2020, 3 telephone interviews wereheld with informal caregivers. Rehabilitants were between 43 and 90 years oldand informal caregivers were between 49 and 77 years old. Rehabilitationdiagnoses were lower limb amputation, trauma, hip fracture, chronic obstructivepulmonary disease (COPD), and acquired brain injury, including stroke.Characteristics of the participants are shown in Thirteen main themes with associated subthemes emerged from the data. The mainthemes can be divided into 2 categories, namely themes involving therehabilitation process and themes involving organizational processes. Thesubdivision of the themes in the 2 categories is described in This category consists of 9 main themes, namely (1) rehabilitant, (2)rehabilitant centered, (3) informal caregivers, (4) communication, (5)exercise, (6) peer support, (7) daily schedule, (8) nutrition, and (9)eHealth.Because of course there are two extremes. For some things youhave to be pulled out of bed, because you don't want to get outof bed, but you have to anyway. And other people start sprintingvery quickly, while in fact well … maybe youshouldn't.Rehabilitants must learn to deal with changing resilience. Participantsagree that some rehabilitants have to be motivated for rehabilitation,while others need slowing down. As one rehabilitant with acquired braininjury said,But even with people who are very close, who really know what isgoing on etc. Well, I still run into things. Then I think yes… even they don't quite get this.Participants experience feelings of dependency and changes in cognitiveand emotional aspects. According to a rehabilitant with a stroke, it isimportant to provide explanations about these changes to both therehabilitant and his informal caregivers,I do agree with you that you really want to be in a like-mindedgroup. But I want to decide for myself where tosit.Rehabilitants value having peers with similar diagnoses in arehabilitation ward. But, as one rehabilitant with acquired brain injurysaid, complete differentiation on diagnoses is not necessary,But in the beginning, it is so important that you have some kindof clarity, of where you want to go. And that those goals areadjusted every time. In the beginning well … when you startsomething, you have no idea what that is.The rehabilitation process must be tailored to the individual goals,abilities, and situation. Working on individual goals can be motivating,but not all rehabilitants are able to set their goals at the beginningof the process, as one rehabilitant with acquired brain injury said,I had that last Saturday. I broke down  … And they stayed with mefor a bit. Yes. Then you have to get over it, put it behindyou.This can be influenced by a grieving process, through which arehabilitant and his informal caregivers need to cope with this lifeevent. In the words of a rehabilitant with a traumatic arm fracture,And then, for example, I went home last weekend … And then shedoes things that annoy me, that I don't think are necessary. Butshe's so scared because she doesn't know what I am able do. Butif they've already helped here a few times, then they gainconfidence in the person.Involvement of the informal caregiver in the rehabilitation process canhave a positive effect. Participants see benefits in terms of increasingunderstanding of the situation of the rehabilitant, creating confidence,and providing additional exercise moments. As a rehabilitant with alower limb amputation said,Of course, therapy doesn't go on all day. So, if you can overcomethat yourself by doing other exercises. That sounds like a goodidea, yes.And as an informal caregiver said about his wish to exercise togetherwith his spouse,Well, look, you hear the word “informal carer” a lot. But I donot consider myself a carer … For my wife, who is going througha difficult time. You just do a bit more, no bigdeal.The extent to which informal caregivers can provide support is determinedby their resilience, but also by their relationship with therehabilitant. As an informal caregiver explained, it is often quitenormal for a spouse to be involved in the rehabilitation process,But I think the most important thing in the whole rehabilitationprocess is to communicate. Look at the person in front of you.Really look. Because that's … And I think 80% of the time it'sOK. But 20% of the time it hurts so much.Adequate communication is important, as a rehabilitant with acquiredbrain injury mentioned,Yes, I just wanted an impression of how she was doing. She wasn’table to provide that.As an informal caregiver explained, special attention is needed forcommunication with the informal caregivers, especially if therehabilitant cannot oversee his rehabilitation process,I thought it was very important that I got a lot of explanationsabout what's wrong. That it was explained. So I could understandmyself.As a rehabilitant with acquired brain injury indicated, it is alsoimportant to provide information about the disease,I think the advantages are that you see that you are not the onlyone stumbling around and tired after cycling for a little while.And that does tell you, you think well he can do it, so I can doit too. That is encouraging.Most participants would like to see a higher intensity of therapeuticactivities. One way to achieve this is group training. Participants withexperience in group training are very positive about it, like thisrehabilitant with a traumatic fracture,Not if it is not tailored specifically to the patient, then grouptherapy is not … If it's all the same patients…But rehabilitants without experience in group training cannot see how itcan be tailored to a rehabilitant's needs, like this rehabilitant with alower limb amputation,But going alone is always therapy. So also sitting down in thechair and everything. At some point all of it istherapy.Participants see an important role for nurses in stimulating andsupporting rehabilitants by practicing meaningful tasks outside therapymoments. As one rehabilitant with traumatic fracture said, therapymoments can be created in all daily activities,I would love to, but then I would want someone there to see whatyou are going to do. I wouldn't dare to do it on my own, just…Rehabilitants think it is important to do patient-regulated exercises,but they want advice concerning the safety of the exercises and theprevention of overburden. For example this rehabilitant with a traumaticfracture, who thinks rehabilitants can be afraid to practice alone inthe therapy room,And that's why it's so nice to be with people who have the sameproblem and you don't have to explain anything, they justunderstand. That always feels so relaxed.Peer support is important for support, motivation, learning, puttingthings in perspective, and recognition. As a rehabilitant with acquiredbrain injury said,You could see it in several people. That, in fact, outsidetherapy there was a sense of aimlessness. It wasn't the activefeeling of “I'm doing rehab now.”Participants prefer to have input in the planning of their therapymoments and have these moments well spread in intensity throughout theday. In addition to therapy, they would appreciate the possibility to doactivities, as an informal caregiver explained,Eating well is also therapy. You need the energy to be able to doyour therapy. I need my breakfast and my food for the diabetes.But I also need to do therapy.Attention to good and tasty nutrition is important in a rehabilitationprocess, as one rehabilitant with a lower limb amputation explained,But I think that for some people, because of course theirrehabilitation takes a long time and they are alone … Then it'snice when you don't feel that you're eating alone on top of allthat.Mealtimes can play a role in task-oriented training but are alsoimportant to stimulate contact between rehabilitants and create a goodambiance. As a rehabilitant with acquired brain injury mentioned,Depending on what those technical things are for, of course. Ifthe technical things contribute more to the recovery of thepatient than the non-technical things, then I am all for thetechnical things. But if it doesn't add much value, then I thinkwell …eHealth is defined as “the use of digital information and communicationto support and/or improve health and health care .” ParticThis category consists of 4 main themes, namely (1) environmental aspects,(2) staff aspects, (3) organizational aspects, and (4) return home.I imagine a rehabilitation department, which is fully integrated.Everything in one place.A rehabilitation center should be close to the residence of arehabilitant. The wards should be small, with a shared living room andthe possibility to go outside. The wards should provide practice optionsfor the rehabilitants, such as aids required for rehabilitation, butalso sufficient space to practice. As an informal caregiver said, itwould be helpful if the therapy rooms are integrated into the ward,Just single rooms, so you can also deal with youremotions.For rehabilitants with acquired brain injury, it is important to havelow-stimulus areas in a rehabilitation ward. Individual bedrooms providea low-stimulus area, exercise options, privacy, and copingopportunities. As a rehabilitant with a lower limb amputation said,Striving for independence, in an active way.Professionals working in a rehabilitation ward must have an empathic wayof working, be able to support rehabilitants emotionally, and stimulaterehabilitants to practice. As an informal caregiver said about thedesired attitude of professionals,Professionals must have good communication skills to communicate withrehabilitants and informal caregivers and within the team. Participantsprefer small teams. This stimulates collaboration among professionalswho feel they are responsible for the rehabilitation process.Participants see a high workload for the professionals and feel that,because of cutbacks in funding, they are mainly working towards a shortlength of stay. They are afraid of negative consequences for theirrehabilitation, although they are in favor of efficiently organizedrehabilitation to achieve optimal results.Because then he could anticipate what it was of course. But it[home visit] was very painful for him, he found it terriblypainful.Although home visits during the rehabilitation can be confronting,participants find them useful. As an informal caregiver related to home visits,Well, I thought it would have been better. That he would feelsafer. Yes, that's what I think. That this is just tooshort.All participants are aware that rehabilitation continues after discharge.Therefore, a good and timely transfer between settings is necessary.Participants are not sure whether rehabilitation at home or on a ward isbetter at the start of the rehabilitation process. Some participantsthink the length of stay is too short. One informal caregiver said abouta longer stay,Yes, the time I am here … I want to keep it as short as possible.Yes, I do.And others want to keep their time on the ward as short as possible, likea rehabilitant with multiple fractures,In this article, for the first time, the perspectives of rehabilitants and informalcaregivers regarding a Challenging Rehabilitation Environment are described. Thethemes identified can be divided into factors concerning the rehabilitation processand factors concerning organizational processes. Regarding the rehabilitationprocess, we found 9 themes: (1) rehabilitant, (2) rehabilitant centered, (3)informal caregivers, (4) communication, (5) exercise, (6) peer support, (7) dailyschedule, (8) nutrition, and (9) eHealth. Four themes were identified regardingorganizational processes: (1) environmental aspects, (2) staff aspects, (3)organizational aspects, and (4) return home.Rehabilitants and informal caregivers experience a lack of attention forneuropsychiatric symptoms during the rehabilitation process, for example, alteredstimulus processing, overburden, a decline of executive functions, dealing withemotions, loss of memory, and loss of initiative. They want professionals to provideinformation about these symptoms repeatedly and in different ways, for example,written, oral, or audio-visual. Recent literature has shown that neuropsychiatricsymptoms like depression, disinhibition, and anxiety are highly prevalent inrehabilitants, and these symptoms are negatively associated with quality of life andhome discharge after rehabilitation –20. InfoParticipants in this study emphasized tailoring the whole rehabilitation process totheir specific situation. They see value in being involved in the process of goalsetting. Wade  andHolsNot all rehabilitants are aware that therapy includes all activities that promoterehabilitation rather than only activities with the physical therapist. Moreover,group training is a way to increase the intensity of therapy, and rehabilitants withgroup training experience are positive about this kind of therapy, whereasrehabilitants without experience cannot imagine it being effective. These factorsseem to indicate the currently insufficient communication on these aspects and thetypes of therapy, although rehabilitants and informal caregivers emphasize theimportance of good communication during the rehabilitation process. This includescommunication about their rehabilitation process, diagnoses, and practical aspectssuch as the daily routine on the ward. Literature has shown that a lack ofcommunication has a negative effect on the rehabilitation process, as the personalneeds of rehabilitants are unclear to the professionals . Good coParticipants in the current study see peer support as important for learning fromeach other, but also for support and recognition. For example, group trainingstimulates peer support and learning from each other, and peer support facilitatesrehabilitants’ and caregivers’ adaptation to long-term disabilities ,28. GrouParticipants support the planning of therapy moments, so they can arrange visitsaround the therapy moments. Working with individualized timetables for rehabilitantsand structured activities can increase a rehabilitants’ activity during inpatientrehabilitation . Itis iThis is the first study into the perspectives of rehabilitants and informalcaregivers regarding CRE. The strength of this study is the variety of informalcaregivers and rehabilitants included. All participants had a recent experience withrehabilitation (and different diagnoses and ages), but were in different phases oftheir rehabilitation process, resulting in a good mix of participants. The use offocus groups stimulated the exchange of ideas, which also resulted in new ideas.Participants were asked for topics they thought were important for a CRE, eventopics that were not mentioned by the researchers. In this way, it was ensured thatall relevant topics were discussed and the internal validity of the study wasincreased. In this study, 15 rehabilitants and 6 informal caregivers from theNetherlands participated. In order to increase the external validity of the study,participants were included until data saturation was achieved. Although allrehabilitants rehabilitated in Dutch rehabilitation institutions, it is likely thatresults can be generalized to other countries.A limitation of our study is that, due to COVID-19, we were unable to include moreinformal caregivers in focus groups and had to switch to telephone interviews. Thislimited the discussion between participants, but these informal caregivers were ableto express their own ideas regarding CRE without interruption. The results of thesetelephone interviews were in line with the results of the focus groups. Therefore,we expect that this adjustment had no effect on the results of this study and thatthe outcomes are broadly supported by informal caregivers and rehabilitants.The second limitation of our study is that most of the informal caregivers werecaregivers of a rehabilitant with a brain injury. The perspectives of the informalcaregiver from a rehabilitant after trauma were in line with the perspectives of theinformal caregivers from rehabilitants with brain injury. Also, the perspectives ofthe rehabilitants themselves with and without brain injury were comparable.Therefore, we expect that this distribution had no effect on the results of thisstudy.Based on this study, 13 themes were identified for modeling CRE from the perspectivesof rehabilitants and informal caregivers. It is important to stimulate rehabilitantsto be as active as possible during their rehabilitation and to tailor therehabilitation process to the individual rehabilitant. Therefore, organizingexcellent rehabilitation care requires a thorough understanding of the concept ofCRE, since it is a complex and comprehensive concept that concerns the wholerehabilitation process. Its effectiveness and efficiency should be researched inprospective studies.Click here for additional data file.Supplemental material, sj-docx-1-jpx-10.1177_23743735231151532 for A QualitativeStudy Exploring Rehabilitant and Informal Caregiver Perspectives of aChallenging Rehabilitation Environment for Geriatric Rehabilitation by Lian M JTijsen, Els W C Derksen, Wilco P Achterberg and Bianca I Buijck in Journal ofPatient Experience


Saposhnikovia divaricata (Turcz.) Schischk (SD) has anti-inflammatory and antiallergic effects.  Allergic rhinitis (AR) is a type I allergic disease induced by IgE. Traditional Chinese medicine κB and IL-6/ROR-γt/STAT3 pathways were measured by immunohistochemistry, quantitative real-time PCR, and western blot. The intestinal microflora abundance in mice was observed by 16S rDNA high-throughput sequencing.  AR model mice were constructed with ovalbumin (OVA) sensitization to observe the improving effect of SD treatment on AR by counting the number of sneezing and rubbing the nose, hematoxylin-eosin, periodic acid-Schiff, and toluidine blue stains. In addition, the allergy and inflammatory cytokines levels and inflammatory cells were observed by ELISA and Wright's-Giemsa stain. The protein levels of the TLR4/TRAF6/NF-α, IL-6, and IL-17, the eosinophils, neutrophils, and lymphocytes number, the LR4, TRAF6, IL-6, ROR-γt, and STAT3 mRNA levels, respectively, while, it increased the IL-2, IL-10, IFN-γ, and TGF-β1 proteins. SD treatment inhibited the NF-κB, p-STAT3, TLR4, TRAF6, and p-IκBα/IκBα proteins. Besides, the effects of OVA and SD treatments were significantly correlated with the abundance of intestinal microflora. The abundances of Cytophagales, Burkholderia, Alteromonadales, Lactococcus, and Clostridiaceae were changed in SD treatment on AR mice.  SD treatment inhibited the sneezing and rubbing times of the nose, decreased the degree of a dense arrangement of cells and mucosal swelling and the number of goblet and mast cells of nasal lavage fluid, reduced the levels of IgE, histamine, Leukotriene B4, IL-4, IL-5, TNF-κB and IL-6/ROR-γt/STAT3 pathways and intestinal microflora modulation. This study provides a possibility that the improvement effect of SD treatment on allergies and inflammation in AR mice may be related to the TLR4/TRAF6/NF- AR is aavate AR . Xu repotivation . Piao's prove AR .Saposhnikovia divaricata (SD), the dried root of Saposhnikovia divaricata (Turcz.) Schischk, is a traditional Chinese medicine with anti-inflammatory and antiallergic effects [ effects , 10. Li  effects . Moreove effects . In part effects . In concClostridium butyricum could promote the expression of IL-10 by antigen-specific B cells, leading to improved immune indicators in AR patients with the downregulation of IgE and Th2 [γ Treg cells were induced by IL-6 which was related to intestinal microflora. Therefore, this study explored the correlation between the etiology of AR and intestinal microecology by 16s rDNA high-throughput sequencing to provide new targets for the prevention and treatment of AR.Besides, in recent decades, scientists found intestinal microflora was essential for host immune function, energy metabolism, and intestinal permeability . Studies and Th2 . EspeciaIn short, the SD that was provided and identified by the pharmacy of the author's hospital was decocted twice with 10 times and 8 times volume water, respectively, for 1 h each time, and the decoction was filtered by No.3 filter paper; the aqueous extract was concentrated using a rotary evaporator at 60°C and was vacuum dried . Each 1 c mice (6 weeks) were purchased by Shanghai Lingchang Biotech Co., Ltd. They were housed in a standard specific pathogen free grade environment with a free diet and light dark alternation with 14 h light and 10 h dark. The 24 mice were divided into three groups, namely, the control group, the AR group, and the SD group. Ovalbumin (OVA)  was prepared with 0.4% aluminum hydroxide to a concentration of 0.2 mg/mL. On the 1st day, the mice in AR and SD groups were injected with 0.5 mL OVA, in which 0.05 mL was injected subcutaneously in each of two points on the hind paws-plantar, two points on the groins, and two points on the back, and 0.2 mL by intraperitoneal injection; on the 7th, 14th, and 21st day, the mice were intraperitoneally injected with 0.5 mL OVA. On the 22nd day, the mice in the AR and SD groups were dosed daily intranasally with 20 μL of 25 mg/mL OVA for 14 days to consolidate allergic reaction. At the same time, the mice in the SD group were administered 16 mg/kg of SD aqueous extracts by gavage for 14 days according to the conversion of animal dose to a human dose based on body surface area [The male BALB/ace area , and micOn the day after the last gavage, the number of sneezing and rubbing of the noses of each mouse was observed individually for 15 min on the final day of gavage.µl of PBS through the catheter (24G IV) that was inserted into the pharyngeal opening were instilled, and the NLF was collected from the nostrils. Subsequently, blood was extracted from the mouse orbit, the supernatant of blood was collected by centrifugation, and the serum was stored at −80°C. After euthanasia, the murine nasal maxillae were removed and immersed for fixation in 10% neutral formalin solution for 24 h; then, the intact nasal cavities were left to be fixed in 4% paraformaldehyde for histopathological examination.On the day after the last gavage, nasal lavage fluid (NLF) was collected for the enzyme-linked immunosorbent assay (ELISA) and cytometry assay. The way of collecting the NLF was as Cho's team described ; in brieμm) were stained by the stain kits of hematoxylin-eosin (H&E), periodic acid-Schiff (PAS), and toluidine blue (TB) stains according to the routine steps [After dewaxing and dehydrating, paraffin sections (4 ne steps –21. MoreE (IgE), histamine (HIS), leukotriene B4 (LTB4), IL-2, 4, 5, 6, 10, 17, interferon-γ (IFN--γ), tumor necrosis factor-α (TNF-α), transforming growth factor-β1 (TGF-β1) in serum, or NLF were measured by ELISA according to instructions. The ELISA kits of IgE (MM-0056M1), HIS (MM-0548M1), LTB4 (MM-0041M1), IL-4 (MM-0165M1), IL-5 (MM-0164M1), IFN-γ (MM-0182M1), IL-6 (MM-0163M1), and IL-17 (MM-0170M1) were purchased from Jiangsu Meimian, Co., Ltd., China. Moreover, the IL-2 and TGF-β1 ELISA kits were provided by Shanghai Enzyme-linked Biotechnology Co., Ltd., China.The levels of immunoglobulin After centrifugation, the precipitate of NLF was resuspended in 1 mL PBS (100 mM) supplemented with 1% bovine serum albumin (BSA) . Eosinophils, neutrophils, and lymphocytes were stained by Wright's-Giemsa stain  for cell counting . The numμm) was subjected to citrate antigen retrieval solution for antigen retrieval, and endogenous peroxidase of it was blocked by H2O2. Moreover, 3% BSA was used to block the tissue section. Subsequently, the NF-κB p65  and p-STAT3  antibodies were incubated with the sections separately at 4°C overnight. After incubation by the corresponding secondary antibody, tissue sections were sequentially stained by a DAB kit  and hematoxylin  [After dewaxing and dehydrating, the tissue section  . Lastly,−ΔΔCt). The primer information is shown in Generally speaking, after total RNA was extracted from mouse nasal mucosa by using the Trizol kit , and reverse transcription was performed by using the HiFiScript cDNA Synthesis Kit . PCR was carried out under the following conditions by SYBR Premix Ex TaqII according to instructions, 95 °C for 10 min and 95 °C for 15 s, then at 60 °C for 60 s, performed 40 cycles . The datκBα , IκBα , NF-κB p65 , ROR-γt , p-STAT3 , STAT3 , and β-actin  antibodies at 4 °C overnight, the samples reacted with the corresponding secondary antibody for 2 h at 25 °C next day. Moreover, an ECL chemiluminescence kit  was used to color the protein band; subsequently, the membranes with the protein band were imaged with a chemiluminescence instrument . The antibodies were all provided by Affinity Biosciences Ltd., Co, USA.The RIPA lysate buffer  was used to obtain the total proteins from mouse nasal mucosa, and a BCA kit  was used to measure the concentration of total proteins. Then, protein denaturation was used by way of 100°C boiling water for 5 min, and the proteins were separated by electrophoresis. Later, the polyvinylidene fluoride membranes were used to transfer proteins in electroblotting, and then they were blocked by 5% nonfat milk. After washing by TBST and incubating with the TLR4 , TRAF6 , p-Ihttps://www.genome.jp/kegg/) and MetaCyc [https://metacyc.org/) databases, the microbial metabolic function of samples was predicted to find out different pathways and obtain the species composition of specific pathways. The enrichment pathway analysis was carried out based on intestinal microflora that has significant differences in the abundance of groups.After euthanasia, the caecum contents of 5 mice in each group were taken and handed over to Suzhou PANOMIX Biomedical Tech Co., Ltd. The total DNA of intestinal contents of mice was quantified by NanoDrop 2000, and the quality of DNA was detected by 1.2% agarose gel electrophoresis. The genome was amplified by PCR to obtain the v4-v5 region of the bacterial 16SrRNA gene. The Vazyme VAHTSTM DNA Clean Beads were added to the purification and recovery of amplification products. The recovered products of PCR amplification were quantified by the Quant-iT PicoGreen dsDNA assay kit, and the quantitative instrument was a microplate reader . According to the sequencing quantity requirements of each sample, each sample shall be mixed according to the corresponding proportion. The sequencing library was prepared with the TruSeq Nano DNA LT Library Prep kit of Illumina company, and then high throughput sequencing was started. Sequence denoising or OTU clustering was performed according to QIIME2 dada2 or VSEARCH, and subsequently, QIIME2 (2019.4) was also used for species composition, alpha diversity, and beta diversity analysis. Based on KEGG . The histopathological injury of nasal mucosal in AR mice was assessed by H&E, PAS, and TB stains. In the AR group compared to the control group, the degree of cellular disarrangement and mucosal swelling was much more severe (P < 0.01). Moreover, SD treatment could markedly antagonize the above trend (P < 0.01).The observation of sneezing and rubbing of the nose behavior was performed to verify the improvement effect of SD on AR mice Figures . The nume severe ; the nume severe  . Moreover, the number of IL-2, IL-10, and IFN-γ was much lower in the AR group compared to the SD group, and the SD treatment could increase those levels markedly (P < 0.01).The levels of cytokines related to inflammation and allergy in the serum were measured by ELISA Figures . The levP < 0.01)    . The degrees of TLR4, TRAF6, p-IκBα/IκBα, and NF-κB proteins were assessed by western blot . In the SD group, they are all decreased compared to the AR group .The mRNA levels of TLR4, TRAF6, IL-6, ROR- Figures . They we Figures . MoreovePseudomonas, Bifidobacterium, Ruminococcus, Allobaculum, Parabacteroides, and so on. The alpha diversity analysis of intestinal flora by different indexes is shown in P < 0.05). In Shannon and Simpson indexes, there are also significant differences in the SD group compared with the control group (P < 0.05). According to the beta diversity analysis of Jaccard and unweighted uniFrac based on PCoA, there were differences between the control group, the AR group, and the SD group  in different groups is shown in Pseudomonas is a common bacterium of the three groups, and its relative abundance ranks first ). In the glycogen degradation II (eukaryotic) pathway and the superpathway of polyamine biosynthesis III, Pseudoalteromonas and Vibrio had the largest abundance in the control group , (c)). Interestingly, in the isoprene biosynthesis II (engineered) pathway, there is only Corynebacterium in the control and SD groups .The marker species were analyzed by LDA effect size analysis . c_BacilT helper 1 and 2 [α, IFN-γ, and IL-1β, in U937 cells [Traditional Chinese medicine has a definite and stable role in the prevention and treatment of AR with the advantages of overall regulation, multidirectional and multitarget . Lenon s 1 and 2 . SD was 37 cells . TherefoEspecially, SD reduced the number of mast cells in the nasal mucosa and the levels of inflammatory factors in the serum and NLF of AR mice in this study. Mast cells are the key effector cells of anaphylaxis and play an important role in the regulation of immune response . ResearcκB and IL-6/ROR-γt/STAT3 pathways by IHC, qRT-PCR, and WB. A study on patients with persistent allergic rhinitis found that the TLR4 mRNA level was significantly higher compared to the control group [κB signaling improved AR, and Wang reported the alleviation of miR-146a on the inflammation in AR mice by inhibiting the TLR4/TRAF6/NF-κB pathway [γt/STAT3/IL-17/NF-κB pathway. It has been reported that MCs could amplify the immune response of T cells in the presence of TLR4 which is required for the induction of immune responses by MCs [κB and IL-6/ROR-γt/STAT3 pathways, which may be the one of reasons that SD improved AR.In addition, we studied the expression degrees of the TLR4/TRAF6/NF-ol group . The inh pathway . Besidess by MCs . This stClostridium butyricum could promote the expression of IL-10 by antigen-specific B cells, leading to improved immune indicators in AR patients with the downregulation of IgE and Th2 [Bacteroidetes, Proteobacteria, and Firmicutes in AR mice were significantly different from those in control mice. A study reported that Bacteroidetes was related to the improvement effect of the compound small peptide of Chinese medicine on intestinal immunity in mice [Burkholderia, which belonged to Proteobacteria, in intestinal contents of fish was increased by the growth-promoting traditional Chinese medicine treatment [Firmicutes was decreased when atopic dermatitis in mice was improved [In recent decades, studies have found that the dysbiosis of intestinal microflora was closely related to the development of allergic diseases . Germ-fr and Th2 . In this in mice . Moreovereatment . Kim's timproved . Similarα, and TGF-β1) and raised the levels of anti-inflammatory mediators  in OVA-induced AR mice. Moreover, SD treatment regulated the levels of NF-κB, TLR4, TRAF6, p-IκBα/IκBα, ROR-γt, and p-STAT3/STAT3 proteins and intestinal microflora in AR mice. This study suggested that the improvement effect of AR by SD treatment is related to the TLR4/TRAF6/NF-κB, IL-6/ROR-γt/STAT3 pathways and intestinal microflora modulation. The results of this study provide a new idea and the basis for traditional Chinese medicine on AR treatment.To summarize, this paper proved the improving effect of SD on behavior and histopathology of AR mice, and SD treatment inhibited the levels of proinflammatory and immune mediators (IgE, HIS, LTB4, IL-4, 5, 6, 17, TNF-


AR and PARD3B gene expressions and their correlations were mined from The Cancer Genome Atlas (TCGA) database and analyzed using the UALCAN system. Analyses using a real-time PCR, cell proliferation, and colony formation and a loss-of-function strategy by suppressing AR activity with its specific inhibitor, enzalutamide, were then carried out to determine roles of the testosterone AR–PARD3B signaling axis in tumor malignance. Results: Expressions of AR, PARD3B mRNA, and proteins in human GBM tissues were upregulated compared to normal human brain tissues. In contrast, levels of AR and PARD3B mRNA in most TCGA pan-cancer types were downregulated compared to their respective normal tissues. Interestingly, a highly positive correlation between AR and PARD3B gene expressions in human GBM was identified. The results of a bioinformatics search further showed that there were five AR-specific DNA-binding elements predicted in the 5′ promoter of the PARD3B gene. Regarding the mechanisms, exposure of human glioblastoma cells to testosterone induced AR and PARD3B gene expressions and successively stimulated cell proliferation and colony formation. Suppressing AR activity concurrently resulted in significant attenuations of testosterone-induced PARD3B gene expression, cell proliferation, and colony formation in human glioblastoma cells. Conclusions: This study showed the contribution of the testosterone AR–PARD3B signaling axis to the tumorigenesis and malignance of human GBM through stimulating cell proliferation and colony formation. Therefore, the AR-PARD3B signaling axis could be targeted for potential therapy for human GBM.Background: Glioblastoma multiforme (GBM) is the most common and malignant brain tumor with very poor prognoses. After surgical resection of the primary tumor, rapid proliferation of residual glioblastoma cells is a critical cause explaining tumor malignance and recurrence. In this study, we evaluated de novo roles of the testosterone androgen receptor (AR)–PARD3B signaling axis in the tumorigenesis and malignance of human GBM and the possible related mechanisms. Methods:  Gliomas are the most common primary brain tumors that originate from transformed glial cells . GlioblaAR gene expression with the DNA repair response in the microenvironment of GBM tissues [AR gene is also positively related to the survival of cancer patients, especially male cases. One possible reason explaining the involvement of AR signaling in the tumorigenesis of glioblastomas is that upregulation of testosterone levels and AR gene expression could disrupt the status of hormones and immunity in the microenvironment of glioblastomas and then worsen the outcome of GBM patients [Androgen receptor (AR), a member of the steroid hormone nuclear receptor family, encompasses three major domains for transcriptional regulation and binding to DNA and the ligand . Functio tissues . Expresspatients . TherefoCell morphologies and shapes are produced through a polarity process . Functiohttps://www.cancer.gov/about-nci/organization/ccg/research/structural-genomics/tcga with data downloaded in June 2022 (accessed on 6 June 2022).). All of the data were further analyzed using a tool of the UALCAN database system .) as described previously [AR and PARD3B genes were also analyzed using the UALCAN database system. In analyses of proteomic data, Z-value is a measure of how many standard deviations (SDs) below or above the population mean a raw score is. Z-scores are a way to compare results to a “normal” population. Thus, the protein expression was expressed as Z-value in this study. The heatmap was analyzed and obtained from the UALCAN database system as described previously [OMICS data of human GBM were mined from The Cancer Genome Atlas (TCGA) database  and Bioresource Collection and Research Center . U87 MG glioblastoma cells were derived from a malignant glioblastoma from a female Caucasian patient . In contat 37 °C .Testosterone was purchased from Sigma-Aldrich . Its purity was >98%. Testosterone was freshly prepared by dissolving it in dimethyl sulfate (DMSO). Our preliminary study showed that testosterone at 1, 10, 100, and 1000 nM time-dependently induced AR mRNA expression in human U87 MG cells. Testosterone at 1000 nM is much higher than clinically relevant concentrations. Thus, human glioblastoma cells were treated with testosterone at 25, 50, 75, and 100 nM for various periods of time. Control cells received DMSO only.To determine the roles of the AR signaling axis in the malignance of human glioblastoma cells, a loss-of-function strategy was carried out via application of enzalutamide, an inhibitor of the AR . EnzalutA real-time PCR was executed to measure expressions of AR and PARD3B mRNAs in human U87 MG and GBM8401 glioblastoma cells following a previously described methodology . After b4 cells/well overnight. Cells were treated with testosterone or enzalutamide. After drug treatment, WST-1, a red tetrazolium salt, was added to the plates and reacted at 37 °C for 4 h. The yellow products reduced by mitochondrial dehydrogenase were measured using an enzyme-linked immunosorbent assay (ELISA) microplate at an optical density of 450 nm.Proliferation of human U87 MG and GBM8401 glioblastoma cells was determined using a colorimetric method as described previously . A water5 cells) were seeded in six-well tissue culture plate at 37 °C overnight. Human glioblastoma cells were treated with testosterone or enzalutamide. After drug treatment, cells were washed with 1× phosphate-buffered saline (PBS) containing NaCl (0.14 M), KH2PO4 (1.5 mM), Na2HPO4 (8 mM), and KCl (2.6 mM), and harvested. Human glioblastoma cells were replated in 35 mm tissue culture dishes at a density of 103 cells per dish for 3 days. Colonies were stained with crystal violet, and then the colonies were counted and statistically analyzed as described previously [Human U87 MG and GBM8401 glioblastoma cells  for n = 6. Statistical analyses of all data presented in this study were conducted using a two-way analysis of variance (ANOVA) and post-hoc Duncan’s multiple-range test. Differences among various groups were considered significant at p < 0.05.In normal human brain tissues and GBM tissues, values indicating expressions of various genes at the mRNA and protein levels represent the minimum, lower quartile, median, upper quartile, and maximum. Pearson correlation analyses were conducted to determine the coefficients between Compared to normal human brains, levels of AR mRNA in human GBM tissues were massively upregulated by 760% A. AdditiAR gene expression in human GBM tissues, expressions of PARD3B mRNA in most TCGA cancers, including breast invasive carcinoma (BRCA), CESC, HNSC, KICH, KIRC, KIRP, LUAD, LUSC, READ, THCA, THYM, and UCEC, were downregulated  (n = 152), African American (n = 10), and Asian (n = 5) groups, Pearson correlation coefficients of AR and PARD3B gene expressions were 0.74, 0.51, and 0.96, respectively  B. In Cauectively C. Result35–−1249 D.PARD3B gene expression in human glioblastoma cells  the detailed mechanisms explaining how PARD3B is involved in proliferation and colony formation of human glioblastoma cells should be further investigated; (2) because both U87 MG and GBM8401 cell lines were derived from female GBM patients, the cells from male patients also must be checked; and (3) animal studies should be carried out to confirm our present findings.Compared to normal human brain tissues, expressions of


Monitoring changes in stable oxygen isotope ratios in molecular oxygen allows for studying many fundamental processes in bio(geo)chemistry and environmental sciences. While the measurement of The online version contains supplementary material available at 10.1007/s00216-022-04184-3. Changes in mentclass2pt{minimuctivity .Typically, the stable isotope ratios of njection –19. Contnjection , 21 and njection , 23. Recnjection , 24 a ponjection , 22–25 s DI/IRMS –29.2 .–29.\docuce of Ar . Even atce of Ar  Ar interon of O2  could thThe goals of this study were (i) to show how to prevent Ar interference in continuous-flow A complete list of chemicals is provided in Section For analysis of The enzymatic reduction of i et al.  and summAssays were prepared by adding 10–67 Dissolved ide down , 24. AllGaseous and headspace samples in crimp vials were analysed by GC/IRMS consisting of a gas chromatograph coupled via a Conflo IV interface to a Delta V Plus isotope ratio mass spectrometer (Thermo Fisher Scientific). Our previously introduced instrumental procedure  was modiGaseous samples in Exetainers were placed on the autosampler of a GasBench II system coupled via a Conflo IV interface to a Delta V Plus isotope ratio mass spectrometer (Thermo Fisher Scientific). Sample gas was transferred automatically into a sample loop  with and without modified peak detection parameters did not allow separation of Ar and s Figure . To corrmentclass2pt{minimTo account for diffuse contamination with ambient entclass1pt{minimaOxygen isotope fractionation of dissolved We evaluated the effects of Ar interference on b of b is an instrument-specific number, determined, for example, by the degree of Ar and b remained constant over at least one month  at 30 mentclass2pt{minimy Tables  and S3. y Tables  and S3. paration , 28. We  DI/IRMS . The corer Table . For accb as correction factors in Eq. m/z 40 and m/z 32 peak areas ratios. Finally, we note that in cases where derivation of correction factors b from the correlation of The reproducible quantification of Ar interferences on mentclass2pt{minimely Fig. , “corr”. Section . An examIf the same type of samples are measured by GC/IRMS equipped with a 60 m molsieve column, we obtain baseline separated Ar and .3‱ Fig. . On a Gans Table . While t CF-IRMS .In laboratory experiments where changes of mentclass2pt{minimologues, –44 couldWe studied the theoretical consequences of Ar interferences on the quantification of mentclass2pt{minimials Eq.  to form Insertion of Eqs. }μM Fig. . In the .8‱ Fig. . \documementclasspt{minimaeactions . Figure and KIEs .Fig. 2Below is the link to the electronic supplementary material.


Story-driven games are growing in popularity across a wide range of genres. However, the narrative potential of video games is still being debated, particularly in light of the so-called tension between gameplay and storytelling. This study proposes that rules and game mechanics perform narrative semiotic functions, offering a ludic grammar of interactive storytelling. Case studies of four representative games show through exploratory player action shaped by rules, the medium of video games can generate meanings that traditional media cannot, thereby better achieving their narrative goals. Detroit: Become Human (2018) has generated a great deal of popular online commentary as well as scholarly interest, the assumption that visually immersive story worlds hold the key to narrative power in the space of video games has been effectively dispelled, especially in the cases of non-action, hand-illustrated text box gamesClosed Hands (2021);Bury Me, My Love (2017); andChinese Parents (2018).The last decade has seen a surge of creative experimentation in video game storytelling granting unprecedented agency to audiences of reality-based storytelling. Digital games increasingly combine cinematic perceptual realism with a modular flexibility and immediacy that exceeds even gamebooks as a medium. AlthoughWhat Remains of Edith Finch, can also be experienced as a traditional time-based narrative, such as movie, since they are entirely linear, and interacting with the environment only gets in the way. When players often cannot find the location of the next scene that contains narrative content. In his view, rather than attempting to tell stories capable of the narrative power associated with cinema and literature, video games are more adept at generating meaning through player actions, particularly by offering independent exploration of virtual worlds and systems within a defined set of rules , the Syrian refugee crisis , the 2017 Manchester, England terrorist bombing (Closed Hands), and the collective memory of childrearing in China during the 1980s and 1990s (Chinese Parents). These games combine earnest and intimate engagement with political topics of global concern with especially ambitious and complex writing. Further, these games are all developed outside the U.S.—the first two are French, followed by British and Chinese titles—highlights the global reach of video game storytelling. Our reading of these games interrogates the apparent correlation between the ethical treatment of reality-based topics and interactive storytelling as a game mechanic. The broader contexts of these games cast questions about player agency (and choice) in a new light.Thus, the four games examined in this study are reality-based. Their stories engage seriously with social, political, and psychological topics. Namely the non-fiction topics informing these case studies are American slavery (Our study builds onretell the story of their game session so that narrative sequence (like the reward of a cut scene) can be generatedthrough  gameplay. Several structural traits are shared by video games and narratives. Crucially, ludologists and narratologists may be operating according to disparate definitions of narrative, with the former understanding storytelling as a fixed causal chain of events that are recounted and/or reenacted, whereas the latter sees narrative “as a loose fictional frame” applied to a variety of experiential phenomena . The early ludology approach thus seems more appropriate for games with fictional frames and interests that seem to swerve away from reality and are instead rooted in fantasy and empowerment. In contrast, the games at the heart of this study are understood as profoundly related to the real-world issues they explore. And the text box itself—emblematic of narrative in games more generally—serves as both a mechanical reworking of real-world issues  and as the point of entry for the player’s own significant involvement in these issues.Althoughenomena . Early tenomena , 50. NarBandersnatch) in the 1970s. Crucially, the Choose Your Own Adventure gamebooks declined in popularity with the rise of narrative video games from the late 1980s through the 1990s. AsNotably, the ethics narratives of our cases represent the digital remediation of print culture’s Choose Your Own Adventure stories first published by Chooseco . For games without a clear ending that decides a winner, narrative is not rendered subordinate to skill grinding to attain points, levels and badges. A less acquisitive model, such as that showcased inWalden: A Game (2017), is indeed the intent forDetroit: Become Human. The player’s quest in each game is for the extraction of meaning through interaction with the virtual world. It should be noted that, whereas ludologists such asWalden: A Game as a “walking simulator” that “devolves into conceptualism,”Detroit: Become Human showcases action scenes featuring police conflicts and dramatic hostage situations within a science fictional setting more common to video games.Detroit: Become Human indeed bears all the trappings of a first-person shooter dystopian action game, only with a choice-driven game mechanic in place of combat as the chief mode of gameplay. The humble and underappreciated text box, along with associated devices of the dialogue wheel, and interactive fiction, constitutes the engine behind not only the storytelling prowess of Cage’s magnum opus, but a wave of indie PC games that transform theChoose Your Own Adventure story into a visceral, dynamic form of play fraught with risk, consequence, and temporal pressure. In the cases selected for this study, winning in the traditional sense is not the goal; pursuing a viable life course through a set of existentially important decisions with radically different outcomes instead transforms the player into an author in games granting agency. In non-choice games with less agency, prescribed narrative is performed according to a more linear, cinematic model. All of the cases examined here represent the ways in which the development of branching narratives entails a labor intensive creative process that breathes new life into this still-emerging medium. Building branching narratives in digital games is “an often underappreciated effort,” according to the developer of the PC game Zenuel: “You wouldn’t expect text in a game to be so divisive, or so complex, but when done right, it empowers every area of a game, enriches even the smallest details and makes a world feel like it knows you’re there” , that gave rise to binge-watching, and now with podcasting, binge-listening, as mainstream forms of media consumption. The sheer volume of content speaks to the encyclopedic property of interactive storytelling, which is enabled by the data storage capacity of computers, asHamlet on the Holodeck, her foundational study highlighting the literary potential for storytelling through emerging technology. Endowed with such a massive capacity for data compared to traditional media forms designed to deliver narratives, spatial storytelling is enabled by the power of computers to represent navigable 3D space. With encyclopedic properties and spatial storytelling, video games can offer either a narrow or wide range of choices to players, depending on the developer’s aims.Scholarly discussion of narrative in video games has addressed the problem of allowing players to act freely, while ensuring their actions produce an interesting story. Management of this tension is a key reason for the larger scale of interactive writing, as seen in the roughly 130,000 words that constitute the narrative architecture ofBury Me, My Love. Although the game contains 20 endings, the player has little agency in determining the course of each of those narrative lines. Indeed, some players ofBury Me, My Love complained of not having enough agency, showing that the game can be about performance rather than a choice structure. Nonetheless, the ludic quality of each of those narrative threads, as the case study will later demonstrate, suggests that narrativity is the primary game mechanic, although more like advancing pages in a novel (through the game’s simulated WhatsApp interface) rather than steering the outcome of a Hollywood screenplay. Micro choices in dialogue still funnel back to the main channel of the narrative, holding players to the course of the fixed outcome, a kind of virtual jungle cruise with a few minor diversions along the way, but never enough to deviate from the inevitable flow of experience. Murray’s (1997) concept of interactive storytelling posits far greater agency than this game affords, one that envisions an elaborate choice structure like those ofDetroit: Become Human,Closed Hands, andChinese Parents. The participatory properties integral to interactive storytelling are defined as the digital medium’s technological capacity to influence the production of the player’s behavior when engaged with the game. Procedural properties constitute the game’s capacity to execute rule in succession to generate behavior  in the twenty-first century that render narrative import through digital media.The latter point regarding rules has been emphasized by ludologists in support of the concept of procedural rhetoric, whichDetroit: Become Human, denies its semiosis. AsThis study therefore takes it as axiomatic that game mechanics, rules, and procedural properties, while often distinct from narrative content, can function as the engine driving interactive storytelling. The following case studies show how ludology is hardly distinct from narratology, but rather one and the same, inextricably bound in a mutually reinforcing relationship. The aim here is to complicate firm distinctions in formulations of games as constituting whatDetroit: Become Human by the French game developer David Cage and Quantic Dream (2017),Bury Me, My Love also by a French game developer Florent Maurin and Pixel Hunt (2017),Closed Hands by the British developer Dan Hett and PASSENGER (2021), andChinese Parents by the Chinese developer Moyuwan Games (2018). These critically acclaimed games are all reality-based and employ distinct game mechanics to deliver complex narratives treating serious issues of learned debate with contemporary and historical significance.Detroit: Become Human is an allegory for U.S. slavery and the Civil Rights Movement (which anticipates the recent BLM protest movement); the Syrian refugee crisis is the focus ofBury Me, My Love; international terrorism constitutes the subject ofClosed Hands; andChinese Parents centers on Chinese collective memory of child-rearing from the perspective of parents.Purposive sampling led us to our information-rich case studies suitable for qualitative research in digital media such as this interpretive critical analysis of ludic narrativity in video games. It aims to achieve not total coverage or generalizability according to quantitative randomized sample studies, but “a deep, albeit partial and contingent, understanding of social reality in a specific context” , 143. OuWe selected games featuring narratives bearing on social and political reality to indicate that a strong correlation exists between technical innovation in video game storytelling and the real-world relevance of their chosen topics. Although our case studies consist of titles that are technically designated as fiction, they are committed to social reality just as “a theatrical play may be documentary as easily as it is fiction,” as Aarseth notes . “For representational games,” he explains, “this means that as long as the game objects refer to events and existents in our world , they do not fictionalize but document.” The realistic import of these narratives heightens their urgency—as well as the precision of the affective and documentary nature of their telling—given their applicability to current political circumstances. We thus approach the fictional games of our case studies as bearing documentary functions with important sociopolitical implications, according to the formulation that “documentary simulations and games do not have to refer to specific objects to be documentary; they can also refer to generic objects  and the resulting simulation is still documentary, not fictional” .Detroit: Become Human, 20 inBury Me,My Love, nine inClosed Hands, and 100 inChinese Parents. The rationale for our selection process prioritized games representing self-conscious attempts at achieving sophisticated narratives from across the global games industry, from mainstream AAA to indie and fine arts sectors. The various approaches to narratives in our sample thus showcase the adaptability of finely crafted narrative to different conventions and technological affordances. Originally released on PS4 and Microsoft Windows,Detroit: Become Human represents narrative innovation in the console game sector. The indie mobile game market’s foray into story-driven games appears inBury Me,My Love, which is designed to be played on a smartphone, yet in an immersive way demanding extended engagement. As a conceptual game from the world of digital fine art,Closed Hands was designed for the PC specifically with use of headphones to enhance the game’s polished sound design carefully attuned to the nuances of the story. WhereasBury Me, My Love andClosed Hands cater to niche audiences,Chinese Parents is a mass market production, which has won considerable market share in the highly competitive Chinese video game industry, particularly the casual indie RPG simulation sector. Thus diversity is represented in the sample in terms of aesthetics and gameplay as shaped by each title’s cultural, geographical, and industrial situatedness.Narrative ambition unites our selected story-driven games, as reflected in the multiple endings possible in each, with six outcomes inThe multilinear and interactive nature of story-driven video games poses a challenge for narrative analysis , 2473. Oludic narrativity, defined as gameplay that tells a story through “units of meaning, or semes” (Games were examined for 1) synchronization of gameplay mechanic with narrative development, 2) formation of narrative structure, 3) thematic coherence, and 4) their impact on player experience. Additionally, paratextual promotional videos, playthroughs, reviews, and developer interviews and conference presentations were also accessed to contextualize the analytical process. Critical interpretation of formal aspects of the games is drawn from semes” , 5. PlayDetroit: Become Human developer David Cage described writing the text for the game as a painstaking process of conceiving of its many different actions, consequences, and outcomes. Interactive writing, he noted, entails consideration of not only space and time, but also possibility. Each situation demands imagining thousands of variables, conditions, and options. Whereas film scripts typically contain roughly 100 pages, interactive stories like that ofDetroit: Become Human can contain between 4-5,000 pages. Such sprawling narrative landscapes are essential to generating a plausible sense of player agency. In conscripting the player in the authorial role, gameplay becomes tantamount to an act of creative writing.Detroit: Become Human thus defiesWhat Remains of Edith Finch, a narrative masquerading as a game, which he believes would have been better told as an animated film.Detroit: Become Human, however, uses the player’s choices to determine the outcome of six different endings. The game’s ostensible subject is its narrative, which gameplay indeed renders “visible, operable, and beautiful,” a process whereby storytelling itself on behalf of player choice is simultaneously ludic and semic  disqualified from the rights and freedoms enjoyed by others  narrative decisions” (12). Quicktime events and dialogue choices extend the narrative branches. The branching story co-authored through gameplay is displayed at the end of each chapter. This detail underscores the importance of narrative as the main accomplishment or product of gameplay, which is constructed as a semantic exercise in critical thinking and interpretation of the simulated environment.Agency is central to shape” , 12. ForFortnite, ends in the death of the player’s avatar. By contrast, the death of the player’s avatar inDetroit: Become Human does not end the game, as play may continue to support the plight of androids through the two other playable characters. Narrative construction is thus showcased as the core value of gameplay, as Cage and his designers preserve the player-generated story by continuing, rather than erasing, progress upon a protagonist’s death. The ludic narrativity of android liberation can thus be constructed through multiple protagonists.The individualism of a traditional first-person shooter, as in battle royale games likeDetroit: Become Human is reinforced through flowcharts which appear at the end of each chapter. The flowcharts allow characters to rewind certain scenes to either recant decisions or lament them. This detail positions gameplay as a form of authorship, not in the abstract, but in the literal telling of the fate of the liberation movement. Conner’s character is not locked into his programming to suppress the liberation; he may deviate from it to aid the uprising, but can also abruptly decide to shoot Markus at his speech during the final android protest. Many chapters contain six different endings. The flowcharts following each chapter highlight not only the decisions players made, but also those they did not. The otherwise invisible work of interactive writing from the designer’s perspective becomes entirely visible to the player, who is invited into this dimension of the process of game production. In the process of gaining new awareness of interactive narrative production from the scriptwriter’s perspective, player consumption is enriched through a new self-awareness of their own choice pattern whereby they might elect to pursue different paths on the next playthrough. The narrative blueprint’s appearance at these key intervals echoes the flowcharts frequently used by novelists and narrative nonfiction writers. A plot chart similarly plays a prominent role inClosed Hands, a game in which the player becomes acutely aware of unchosen paths and their alternative consequences.Detroit: Become Human thus epitomizes the principle of gameplay that entails revealing consequences of actions to players within the context of the storyworld. AsPlayer investment in shaping the through line of the unfolding story ofDetroit: Become Human, identification with marginalized game characters can become what Leach and Dehnert (2020) call “a means of exploring the social locations and experiences of marginalized others,” especially in the construction of racial identity and strong female protagonists (23).Bury Me, My Love  similarly immerses players into the experience of a marginalized population, particularly through the reality-based journey of a Syrian refugee migrant. Rather than recreating a visually ornate and elaborate storyworld to simulate that experience, Florent Maurin and his team of developers of Pixel Hunt designed the game from the perspective of the migrant’s loved one, as told through this digital correspondence in a recreated version of a WhatsApp interface. Players are recommended to experience the game on their phones to better approximate the communication between the migrant woman Nour and her husband Majd at home. That correspondence takes on a wide range of subjects and tones, from playful and intimate to serious and strategic depending on Nour’s situation along her journey. The result is a pattern of gameplay that advances the narrative via the communication with Nour, who faces desperate and life-threatening circumstances that the player must guide her through from the perspective of Majd.The parasocial “trying on” of alternative identities can raise player awareness and empathy for disadvantaged and systematically oppressed populations. As shown inBury Me, My Love, each of which contributes to a unique form of ludic narrativity. Majd in this game can be construed as the player’s avatar, as the player guides Nour to safety through him and all gameplay choices dictate the content of his communication. The effects of player choices, according to Murray’s principle of best practice for narrative-driven games mentioned earlier, are immediately apparent in how they shape Nour’s condition. Majd—and thus the player—is tasked with a challenge fraught with violence and mortal risk that the developers conscientiously elected to portray off scene, or at least metonymically through the WhatsApp exchanges that take place through text box options. In addition to player-avatar relations to enhance the parasocial functions of the narrative,Bury Me, My Love’s adopted medium of the mobile games is not typically associated with immersive, story-driven titles. A deliberately non-visual interface for scene construction paradoxically heightens the emotional intensity of communication choices that constitute the gameplay mechanic.Thus traditional gameplay is undermined on several fronts inBury Me, My Love was originally inspired by Lucie Soullier’sLe Monde article, “The Journey of a Syrian Migrant as Told by herWhatsApp Messages.” An experience told through a record of social media correspondence is impressive in print, but takes on an entirely new feel when such messages are activated on one’s own phone in the role of Majd. The character and player thus become one through the correspondence with Nour. As developerThe reality-based ludic narrativity ofBury Me, My Love is therefore pre-scripted. “The player has no agency,” according toAlthough Nour’s survival depends on the narrative path assigned to the player, no combination of choices made by the player has a bearing on the outcome. The gameplay leading to twenty possible endings ofBury Me, My Love shares with Dan Hett’sClosed Hands the overarching goal of raising player consciousness about the personal impact of political violence. UnlikeBury Me, My Love’s mobile design and performative narrativity with limited agency,Closed Hands offers radical player agency in shaping the selected protagonist’s narrative. Character fates do not play out on separate vectors, but can be intertwined based on player choice, predominantly through text and dialog boxes. As withDetroit, Become Human, player agency is positioned as an interpretive act demanding thoughtful and conscientious literacy from the player. Developer Dan Hett, who lost his brother in the 2017 Manchester terrorist bombing, structured the game around the event, which is not shown visually. Players choose from one of five characters with the option of switching among them at any time, as the narrative flowchart is accessible at any moment during gameplay. Too large to fit on the screen at once, this story tree of the game’s intricate plot options can be explored by clicking and dragging to unseen portions of it. As with the flowchart feature ofDetroit: Become Human, this overview of the completed nodes in the plot sequence signals the effects and consequences of gameplay to the player. At the center of the flowchart is a box labeled “Incident,” a fictional terrorist bombing in a British city from which the player can select a node in the network featuring the experience of one of the characters  stadium; Farah’s desktop background bears an official government seal reflecting her work for the Police Intelligence Service. Simulated digital interfaces provide the dramatic stage and gameplay interface for characters’ online communication. Haziq, the Muslim shop owner and father of a perpetrator of the bombing, at one point accesses his son’s computer and communicates via instant messaging with a friend of his son to ascertain his whereabouts after he had gone missing; Beth, a reporter at odds with her editor who pressures her to sensationalize the story, voice texts with him from the scene of the bombing; Markus Bashir, an eyewitness of the event who advocates for a compassionate response to the Muslim community, receives a threatening message from the Patriots that escalates into a heated correspondence on his laptop ; statistics will affect the cost of skills learning, and the final statistic and skills acquired will determine what kind of life the role can have at the end. Choices need to be made in each round on how to plan the character’s schedule. Different arrangements impact the character’s statistics in different ways. For example, pushing your character to excel in academic fields will increase IQ. However, it will also add up the stress level. When under excessive stress, the character may experience serious mental issues which will result in game over. Playing Nintendo games can help relieve stress, but it will lower parents’ satisfaction. Since every choice has a trade-off, there is no easy way of gameplay, just like there is no easy mode of life, especially for new players. In addition to the player's scheduled events, there will be unexpected incidents every round, such as “being the last kid to be picked up after school.” These incidents can also affect the role’s statistics in a certain way, thus adding more unpredictability to the character’s life. After the first playthrough, the player can start a new cycle by role-playing the next generation.Our last case isIn general, the game accurately depicts the life course and captures many shared experiences of Chinese children, such as working hard to meet the high expectations of their “tiger mother,” preparing hard for the ultimate challenge: Gaokao (the university entrance exam). It especially reflects the childhood of those who were born between 1980-2000. Growing up in a time that had seen an unprecedented fast economic expansion and social upheaval in Chinese history, this generation had no memories of living in abject poverty, and collectively received a good education and had relatively unrestricted access to information. Considering this, it is no surprise to see the character in the game never experience any pain of hunger or poverty. Another interesting detail is that the character has no siblings. This goes in line with the experience of those post 80s and 90s, since they are the first generation affected by the one-child policy, which limited most Chinese couples to one offspring each .In this sense, the story told by this game is actually the story of a person’s life, or more precisely, the collective memory of a generation. By allowing players to step into the shoe of a typical Chinese child and play both the role of parents and the kid, the game gives the grown-up post 80s and 90s a chance to rethink their lives and their relationship with their parents.Chinese Parents, whose gameplay is heavily based on turn-based strategy. Each turn, players select a course of action from a text box that displays the available strategy options, click to execute, and the system automatically completes all actions for that turn and gives feedback. Much of the feedback is presented in the form of event summary in a pop-up text box, e.g., “Dad gets home drunk and starts shouting a large variety of well-selected curse words at you.” This event causes the character's intelligence attribute to be reduced by five. With this game mechanic,Chinese Parents organically integrates a large number of events that pass collective memories into the player's game experience.This narrative goal is highly supported by the game mechanics ofChinese parents, the events are also not organized into a drama structure. If the game were transformed into a text, the result would be a daily stream of events with flat characters and a monotonous plot, rather than an interesting, coherent story. However, once played, it’s totally different. What a simple narrative like “Dad gets home drunk and starts shouting a large variety of well-selected curse words at you” presents is not just a daily incident but one that could result in a reduction of the character’s intelligence. The subsequent occurrence may have nothing to do with the preceding incident in reality, but it may exacerbate or mitigate the intellectual harm caused by the preceding event in the game. Events that lack connection in reality can constitute a meaningful and coherent experience for the character in the game.This mechanism effectively increases the narrative speed, making it possible to tell the story of a growth spurt of about twenty years in about three hours. It also means that the game can have a higher narrative density, as more anecdotes can be incorporated into the story. More crucially, by adopting this mechanism, the telling of events in this game is freed from the constraints of traditional storytelling structures, which usually require the chosen events to form a high-level story structure such as a three-act structure. This is a challenge for role play games, especially for sandbox games whose plot is highly determined by players. The player may spend ten minutes doing nothing but wandering, resulting in a personal story which is far from interesting. InThis highlights a distinctive storytelling capability of video games: they are able to communicate stories that are challenging to convey through conventional narrative techniques. Many human experiences are frequently ignored because they are difficult to logically incorporate into conventional plot structures or dispersed across numerous characters. Games, with the aid of their own particular rules, can save these human experiences and bring them back to light. Therefore, when playing the game, players are not just retracing their steps but rather experiencing it in a new setting with a fresh perspective, seeing and remembering many of the things they had previously overlooked. This could prompt players to reevaluate important social issues like the relationship between parents and children, what constitutes a good education, what constitutes a successful life, etc.reading a game in relation to ludology vs. narratology debates. Reading as a mechanic helps reveal how ludology and narratology are mutuallyreinforcing rather than mutually exclusive categories in each of the ensuing case studies. The first of the cases considered isDetroit: Become Human, which represents a visually robust, action-based blockbuster noted for its narrative prowess by industry critics and media scholars  the linking even eliding of play, choice, player agency, and literacy.  I do appreciate the "readings" of? The notion of the "text box" as mechanic and readerly/playerful interface is really interesting and could be foregrounded more. Moreover, given the focus on how text and story is deployed by each game, we do not see muchclose reading of the language and narratives themselves.  This respondent questions the immersive fallacy  and by extension what I have called the interactive fallacy wherein player choice, player agency, the ability to navigate interface, decision trees, and discover different endings belies the permissions, prescriptions, and protocol  always-already predetermined by the game's code. That said, I would like to know more about the "conscientious literacy" raised by the article and how that intersects or updates the arguments made by edu-game scholars like James Paul Gee or how that differs from the slide toward gamification: is reading and playing the same thing? Is playing and "authorship" homologous Finally, I appreciate the response to Bogost's polemic and wonder if that contention is too binary, too. I do think the article could incorporate and respond to some more recent work by queer game scholars and scholars of color. As with the concern over immersion, the desire to read and play games as "empathy machines" could be interrogated further via the work by Kishonna Gray, Anna Anthropy, Tanya Pobuda, Bo Ruberg, and others.  Overall, the article is thoughtfully written, accessible, and the case studies will be of great use to game scholars, developers, and players.Is the work clearly and accurately presented and does it cite the current literature?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Video game studies, analog game studies, queer game studies, literature, pedagogy, "close playing," digital humanities, popular cultureI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The paper provides an analysis of 4 games that were identified by the authors as providing compelling cases that the opposition between ludology and narratology is thin, and perhaps an unproductive way to view video games. The first part of the paper describes the opposing views from proponents of a narrative understanding or approach to video games, and those favoring game mechanics and other terminology or approaches that place the focus of their investigation on the interactivity of games. The main argument is sensible and well-presented. The viewpoints, arguments and stances from each camp are adequately summarized. There may be a bit of caricaturing or simplifying of views, which is understandable as much has been written on the subject, but still could be worded a bit better at times. This is a minor perfectible area of the paper. To game studies specialists, the time spent in exposing the two conflicting positions of narratology and ludology will probably look like an overly long re-treading of an all-too familiar debate, as the question has been addressed for more than twenty years now. I recommend the authors make it more explicit in the introduction that the part “theorizing ludic narrativity” presents the debate, more particularly to the benefit of readers who may not be aware of the historical development of game studies during the 2000s. I also recommend the author(s) amend the abstract, which claims that “the narrative potential of video games is still being debated”. The debate seems moot, and the most recent writing the author(s) share to that effect is an almost 6-year old text by Bogost in a newspaper. These minor issues aside, there is a more substantial hurdle in the paper’s general logic and contribution. Overall, the paper’s argumentation seems like a self-fulfilling prophecy; the time spent in setting up the conflicting positions of narratology and ludology is not well spent since the author(s) have chosen four games that do indeed focus on storytelling rather than mechanics. I appreciate the authors' claim that reading and following the narrative is itself a ludic act / toolkit and vice-versa, but I think the framing context to get to that claim is on an off-axis base. Rewording the first pages would help to streamline the overall thrust of the paper. The ”Theorizing ludic narrativity” functions well as a primer for readers unaware of the field of game studies, and the next argumentative move is pertinent in illustrating the ways in which modern games can tackle the issues of narrative progression and narrative comprehension intermingled with the interactive experience. The analyses of the four games is a great contribution this paper proposes. The writing is sharp and focused, the points are well-made and the work is illuminating. Overall, the fourth analysis (“Chinese Parents and storytelling of life course”) would benefit from some rewriting and a bit of expansion, if the space allows. It offers less substance than the other three analyses and the writing falls a bit short. The section is descriptively rich , but I was expecting a more substantial discussion of the implications of these choices and particularities for storytelling with regard to game storytelling. What’s there is good, I was simply expecting a bit more. Overall, the paper offers a good contribution through its analyses. It also provides a service to non-game studies scholars for its quick and readable survey of the issues in games and storytelling. Some minor rewrites would be beneficial. A minor rewrite and expansion upon a part is needed for publication. I recommend indexing after these minor revisions are done.Is the work clearly and accurately presented and does it cite the current literature?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?PartlyAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Game studies, narratology, interactive narrative, history of video games, aesthetics, film studies, animation filmI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Although 71 patients (85%) received PAT, the presence of SN at baseline, regardless of PAT completion, was associated with lower functional independence, higher risk of falls, and a lower functional level of the affected upper limb both at admission and at discharge. The severity of SN was associated with inferior rehabilitation outcomes. Nonetheless, patients with SN who received PAT had similar rehabilitation gains compared to patients without SN. Thus, the present study suggests that integrating PAT in an intensive rehabilitation program will result in improved responses to regular therapies in patients with SN.Spatial neglect (SN) impedes functional recovery after stroke, leading to reduced rehabilitation gains and slowed recovery. The objective of the present study was to investigate whether integrating prism adaptation treatment (PAT) into a highly intensive rehabilitation program eliminates the negative impact of spatial neglect on functional and motor recovery. We examined clinical data of the 355 consecutive first-time stroke patients admitted to a sub-acute inpatient neurorehabilitation program that integrated PAT. The 7-item Motor Functional Independence Measure, Berg Balance Scale, and Motor Activity Log were used as main outcome measures. We found that 84 patients (23.7%) had SN, as defined by a positive score on the Catherine Bergego Scale via the Kessler Foundation Neglect Assessment Process (KF-NAP Between 30% and 50% of stroke survivors suffer spatial neglect (SN) symptoms in the acute to subacute stage ,2,3. TheMotor recovery is highlighted in stroke rehabilitation and is significantly affected by SN at different stages post-stroke. Chen et al.  assessedIntegrating prism adaptation treatment (PAT) into standard rehabilitation care may reduce the adverse impact of SN on rehabilitation outcomes in U.S. inpatient rehabilitation facilities . The proThe Czech Republic has quite a different inpatient rehabilitation care system for stroke survivors than the U.S. For example, in the Czech Republic, the length of stay is 10–12 weeks (much longer than in the U.S.) for all patients admitted to the intensive brain injury rehabilitation program, and patients are rarely discharged earlier. We recently implemented a set of evidence-based assessments and treatment of SN in such a brain injury rehabilitation center in the Czech Republic. The implementation was initiated as a prospective research study , and latThis study was approved by the Institutional Review Board of the Rehabilitation Center . We reviewed the medical records of patients admitted to the Intensive Brain Injury Rehabilitation Program at the Rehabilitation Center Kladruby (BIR Program) from June 2017 to July 2020. The BIR Program accepts patients who meet the following criteria: (1) are 18–75 years of age; (2) have an acquired brain injury; (3) have the potential to benefit from a minimum of 4 h of daily therapy in at least two of four different areas , as determined by post-admission evaluations in each of these domains; (4) have an informal caregiver  who will work with rehabilitation specialists during the inpatient stay; and (5) are expected to be discharged home.From the available database of the BIR Program, we included patients with first-time stroke who had no prior brain injury documented in their admission medical record, in order to increase the homogeneity of the sample. We excluded patients with incomplete documentation or missing information. The final sample consisted of 355 patients.All of the patients in the BIR Program received a comprehensive neuropsychological assessment upon admission. The assessment included several visuospatial tests that could reveal neglect signs and the Bells test, which specifically detects and measures SN . The Bel®) for scoring on the Catherine Bergego Scale [Patients were assessed for SN by occupational therapists who followed the Kessler Foundation Neglect Assessment Process , Berg Balance Scale (BBS), and Motor Activity Log (MAL) were used routinely in the BIR Program for evaluation of functional and motor recovery rehabilitation success. We collected clinical data on these measures and calculated the change scores from admission to discharge as improvement indicators.7-item Motor Functional Independence Measure . The 7-iBerg Balance Scale ,33. The Motor Activity Log .The MAL U-test for continuous variables or the chi-squared test for categorical variables. The impact of SN presence at admission on each of the rehabilitation outcome measures  was examined using generalized linear models (GLMs) due to the heterogeneity of the sample . Besides the presence of SN at admission, the model also included rehabilitation outcome measures  at admission; time post-stroke at admission; as well as sex, age, and years of education, in order to control for potential mediational effect of these factors. The same GLM structure was used to explore whether SN severity based on the classification of SN (moderate-to-severe vs. mild) at admission had an impact on rehabilitation gains. The significance level, or alpha, of all tests was set to 0.05, and p-values were based on two-sided tests. Analyses were performed with SAS 9.4.Descriptive statistics and group comparisons were performed using the Mann–Whitney p = 0.041). At the time of admission, the SN+ group had a lower score on the 7-item mFIM (p < 0.001), BBS (p < 0.001), and MAL of the affected upper limb (p < 0.001) compared to the SN− group  had SN (KF-NAP > 0). We excluded 10 patients from the analysis because they did not receive PAT, but rather an experimental sham treatment as they participated in a randomized sham-controlled trial , and anoN− group . Thus, tThe SN+ and SN− groups had similar lengths of stay , which wF  = 64.15, p < 0.0001. For the model based on MAL gain, it explained 13.25% of the variance, F  = 7.59, p < 0.0001. The model based on the 7-item mFIM gain explained 60.7% of the variance, F  = 76.54, p < 0.0001. p = 0.382), BBS (p = 0.600), and MAL (p = 0.259).The results of each GLM on a given outcome measure are described below. Regarding the BBS gain, the model accounted for 56% of the variance, Fifty-four of the 71 patients (76.1%) with SN were classified into the mildSN+ group, and 16 patients (22.5%) were placed into the m-sSN+ group. One patient with SN was excluded from this analysis, as the data about the severity of SN were missing in the medical record. While receiving a greater number of PAT sessions , the m-sF  = 16.37, p < 0.0001. The model on the MAL gain explained 18.16% of the variance, F  = 2.29, p = 0.0461. The model on the 7-item mFIM explained 68.13% of the variance, F  = 22.09, p < 0.0001. None of the outcome gains could be independently explained by SN severity after controlling for outcome at admission, time post-stroke at admission, years of education, age, and sex (p = 0.901), BBS (p = 0.167), and MAL (p = 0.120)  .The present observational study showed that motor function in patients with SN improved to a similar extent as patients without SN. Thus, addressing SN during an inpatient rehabilitation program has the potential to facilitate motor and functional recovery after stroke. This finding, however, is in contrast with previous findings in which SN slowed functional recovery ,10,11. AAnother important finding was that people with moderate-to-severe SN responded to intensive rehabilitative therapies to a similar extent as people with mild SN. This finding is again inconsistent with previous reports that suggest an association between greater severity of SN and poorer rehabilitation improvements ,13. ThusThe rehabilitation care system, in which the present study was conducted, is a specific clinical setting that differs from other care systems. The standard care provided in the BIR Program involves not only physical and occupational therapy, as many other rehabilitation programs offer, but also psychological, neuropsychological, and speech and language therapy that is not considered optional, which is uncommon elsewhere . The intSN impedes rehabilitation outcomes even after an intensive therapy regime. In the present study, the presence of SN was adversely associated with functional and motor recovery status at the time of admission and predicted inferior functional and motor recovery status at the time of discharge from the BIR Program, which was in agreement with previous studies ,9,10,14.One of the limitations of this study is the patient selection bias. Patients were first screened by a neuropsychologist using paper-based neuropsychological tests; however, those tests are not as sensitive as ecological assessment methods ,50. ThisAnother limitation of this study is that we did not have information on subtypes of spatial neglect and brain lesion sites. SN is a very heterogenous disorder, and some studies have shown that PAT is not equally effective for all patients ,52,53,54The study findings are specific to a clinical setting where patients meet specific admission criteria and receive intensive inpatient rehabilitation care. Together, these features limit generalizability, but stakeholders are encouraged to consider implementing inpatient care with high intensity, rich resources, and accessibility to researchers.SN has adverse effects on rehabilitation outcomes. Addressing SN during rehabilitation may facilitate rehabilitation gains. Despite the same improvement rates, patients with SN in the present study reached lower levels of functional and motor recovery outcomes than patients without SN. Therefore, we recommend further efforts in developing and implementing therapeutic treatments and interventions for patients with SN.