We aimed to detect the changes in nasalance, articulation errors, and speech intelligibility after bimaxillary orthognathic surgery in skeletal class III patients. 0), 1 and 6 months  postoperatively by a speech therapist. The significance level was set at 0.05 using SPSS 21.This double-blinded before and after quasi-experimental study was conducted in the Department of Maxillofacial Surgery, Qaem Hospital, Mashhad, Iran from Mar 2019 to Apr 2020. The main intervention was maxillary advancement with LeFort I osteotomy and mandibular setback surgery with bilateral sagittal split osteotomy (BSSO). The nasalance score, speech intelligibility, and articulation errors were evaluated one week preoperatively (TP<0.001). Pre-operative articulation errors of consonants /r/, /z/, /s/ and /sh/ were corrected following the surgery. The percentage of speech intelligibility was significantly increased over time (P<0.001).Eleven women (55%) and 9 men (45%) with a mean age of 31.95 ± 4.72 yr were enrolled. The mean maxillomandibular discrepancy was 6.15 ± 1.53 mm. The mean scores of nasalance for the oral, nasal, and oral-nasal sentences were significantly improved postoperatively (The patients might show a normal articulation pattern and a modified nasalance feature, following maxillary advancement plus mandibular setback surgery.  The shaping of the vocal tract using the lips, tongue, jaw, and velum for speech output is called articulation; the lips, tongue, jaws, and velum are the articulators. 1, 5-7The consonants produced in any language can be described by their distinctive features as follows: 1) the place of production; 2) the degree of constriction between the two articulators; 3) the path of emission or energy enhancement, via the mouth versus the nose; and 4) the voicing, whether or not the vocal folds are in vibration. 1, 6, 8-10Individuals who have Class III malocclusion often present with difficulty producing labiodental and lingua-alveolar consonants. Furthermore, they tend to have difficulty with the lingua-alveolar consonants /t/, /d/, /l/, /n/, /s/, and /z/. These sounds should be produced with tongue-tip approximating the alveolar ridge. 1, 4, 5, 11 Velopharyngeal dysfunction (VPD) is a generic term that describes a set of disorders resulting in the leakage of air into the nasal passages during speech production and articulation. Consequently, speech samples can demonstrate hypernasality, nasal emissions, and poor intelligibility. 6, 12-18 Therefore, it is important to differentiate these speech characteristics distinctly. Velopharyngeal dysfunction or insufficiency often co-occurs with malocclusion in individuals who have Class III malocclusion. 2, 15, 19, 20 Although orthognathic surgery enhances the masticatory function and facial esthetic, it has many impacts on speech characteristics. 3, 10, 21, 22One of the main surgical interventions for managing class III dentofacial deformities is mandibular setback surgery with or without maxillary advancement. 12-14, 16, 22-24 Consequently, evaluating the voice changes after bimaxillary orthognathic surgery in non-syndromic class III patients seems obligatory.Bilateral sagittal split osteotomy (BSSO) and maxillary LeFort I osteotomy surgeries not only alters the relationship between the jaws and teeth but also affects the oral and pre-oral soft tissues, both of which can affect speech characteristics such as voice resonance and articulation quality. 3, 13-17, 21 Mandibular setback surgery leads to remarkable changes in the upper airway dimensions. 12, 18, 23, 25 However, few studies investigated the impact of mandibular setback surgery on voice characteristics. 2, 3, 19, 26 Moreover, there is no universal agreement on the impact of bimaxillary orthognathic surgery on voice resonance and articulation in non-syndromic patients. 2, 3, 19, 22, 23, 26, 27Several studies have analyzed the multidimensional aspect of speech such as acoustic characteristics, voice resonance, and articulation pattern, as well as velopharyngeal dysfunction in patients with maxillofacial deformities and syndromes, especially cleft lip and palate disorders. We aimed to detect the changes in voice nasalance, articulation errors, and speech intelligibility following bimaxillary orthognathic surgery (pure mandibular setback plus maxillary advancement) in skeletal class III deformity Persian speaker’s patients.Study design and patient selectionThis quasi-experimental study was approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.DENTISTRY.REC.1398.010). We followed the guidelines of CONSORT and the Helsinki Declaration. All patients signed an informed consent agreement before the study. This before-after experiment was carried out in the Department of Maxillofacial Surgery Qaem Hospital, Mashhad, Iran from Mar 2019 to Apr 2020. Inclusion criteria were all healthy (ASA I & II) non-syndromic Persian speaker patients aged 18 to 40 yr planned for bimaxillary orthogenetic surgery (Bimax) consist of pure mandibular setback surgery using bilateral sagittal split osteotomy (BSSO) plus pure maxillary advancement with LeFort I osteotomy. The subjects with a history cleft palate, velopharyngeal disorders, and history of dysphonia as well as hearing or perception problems and craniofacial syndromes were excluded.The participants planned for genioplasty or maxillary inferior repositioning and impaction surgery impaction surgery were omitted from this analysis to remove potential confounding factors. Moreover, the patients with skeletal open bite, as well as who needed clock-wise or counter-clockwise occlusal plane rotation were excluded as well.The type of deformities and surgical treatment plans and the age of the patients, sex, and the amounts of intraoperative mandibular and maxillary displacement (in millimeters) documented by the student under the supervision of the surgical staff in the checklist. Remarkably, the amount of pre-operative maxillomandibular discrepancy was measured clinically from the incisor tips. Besides, the clinical and cephalometric examinations determined the need for the mandibular setback plus maxillary advancement (Bimax) in our cases.One speech therapist examined all patients’ voices before and after operations. Neither the examiner, who was a speech therapist nor the statistical analyst was aware of the surgical procedure. Nonetheless, the surgeon, the patients, and the student who completed the checklist were aware of the operation type. Therefore, it was a double-blinded study.All of the patients underwent preoperative orthodontic decompensation. All orthognathic surgeries were conducted by the same surgeon and the same surgical team and hospital.Variables and Data recordingThe patients' age and gender were recorded. The authors observed and recorded the amount of skeletal movements of jaws during maxillary advancement and mandibular setback, intraoperatively. The amounts of mandibular setback displacement and maxillary advancement (in millimeter) were the study predictor variables. Besides, the nasalance score as well as speech intelligibility and articulation errors were the study outcome variables.The evaluation and analysis of nasalance value, articulation errors and speech intelligibility were performed one week preoperatively (T0) and one month (T1) and six months (T2) postoperatively. All patients had orthodontic bracket appliances before and after surgery.Articulation 1, 4, 5 For articulation analysis, consonant and vowel productions were compared with target productions and analyzed for error types at the segmental level. All analyses were based on a consensus narrow phonetic transcription made by the speech-language pathologist using the symbols and diacritics of the International Phonetic Alphabet. Only productions that were spontaneous naming of the stimulus pictures and of which the target was unmistakably clear were retained in the analysis. The speech samples for the assessment of articulation were elicited using the phonetic picture naming test. This test requires subjects to name black and white drawings of common objects and actions. It elicits a speech sample containing instances of all Persian vowels and consonants in first, middle, and last positions of words. The speech sample to detect speech intelligibility contained 30 sec of spontaneous speech in response to open questions about the participants' hobbies and daily pastimes. The following formula was used to calculate the percentage of speech intelligibility: The number of correct words produced/the total number of words produced ×100. The speech intelligibility of 100% is ideal.All voice recordings and analyses were made in an acoustic room at Qaem Hospital using a headset microphone  and recorder . A distance of 10 cm between the mouth and the microphone was set for each patient.Nasalance11, 28 If the subjects made a reading error, they were asked to read the passage again. Before testing, the Nasometer was calibrated and the Headgear was adjusted according to instructions provided by the manufacturer .For the objective assessment of nasalance, the Nasometer was used. The Nasometer , a microcomputer-based system manufactured by Kay Elemetrics13, was used for measurements of the nasalance values. Before initiating data collection, the Nasometer was calibrated in an acoustic room following the procedures outlined in the manual. Each subject was then asked to read three passages. The first passage contained ‘oral-nasal sentences’ (rainbow passage), covers 11.6% of nasal consonants as found in standard Persian speech. The second passage (Bahareh's Bag passage), as ‘oral sentences’, excludes nasal consonants and is normally used to detect hypernasality in a subject’s speech. The third passage was the ‘‘nasal sentences’’ , loaded with nasal consonants and is designed to detect hyponasality in a subject’s speech. The validity and reliability of each of these three passages had been determined in Ghaemi and Memarian studies. 7, 11Based on the evidence about the Nasalance analysis in Iranian populations, the normal range of Nasalance score for oral sentences was 19.43±7.45 and for nasal sentences was 67.15±5.67. Data analysisP-value<0.05 was considered statistically significant.The statistical analysis was carried out using SPSS version 21 . Qualitative variables were expressed as percentages, while the mean ± SD (standard deviation) was indicated for quantitative variables. The Shapiro-Wilk test was used to check and validate the data's normality. T-test was employed to compare the changes in the studied variables between males and females. The Pearson correlation test was applied to evaluate the relations between the variables. Moreover, the repeated measurements ANOVA test was used to compare the nasalance score, articulation error, and speech intelligibility analysis during the T0, T1, and T2. Twenty individuals, including 11 females (55%) and 9 males (45%) with a mean age of 31.95±4.72 yr, and an age range of 21 to 40 yr participated. The mean discrepancy of maxillomandibular was 6.15±1.53 mm with a range of 4 to 8 mm. Moreover, the mean amounts of mandibular setback displacement and maxillary advancement were 3.30±0.86 mm and 2.85±0.74 mm, respectively. Fortunately, neither bad split nor inferior alveolar nerve injury was observed in our cases.All individuals were evaluated at three-time intervals for voice nasalance score as well as articulation errors and speech intelligibility at three-time intervals .P>0.05) (P<0.001). However, the mean nasalance score of nasal sentences increased significantly over time intervals (P<0.001). The percentage of speech intelligibility was increased significantly from 90.90% at T0 to 98.05% at T1 and increased to 100% at T2 (P<0.001)  . The PeaP>0.05) . Table 3In this study articulations errors for all Persian consonant was evaluated in each of 20 patients. The various frequency of articulations errors, including /s/, /sh/, /z/ and /r/ were observed in patients. The highest number of articulation errors at T0 is related to /s/ and /sh/ letters, each with 19 cases. Followed by letter /z/ and /r/ with 18 and 11 cases, respectively. Moreover, the highest number of articulation errors at T1 is related to the letter /r/ and /sh/ each with 6 cases, followed by letter the letter "z" in 2 cases . InteresThis before-after study aimed to evaluate the effect of bimaxillary orthognathic surgery, including mandibular setback with maxillary advancement on nasalance scores and articulation quality in patients with class III skeletal deformity. In this study bimaxillary orthogenetic surgery had a significant positive impact on the nasalance values probably due to modifying the structure and function of the velopharyngeal valve in the post-surgical condition. In other words, this surgery improved voice resonance features. Interestingly, all articulation errors were completely eliminated in postoperative tests. Subsequently, it led to complete and perfect speech intelligibility.12-14, 16, 22-24 Nevertheless, studies examining the outcome of speech after BSSO with mandibular setback are limited, and contained contrary results. 2, 3, 19, 26 Moreover, the patient population and the surgical management in the above-mentioned studies were quite heterogeneous, without any attention to the type of surgery performed. 2, 19, 22, 24, 26 To the best of our knowledge, there was no agreement on the effects of orthognathic surgery on speech and voice. 2, 3, 19, 22, 23, 26, 27The effect of maxillary advancement with LeFort I osteotomy on articulation, resonance, velopharyngeal function, and voice was considered in many studies. 9 (nine class III patients), Sahoo et al. 26 (ten class III patients), Mishima et al. 3 (16 class III patients) and Ahn et al. 2 (eight class III patients). Considering our research inclusion and exclusion criteria, the sample size was 20 patients, which was more than all similar studies, including Lee et al. 20 It was not possible to evaluate one year follow-ups due to the COVID-19 pandemic. However, the results of this study were satisfactory and significant.All assessments were performed before treatment (T0), one month after surgery (T1), six months after (T2), similar to Yavari et al. study. 2, 20, 24, 25, 29 The above-mentioned factors might influence the voice production and articulation.The patients who had a history of cleft palate, velopharyngeal and nasality disorders, and craniofacial syndromes, as well as who were candidates for genioplasty or maxillary impaction surgery or maxillary inferior repositioning were excluded from the present study to eliminate the additional confounding factor. Moreover, the patients who had skeletal open bite, or who needed clock-wise or counter-clockwise occlusal plane rotation were ecluded. The maxillary impaction and inferior repositioning may lead to compensatory clock-wise or counter-clockwise mandibular plan rotation, and the hyoid and tongue displacement consequently. 7The Nasometer, as an instrumental assessment, is one of the most appropriate clinical tools for assessing and diagnosing nasalance problems. Nasometer was one of the most suitable instruments for evaluating resonance disorders in Persian populations. 8, 21 This forward movement of the hard palate may increase the anteroposterior dimensions of the nasopharynx and consequently alter the anatomical–topographical–functional relations of the velopharyngeal area. 6, 9, 24, 30 Velopharyngeal closure may, therefore, be compromised as a result of the increased distance the soft palate must move to close with the posterior pharyngeal wall completely during speech and subsequently may affect the resonance. 2, 6, 24, 31 Hyper-nasalization after maxillary advancement has always been a concern for maxillofacial surgeons. 6, 13, 21 On the other hand, the mandibular setback modulated the increase in the anteroposterior dimensions of the nasopharynx and caused the normal function of the velopharyngeal valves, and finally, we observed the normal nasalance score in patients. Regarding the literature, surgical advancement of the maxilla, as was done in all of our patients, involves the anterior repositioning of the hard palate and the attached soft palate and velum. 18,32 The Nasalance score of oral sentences was changed significantly over time, decreased at each time interval compared to the previous time interval. This was in line with another study result. 6Based on our results, the mean nasalance score for nasal sentences was increased significantly over time, which in line with other studies. 14, 23, 32 Velopharyngeal valve closure was performed with a more natural quality to prevent airflow from entering the nose, and transferring to the mouth, during the articulation of oral consonants. 5, 6, 13, 18 On the other hand, during the articulation of nasal consonants, the velopharyngeal valve completely prevents airflow from entering the mouth and directs it into the nasal cavity with better quality than before. In other words, we observed more air emission from the nasal cavity for nasal consonants, and more air emission from the mouth for oral's consonants. 6, 7, 11, 21The mandibular setback and maxillary advancement can improve the structure and function of the velopharyngeal valve. 4, 11 Therefore, as mentioned earlier, the oral consonants became more oral after the surgical procedure, and a decrease in the nasalance score in the oral-nasal sentences has happened. Similar to oral sentences, the mean score of oral-nasal sentences also decreased significantly in postoperative intervals. Oral-nasal sentences include both groups of oral and nasal words. In oral-nasal sentences, the frequency of oral consonants was higher than in nasal consonants. 6, 18 The forward movement of the maxilla leads to a change in airflow from a turbulent pattern to a suitable laminar and linear airflow pattern which causes the enhancement of voice resonance and nasalance. 23, 25In general, the facial skeleton  directly affects the morphology of the resonant cavities of the vocal tract and the articulation of sounds. 27 Large amounts of mandibular setback may impede biological adaptation and significantly reduce the posterior airway space. The maxillary advancement concomitant with mandibular setback should be used in patients with class III malocclusion with severe anteroposterior discrepancy. 33Mattos et al. documented the moderate reduction in oropharyngeal airway space following isolated mandibular setback surgery but a mild decrease in the oropharyngeal airway volume in the bimaxillary surgery. 21 Similarly, a significant increase was found in nasopharyngeal airway space following bimaxillary surgery. 32A rhinomanometry study revelead that maxillary advancement improved nasal airflow and voice resonance in bimaxillary surgery. 10,12,18According to our study, phonetic test results at T0, all patients had similar type of articulation error which was distortion in sibilant sounds  and liquid sound / r /. At T1 and T2 the number and type of errors gradually decreased and so that at times T2, the errors were corrected entirely. This finding was consistent with other results. 18The measurement of speech intelligibility was applied to show the process of improving articulation errors. The mean of speech intelligibility in our subjects was significantly increased over the postoperative intervals, which was consistent with another study's results. 1, 6, 8-10 They often produce this sound with the tip of the tongue contacting the maxillary incisors, called dentalization. This dentalization of the tongue tip alveolar fricatives /s/ and /z/ is usually described by listeners as a lisp or distortion. 6, 8, 12, 18, 30 The normal articulation of the /r/ consonant requires moving the tongue up and back toward the alveolar ridge and then beating it down and trilling. 6 In the present study, tongue was affected by the protruded position of mandible in the preoperative situation. Therefore, they had difficulty in trill movement of tongue and articulation. Individuals who have Class III malocclusion often present with difficulty producing labiodental and lingua-alveolar consonants. These patients tend to have difficulty with the lingua-alveolar consonants /t/, /d/, /l/, /n/, /s/, and /z/. 6, 9, 10, 18 A distorted articulation of /r/ sound was improved following orthognathic surgery in class III patients. 6 It was in line with the present study findings. The speech changes of 20 patients was investigated who underwent surgery for the correction of various skeletal defects. The numbers of errors at the 3- and 6-month postoperative periods were lower than the preoperative numbers. 10 Vallino studied the articulation, voice, resonance, hearing sensitivity, and middle ear function of 34 patients who underwent orthognathic surgery. Thirty of the 34 patients showed speech errors before the surgery. The errors were mainly distortion of the sibilants /s/ and /z/. Articulation improved after surgery without speech therapy. Most of the preoperative articulation errors were eliminated 3 months after the surgery. 18 Nine Cantonese speakers undergoing osteotomy were studied for Class III skeletal deformity. The speech sample consisted of 6 words with the initial sibilant sound /s/. They reported a decrease in articulatory errors for the group after the surgery. 9There are limited studies about the articulation errors analysis after orthognathic surgery. 6, 7, 18, 29, 31In preparation for orthognathic surgery, particularly when the patients, exhibit speech or resonance disorders, it is appropriate to have a speech-language pathologist evaluate the patient’s speech in order to identify patients who may be at risk for deterioration of speech articulation or resonance and airflow control following these procedures. The patients might show a modified articulation pattern  rather than the presurgical condition, following bimaxillary orthognathic surgery (maxillary advancement and mandibular setback with BSSO. The articulation errors were eliminated in patients at six months postoperatively. Moreover, bimaxillary orthognathic surgery might improve the nasalance scores in class III patients.In preparation for orthognathic surgery, particularly when the patients’ exhibit speech or resonance disorders, it is appropriate to have a speech-language pathologist evaluate the patient’s speech to identify patients who may be at risk for deterioration of speech articulation or resonance and airflow control following these procedures. It is suggested to conduct more clinical trials with larger sample size, and long-term follow-ups in the future.


With its population of 6.8 million people, it accommodated about 250 000 Palestinian refugees since the 1950s and 1.5 million Syrian refugees since 2010. Lebanon officially recognizes 18 religious communities within its population, with a Muslim and Christian majority.2 Since August, the country faced a surge in the COVID-19 cases number reaching around 1500–2000 daily cases in mid-December.3Lebanon reported the first case of coronavirus disease (COVID-19) on February 21, 2020: a 45-year-old woman returning from a pilgrimage to Qom, Iran, tested positive for the virus responsible for COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and was admitted to a Beirut hospital. The government engaged in massive testing for suspects and initiated a national curfew, which helped limit the disease’s spread at the first 5 months with less than 100 daily cases on average.4On August 4, 2020, Beirut, Lebanon’s capital witnessed one of the most intense non-nuclear explosions in history. An estimated 2750 tons of ammonium nitrate that were deposited in the city port exploded shortly after 6:00 PM local time, causing at least 204 casualties, 6500 injuries, and US $15 billion in property damage, leaving an estimated 300 000 people homeless. The explosion was felt in neighboring countries, including Turkey, Syria, Israel, Palestine, and areas of Europe. It was detected as a seismic phenomenon of magnitude 3.3 by the United States Geological Survey.4Following this, the country’s hospitals were filling up with hundreds of injured patients. Health care workers engaged in their full capacity to cope with the crisis situation. Multiple facilities got destroyed and numerous patients, including COVID-19 cases, had to be transported to the remaining functional structures. With hospitals and health workers being oversaturated dealing with the blast casualties, COVID-19-suspected people had less access to health care services.5 Such outcomes can have unfavorable effects on people’s COVID-19 risk perception levels and their respect of health guidance.With only 2 psychiatrists per 100 000 people, the country was facing the pandemic and a deteriorating socioeconomic situation negatively affecting its population’s mental health. After the explosion, the situation got worse with a soaring number of calls for helplines and cases of mental illnesses.4During and after the blast, numerous people paid no attention to social distancing rules and went out to streets, hospitals, and crowded areas to check on others, offer support, or just watch. The government got overburdened dealing with the aftermath. This restrained their capacity to oversee and control the implementation of COVID-19 preventive measures.In reaction to the crisis, the Lebanese Government declared a 2-week state of emergency.5The people who were protesting since 2019 regarding the planned taxes on gasoline, tobacco, and Voice over Internet Protocol calls broke COVID-19 restrictions and went back to the streets again to demonstrate against the unsatisfactory government actions. This caused the prime minister and his cabinet to resign.In summary, the Beirut explosions have worsened the economic and political situation in Lebanon. They have affected people’s living conditions and health negatively, especially their mental health. It has also played a role in COVID-19 transmission within the community. More focus should be made on community support and engagement on different levels to ensure better trust and involvement in following health guidance. Multisectoral and interprofessional approaches and strategies are essential to move ahead with the current situation. Mental health care can have a crucial effect in improving people’s conditions and attitudes.


VEGF polymorphisms have been implicated in the development of several lung disorders. Consequently, we assessed, for the first time, the role of VEGF polymorphisms in the susceptibility and severity of ILD. A total of 436 Caucasian ILD patients  and 192 with non-IIP) and 536 ethnically-matched healthy controls were genotyped for VEGF rs833061, rs1570360, rs2010963, rs3025020, and rs3025039 polymorphisms by TaqMan assays. Pulmonary function tests were collected from all the patients. VEGF serum levels were determined by ELISA in a subgroup of patients. No VEGF genotype, allele, carrier, or haplotype differences were found between ILD patients and controls as well as between IIP and non-IIP patients. However, an association of rs1570360 with IIP in women and also with lung function in IIP patients was found. None of the VEGF polymorphisms were associated with VEGF levels. In conclusion, our results suggest that VEGF does not seem to play a relevant role in ILD, although rs1570360 may influence the severity of ILD in women and a worse outcome in IIP patients.The search for biomarkers that can help to establish an early diagnosis and prognosis of interstitial lung disease (ILD) is of potential interest.  The term interstitial lung disease (ILD) comprises a large group of diseases caused by chronic inflammation and fibrosis of the alveoli wall that share similar functional, clinical, radiological, and anatomopathological characteristics. ILDs can be classified according to their cause into idiopathic interstitial pneumonias (IIPs) or known cause ILDs ,2,3. IdiThe study of potential blood biomarkers in the pathogenesis of ILD is considered to be of potential interest, since they may be used as additional tools for the early diagnosis and severity prognosis of these pathologies. Furthermore, they are more reproducible and easier to obtain than conventional invasive methods of diagnosis ,8,9.VEGF functional polymorphisms have been shown to influence the susceptibility to several lung disorders such as pulmonary hypertension and chronic obstructive pulmonary disease (COPD), among others [VEGF in ILD are scarce although VEGF protein levels have been proposed as a potential prognostic biomarker in IPF [Vascular endothelial growth factor (VEGF) is a tyrosine kinase glycoprotein that plays a key role as a mediator of angiogenesis and vasculogenesis in both physiological and pathological processes, being implicated in numerous inflammatory and chronic conditions ,16,17,18g others ,24,25,26r in IPF ,28. In fr in IPF .VEGF is implicated in ILD. Therefore, in this study we aimed to assess, for the first time, the role of VEGF polymorphisms in the susceptibility and severity of ILD in a large cohort of Caucasian patients with this disease.Given that lung inflammation, altered fibrosis, and aberrant angiogenesis are typical processes in ILD pathogenesis, it is plausible to think that A total of 436 Caucasian patients with ILD, fulfilling the American Thoracic Society/European Respiratory Society classification and diagnosis criteria for ILD ,4,30 werFive hundred and thirty-six ethnically-matched healthy controls, without a history of any pulmonary or chronic inflammatory disease, from Hospital Universitario Marqués de Valdecilla (Santander) and National DNA Bank Repository , were also included in this study.All patients with ILD and healthy controls gave their informed consent to be included in the study. The procedures followed were in accordance with the ethical standards of the approved guidelines and regulations, according to the Declaration of Helsinki. All experimental protocols were approved by the local ethics committees of each participant hospital.VEGF polymorphisms were selected based on the following criteria: Polymorphisms with a frequency >5% in Caucasians previously assessed and reported to be involved in susceptibility to several inflammatory and pulmonary diseases [VEGF rs833061 and rs1570360 located in the VEGF promoter region, rs2010963 located in 5′untranslated region (UTR), rs3025020 located in intron 6, and rs3025039 located in 3′UTR of the VEGF gene were chosen.diseases ,24,25,31diseases ,32; and VEGF rs833061 T/C, rs1570360 G/A, rs2010963 G/C, rs3025020 C/T, and rs3025039 C/T polymorphisms by TaqMan assays. Negative controls and duplicate samples were included to check the accuracy of the genotyping. Genotyping was performed in a QuantStudioTM 7 Flex real-time polymerase chain reaction system .Genomic DNA was extracted from peripheral blood using the REALPURE “SSS” kit . The quality and quantity of extracted DNA was measured in a spectrophotometer . All patients and healthy controls were genotyped for VEGF serum levels were determined in a subgroup of 272 ILD patients (133 IIP and 139 non-IIP) by a commercial ELISA kit  in accordance with the manufacturer’s instructions. Samples were analyzed in duplicate. VEGF levels were quantified using a four-parameter logistic curve fit suitable for calculating concentrations from symmetrical sigmoidal calibrators through MyAssays software.VEGF genotypes, alleles, and carriers of the minor allele frequencies between the whole group of ILD patients and controls were calculated and compared by a chi-square test. Similarly, genetic differences between IIP patients and the whole group of non-IIP patients as well as between IIP patients and the different categories of the group of non-IIP patients  were assessed. Additionally, differences in the frequency of VEGF polymorphisms were analyzed between ILD patients and controls as well as between the group of patients with IIP and non-IIP patients, stratifying the population according to sex. Haplotype frequencies were calculated by the Haploview 4.2 software and then, compared between the groups mentioned above by a chi-square test. Strength of associations was estimated using odds ratios (OR) and 95% confidence intervals (CI). OR and p-values were adjusted by sex, age, smoking history, and packs of cigarettes per year when genetic differences between IIP and non-IIP patients were evaluated. Analyses regarding the association between VEGF and PFTs or VEGF serum levels in IIP and non-IIP patients were performed with carriers, given that the frequency of the TT genotype of rs3025039 was lower than 5%. These associations were assessed by linear regression, adjusting p-values for the potential confounding factors previously mentioned. In addition, to account for the five polymorphisms assessed, the Bonferroni adjustment was applied. Consequently, p-values < 0.01 were considered statistically significant. All statistical analyses were performed with STATA statistical software 12/SE .Data were reported as the number of individuals (n) and percentage (%) for categorical variables and mean ± standard deviation (SD) for continuous variables. All genotype data were checked for deviation from Hardy–Weinberg equilibrium (HWE). For the estimation of allele frequencies, the number of individuals was duplicated considering that each individual carries 2 alleles of each polymorphism . Differences in Estimations of statistical power were obtained with CaTS Power Calculator for Genetic Studies software .The rs833061, rs1570360, rs2010963, rs3025020, and rs3025039 genotype distribution was in HWE. The genotyping success rate was 98.7% for rs833061, 97.9% for rs1570360, 99.1% for rs2010963, 98.6% for rs3025020, and 99.3% for rs3025039. Genotype and allele frequencies were in agreement with the data of the 1000 Genomes Project for Europeans.VEGF between the whole cohort of patients with ILD and healthy controls were compared. As shown in VEGF polymorphism were found between these groups.Genotype, allele, and carrier frequencies of VEGF frequencies between the group of patients with IIP and non-IIP patients. In this regard, no statistically significant differences in the genotype, allele, or carrier frequencies of each VEGF polymorphism were disclosed between them  and DLCO (% predicted) was observed in IIP patients carrying the minor allele A of rs1570360 compared to non-carriers: 69.41 ± 22.34 versus 76.44 ± 21.88 for FEV1 and 32.07 ± 14.34 versus 38.30 ± 15.03 for DLCO, p = 0.004 and p = 0.008, respectively  and rs3025020 with VEGF serum levels in Spanish patients with COPD [Finally, we determined whether the ith COPD . In addiith COPD . In accoith COPD .VEGF in ILD. Nevertheless, they suggest that rs1570360 could be a marker of severity of ILD in women and may indicate a worse outcome in patients with IIP.In conclusion, our results do not support a relevant role of


Lower limb muscle-strength, cognitive profile, and PF tests were concomitantly evaluated with plasma levels of albumin, anti- and pro-inflammatory cytokines [Interleukin-10 (IL-10) and Tumor Necrosis Factor-alpha (TNF-α) respectively], TNF-α/IL-10 ratio, and myeloperoxidase (MPO) activity at four different time-points: Baseline (T1), after 16 weeks of multifactorial intervention (T2), then after a subsequent 8 weeks washout period (T3) and finally, after an additional 16 weeks of multifactorial intervention (T4). Improvement of cognitive profile and muscle strength-related albumin levels, as well as reduction in the TNF-α levels were found particularly in ME plus BCAAs group. No significant variations were observed over time for TNF-α/IL-10 ratio or MPO activity. Overall, the study showed that MIP triggered slight alterations in the inflammatory and physical function of the frail older participants, which could provide independence and higher quality of life for this population.Nowadays, it is accepted that the regular practice of exercise and branched-chain amino acids supplementation (BCAAs) can benefit the immune responses in older persons, prevent the occurrence of physical frailty (PF), cognitive decline, and aging-related comorbidities. However, the impact of their combination  in albumin and the inflammatory markers is not fully understood. Therefore, we investigated the effect of a 40-week multifactorial intervention  on plasma levels of inflammatory markers and albumin in frail older persons (≥75 years old) living at residential care homes (RCH). This study consisted of a prospective, naturalistic, controlled clinical trial with four arms of multifactorial and experimental (interventions-wahshout-interventions) design. The intervention groups were ME + BCAAs ( Aging is characterized as a natural degenerative process strongly linked to diminished immune efficiency, and also to enhanced inflammatory responses, and thus, to higher risks of infections in older persons . The sedThe age-related PF syndrome is defined by loss of muscle mass (and sarcopenia), by low physical activity levels, and often accompanied by low protein intake . CognitiParticipation of older persons in rPE ameliorates not only antigen recognition, but also immune responsiveness in general, as some evidence has shown that increased levels of physical activity using exercise routines can even extend the protection provided by the influenza vaccine in older persons , as wellSupplementation with BCAA, in the absence of branched-chain aminotransferase (BCAT) activity in the liver implies that a dietary supply of BCCAs would ensure an almost intact passage through the liver directly to the muscle tissue, which seems to be advantagous to restrain sarcopenia and frailty . SupplemAmong several pro/anti-inflammatory biomarkers used in the context of exercise and nutrition sciences , myelopeTherefore, the aim of this work was to evaluate the effect of a 40-week MIPon plasma/serum pro- and anti-inflammatory markers of the immune system in older persons living in residential care homes (RCH). Furthermore, we hypothesized that ME plus BCAAs may have an impact on the systemic albumin levels, inflammatory variables, cognitive profile, and physical function of the participants.This is a prospective, naturalistic, controlled clinical trial (treatment vs care). All subjects volunteered to participate in the exercise classes or the supplementation programs. Consent forms were signed by the institution’s directors, the participants and their legal representatives before testing and intervention. This study was approved by the Ethical Committee of Faculty of Sport Sciences and Physical Education, University of Coimbra (reference number: CE/FCDEFUC/00282018), respecting the Portuguese Resolution  on ethics in human research and the Helsinki’s Declaration. This study was properly registered with clinicaltrials.gov register NCT04376463.Study participants were selected through a non-probabilistic trial (plus controlled sampling) living in public and private RCH. The eligible criteria for the participants in this study were, at the time of first screening: (i) Participants had to be 70 years old or more; (ii) physically frail and pre-frail; (iii) clinically stable with their drug therapy updated; (iv) being able to perform the Time Up and Go test in ≤50 s that indicate severe mobility independence ; (v) notn = 7), ME + BCAA (n = 8), BCAA (n = 7), and the no-regular exercise/no-supplementation control group . All the procedures were performed according to the Consolidated Standards of Reporting Trials (CONSORT) guidelines [All the participants were selected through a non-probabilistic trial (plus controlled sampling) based on the geographical area of Coimbra, Portugal, living in public and private residential care homes (RCH) or frequenting day centres in the local community. From the 80 participants initially screened, 50 eligible participants were allocated in their respective intervention groups. However, for the specific reasons highlighted in idelines .This study is a four-phase prospective, naturalistic, controlled clinical trial with four arms of MIP experimental design . In the first phase, a baseline data collection (T1) was done followed by 16 weeks of MIP. The second phase consisted of a second data collection (T2) followed by an 8 week washout phase. Phase 3 consisted of a third data collection, followed by the resumption of the MIP for a period of 16 weeks. The last data collection took place after the 16 weeks of intervention (T4) .All the assessments were performed in the morning, between 10 and 11:45 a.m. One session was used to apply a short test battery to measure biosocial, global health status, cognition profile, nutritional, physical, and physical frailty status. In the second consecutive day, blood samples were collected and stored at −80 °C until further analysis.The phenotype of Fried’s physical frailty index was used . Weight Daily diet at the RCH was prescribed by a registered nutritionist and was provided for all the participants without any change or interference of the research staff. On the basis of the information provided, the diet was analyzed using specific tools  for the Portuguese population ,35,36. DThe Five-Times-Sit-to-Stand-Test (5TSS test) was applied. This test assesses the functional strength of the lower limbs, transition movements, balance, and risk of falling. The participant is instructed to stand as quickly as possible five times, without stopping in the middle. In addition, the participant should be encouraged to keep his arms crossed over his chest. The instructor must count the time with a stopwatch and must count each position out loud so that the participant remains oriented. The test is stopped when the participant reaches the orthostatic position at the 5th repetition .®, model 770,Berlin, Germany) with a precision of 0.1 kg, whereas stature was determined using a portable stadiometer  with a precision of 0.1 cm. Body mass index (BMI) was calculated according to the formula (BMI = body mass/stature2). The standardized procedures described in previous studies were followed [The Charlson comorbidity index (CCI) was calculated based on the registry of individual comorbidities combined with age and gender, to account for a final score . The antfollowed .The Portuguese version of the Mini Mental State Examination (MMSE) was used . The MMSNon-fasting blood collection was done in the morning (between 10:00 a.m. and 11:00 a.m.). Blood samples were collected by venipuncture, after 15 min of individual rest in an isolated and quiet room, at the four time-points of the study assessment. The participants were asked to avoid alcohol and caffeine intake on the previous day of blood collection, and also to maintain their sleep habits during the previous night. After centrifugation at 3000 rpm at 4 °C during 15 min, plasma and serum samples were aliquoted into Eppendorf tubes and stored at −80 °C until used for the determination of interleukin-10 (IL-10), tumour necrosis factor alpha (TNF-α), myeloperoxidase activity (MPO), and total albumin concentrations. The ELISA  intra-assay coefficients of variability were 4.1% for IL-10 and 3.0% for TNF-α.®, Cheshire, UK), accounting for 20 kcal per portion, comprising 5 grams (g) of supplement: 1.85 g Leu, 0.93 g Ile, and 0.93 g Val. The unflavored supplement was used as to not induce ingestion preferences for specific flavors. The BCCAs were diluted in 200 mL of water and given immediately after the exercise sessions to the participants in the ME + BCAAs and BCAAs groups [The BCAAs power mixture was composed of L-leucine (Leu), L-isoleucine (Ile), and L-valine  in the proportion of 2:1:1 . The participants were closely supervised for two initial sessions aiming for equipment familiarization and adjustments to the Rating Perceived Exertion (RPE OMNI) scale [max being calculated by an adjusted formula for older persons [The exercise program was divided in two interventions of 16 weeks each, separated by an 8-week detraining (washout) period. Exercise sessions were offered twice a week, with an interval of 36 h for adequate physiological recovery and rest. The exercise protocol respected the guidelines of exercise prescription for older persons and the guidelines of exercise periodization by the American College of Sports Medicine (ACSM) ,48. The I) scale . During  persons .HR =  and the proposed physical effort, imposed by different intensity color bands, according to the OMNI table . The elaIn this phase, the participants endured a detraining period of 8 weeks, when the ME programs were suspended. The aim was to check if the physiological adaptations acquired during the first phase of ME were maintained or if an 8-week interruption was able to revert the possible effects on immune changes .®, Hygenic Corporation, Akron, OH, USA) elastic bands (The phase 3 (exercise retraining) protocol was also based on the resistant TheraBand . All statistical analyses were performed using the SPSS 21 , and the level of significance was set at p < 0.05.The descriptive statistics for each group, at the baseline and follow-up evaluations, were reported as the mean plus standard deviation (M ± SD), except when mentioned otherwise. All the variables were checked for the normally residual distribution and values were logarithmically transformed when appropriate. One-way Analysis of Variance ANOVA was used to determine baseline differences between the four groups in all the parameters. Effects of time, group, and time x group interactions were assessed through repeated measures ANOVA and Bonferroni post-hoc for multiple comparisons. Additionally, univariate analysis was performed using the paired p < 0.05). However, all the groups were within the well-nourished category.The dynamics of the MIP groups and drop-outs are presented in detail in p = 0.690) or time vs. experimental groups were found , F = 1.567, p = 150), but also Bonferroni post-hoc comparisons did not result in significant variations between time vs. groups (p > 0.05). Regarding the TNF-α levels, although we did not observe any interference of time on these pro-inflammatory cytokine levels , but also a significant decrease of TNF-α was observed between T3 and T4 within the same experimental group . The TNF-α values were unchanged in all other experimental groups. Regarding the TNF-α/IL-10 ratios, no significant variations were observed over time (p = 0.703) or within the interactions .p = 0.059. Particularly, the Bonferroni post-hoc comparisons showed that the BCAAs group presented higher MPO activity after re-supplementation (T4) than the values found in the T2 time-point . No significant alterations in the MPO activity were observed in other comparisons between groups.Concerning MPO activity, p = 0.02), but no other (time vs. group) significant difference was detected between the albumin levels (p = 0.219). The pairwise comparison using Bonferroni post-hoc showed a decrease of albumin levels in the BCAAs group in the T3 time-point  as compared to the values found in T1, whereas no other significant variations were observed in the other groups (p > 0.05).In terms of serum albumin , a statip = 0.841) or interactions  on the time elapsed to perform the 5TSS test. However, post-hoc adjustments showed that the ME + BCAAs and BCAAs groups presented a significant reduction of the time elapsed to perform this test at time-points T2, T3, and T4 .n = 23) scored below the 24-point threshold in the MMSE test, indicating that a significant fraction of participants was within the mild/moderate cognitive impairment classification. In addition, at the same time-point (T1), significant differences were found for the cognitive score between the ME + BCAAs group and the other groups (p < 0.05). An effect of time  = 4.262, p = 0.007), but not interaction , was observed for the MMSE results. The cognitive MMSE scores increased in the control group between T1 and T2 but decreased subsequently in T3 and T4 (p = 0.008). No significant alterations were observed in the other groups. At baseline, 45.7% of the participants were classified as frail and 54.3% as pre-frail.The results obtained in the cognitive profile , show thThis study evaluated the effects of exercise and BCAAs on biomarkers of immunity, total albumin, and the cognitive profile of institutionalized older persons. The main findings were that ME showed more proemint result, particullary with BCAA in the improve cognitive profile and muscle strength-related albumin levels in plasma and diminish the frailty status. Moreover, exercise induced slight changes on the pro-inflammatory marker TNF-α.Albumin levels tend to decrease with age, and this effect seems to imply an increased risk of complications and higher rate of mortality, morbidity, and disabilities such as sarcopenia and frailty . DespiteOur results showed that the serum albumin levels were efficiently sustained or even augmented, in exercising participants (both ME and ME + BCAAs groups) during the first 16 weeks of intervention (phase 1). However, the withdrawal of BCAAs during the washout period (phase 2) quickly decreased those albumin levels, especially in the BCAAs group. The prominent effect of exercise on albumin levels was evident since its levels in both ME and ME + BCAAs groups were fully restored after the phase 3 period (T3 to T4 time-points), whereas only partial recoveries were observed in albumin levels in the BCAAs group at the same time-point. Low serum albumin levels were shown to be the most relevant biomarkers associated with poor physical strength in the older persons .It is broadly accepted that the regular practice of exercise training imposes metabolic, endocrine/physiological, immune, and cognitive adaptations that, among many benefits, can increase skeletal muscle mass and strength, thus, circumventing the deleterious effects of sarcopenia in older persons .The chronic exercise-mediated adjustments on insulin/glucagon balance, thyroid, and steroid hormones, such as testosterone, cortisol, and estrogens, can also be involved in the enhancement of hepatic and protein muscle metabolism , with clear consequences on the circulating amino acid levels , blood pH and electrolyte balance (hydric/ionic homeostasis), and renal functions .However, it was reported that the putative effect of amino acid/protein supplementation in older women could be masked by sufficient daily protein intake, as we attested in all institutionalized participants in this study . Thus, tContrarily to the albumin results, the monitored inflammatory markers  did not show significant alterations over time. Apparently, we can putatively suggest, that the physical exercise intensities reached in the sessions, as well as the BCAAs supplementation effect compared to the daily protein intake in this population, were not sufficient to induce a significant impact on the inflammatory status in the participants in this study. Other interventions with older persons have been able to show a strong anti-inflammatory effect of exercise training, but it seems that these results were observed for intervention periods longer than 16 weeks ,44.Interestingly, even though an increase in the levels of the pro-inflammatory cytokine TNF-α was observed in the ME + BCAAs group from T1 to T2 and T3, this finding was accompanied by a proportional increase of the anti-inflammatory cytokine IL-10, since the TNF-α/IL-10 ratio was not different in this group over time. Moreover, at the end of the intervention, TNF-α levels significantly decreased in this group. In accordance with the literature, IL-10 is a key anti-inflammatory cytokine that acts by inhibiting systemic inflammation mediated by TNF-α .Concomitantly, BCAAs alone did not induce alterations in both IL-10 and TNF-α levels. These results differ slightly from what is observed in the literature regarding this type of intervention on inflammatory status . Based oDespite the fact that literature defines the ability to induce an anti-inflammatory change as a hallmark of physical exercise, in general, our results did not corroborate this fact. It is paramount to mention that some factors could putatively influence the lack of significant results in the inflammatory analysis. Firstly, the occurrence of inflammaging and pathophysiological disturbances in our participants could be crucial for the response magnitude observed during the interventions here. Second, the low level of physical activity of our participants before the interventions could mitigate the benefits that would be achieved with the physical exercise sessions and, consequently, limit physiological adaptation. These factors, associated with polypharmacy, a high rate of comorbidities, and the small sample size that finished the study, may determine the lack of significant effects observed.There is a consensus in the literature that physical exercise sessions stimulate the release of cytokines, such as IL-6, IL-10, and TNF-α, in response to contracting skeletal muscles, which are responsible not only for tissue restoration and energy metabolism, but also for the adjustment of the systemic inflammatory status .As appeaThere are solid pieces of evidence that the loss of muscle strength and power in the lower limbs, which is characterized by a decline of up to 50% in overall muscle strength from the age of 30 to 80 years ,53 is asParticularly, physical exercise training improves body composition, muscle strength, metabolic parameters, bone health, and functionality as well as reduces the risk of mortality, chronic diseases, cognitive deterioration, falls, and depression . Here, wIt is important to point out that strength exercise training has been proposed as one of the most effective methodologies, presenting best results in bringing back safety in per-forming the common tasks of daily life, focusing on the optimization of neuromuscular function for better benefits .Multicomponent programs combine aerobic and strength exercises, including other physical skills, such as balance and flexibility , in ordeTaking into account that cognitive impairment is one of the main factors that cause morbidity and high health costs worldwide , our resThe entire study was conducted with human octogenarians and, given the difficulty to control several influencing factors in this type of population, this study had the additional merit of causing a minimal impact on their daily routines at the residential care homes. In addition, our results here represent real-world data reflecting the reality at residential care homes. We screened participants with disabilities and comorbidities that, although expecting high rate of dropouts and low motivational issues, we could accomplish the proposed goals with a reasonable number of participants. The execution of a controlled study over 40 weeks with such a particular population also introduces other limitations. We suggest that the use of other methods of exercise training, such as the use of playful activities (dance and music sessions) might elevate the adherence of this population to the program.This study showed that multicompetent exercise training, with minor effect of BCAAs, triggered alterations in the inflammatory status and physical profiles of older persons, while helping maintain cognitive levels. Taken together, the achieved results, could help increase autonomy and efficiency in the performance of daily activities. Unlike other studies, our results showed that supplementation with BCAA did not induce substantial changes in health-related parameters at older ages. It is possible that the heterogeneity and limited sample size might have limited the statistical relevance of our results. Despite a slight and transient variation over time observed in some inflammatory and cognitive parameters, it is possible that the results here were influenced by the comorbidity status of each group.


In the elderly, both frailty and ischemic stroke are not only common, but are also associated with mortality. The aim of this research was to investigate whether a significantly reduced ALT level increases the all-cause mortality rate in the elderly with ischemic stroke. (2) Methods: Between February 2014 and April 2019, a retrospective study of 901 patients with ischemic stroke admitted to a university-affiliated hospital was conducted. Cox proportional hazard regression was used to determine whether a significantly reduced ALT level is an independent risk factor for mortality in elderly patients after an ischemic stroke. (3) Results: This study enrolled 323 older adults (age ≥ 65 years) who were first diagnosed with ischemic stroke. The mean age of the participants was 76.5 ± 6.6 years, the mean survival time was 37.1 ± 20.4 months, and the number of deaths was 96 (29.7%). Our results showed that reduced ALT level (less than 10 U/L) increased the risk of all-cause mortality in the elderly after ischemic stroke (adjusted HR: 3.24, 95% CI: 1.95–5.41;  Serum alanine aminotransferase (ALT) activity has been used as a predictor of overall health status, as well as for liver function monitoring . The livThe term “frailty” refers to a condition of vulnerability to external stress, wherein the physical function is reduced to protect homeostasis; however, frailty itself does not raise the risk of death . FrailtyFrailty and ischemic stroke are common among the elderly. To our knowledge, no study has investigated the relationship between a significantly reduced ALT level and mortality after ischemic stroke. We assumed that a significantly reduced ALT level is related to frailty and could increase the all-cause mortality rate following an ischemic stroke. The aim of this research was to investigate whether a significantly reduced ALT level increases the all-cause mortality rate in the elderly with ischemic stroke.Between February 2014 and April 2019, a retrospective study of 901 patients with ischemic stroke admitted to a university-affiliated hospital was conducted. A review of the medical records of these patients diagnosed using magnetic resonance imaging or computed tomography was performed. The exclusion criteria and number of patients excluded were as follows: suspected liver disease , not the first episode of acute ischemic stroke (n = 244), insufficient medical records (n = 8), and age < 65 years (n =234).Finally, 323 participants were enrolled in the study , which wOf the 901 patients, 92 patients with ALT levels over 40 were excluded and 244 patients had a previous history of stroke. Of the remaining stroke patients, 8 patients had insufficient medical records, and 234 patients under the age of 65 were excluded. Finally, 323 subjects were enrolled in the study.Age, sex, and body mass index (BMI) data were evaluated. The investigated medical data related to ischemic stroke included lesions of ischemic stroke, thrombolytic treatment (including IVtPA (intravenous tissue plasminogen activator) and stent retriever), and etiology, as per the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and history of atrial fibrillation, diabetes, hypertension, coronary artery occlusive disease, cancer, alcohol, and smoking. The initial National Institutes of Health Stroke Scale (NIHSS) score at admission was used to adjust ischemic stroke severity. Laboratory data of albumin, ALT, creatinine (Cr), erythrocyte sedimentation rate (ESR), neutrophil-lymphocyte ration (NLR), glucose, total cholesterol, and hemoglobin (Hb) were collected from the time of diagnosis. Systolic blood pressure (SBP) at admission and systolic blood pressure variability (SPBV) during first 24 h were also investigated. Mortality surveillance was investigated using the National Health Insurance database, as of 28 September 2020.Factors known to be linearly associated with mortality, such as initial NIHSS score at admission, age, Cr, total cholesterol, and ESR, were used as continuous variables ,19,20,212) was used as a categorical measure, and participants were divided into the following four groups: underweight (18.5), average weight (18.5–24.9), overweight (25.0–29.9), and obese (over 30) [A serum albumin level of less than 3.5 g/dL, glucose level of more than 7.3 or less than 3.7 mmol/L, and Hb level of less than 11 g/dL are all considered risk factors for death ,18,22. Bover 30) ,24. Accot-test for continuous variables and Fisher’s exact test or chi-square test with a post-hoc Bonferroni test for categorical variables were used. Continuous variables were defined as the mean standard deviation for normally distributed variables and categorical variables as frequency and percentage.Participants of the study were divided into the expired group  and surviving group . The differences between groups were compared statistically. An independent The cumulative risk of overall survival at 79 months was estimated using the Kaplan–Meier method. Stratified analyses were made for the ALT level . Time-to-event comparisons were made using the log-rank test.The relationship between a significantly reduced ALT level (less than 10 U/L) and mortality was assessed using a multivariate Cox proportional model  that controlled for possible confounding factors including age, sex, TOAST classification, stroke location, hemispheric localization, initial NIHSS at admission, SBP at admission, SBPV, thrombolytic treatment, reduced albumin level (less than 3.5 g/dL), reduced Hb level (less than 11 g/dL), abnormal glucose level (more than 7.3 or less than 3.7 mmol/L), serum Cr, ESR, NLR, total cholesterol levels, BMI, history of hypertension, diabetes mellitus, atrial fibrillation, coronary artery occlusive disease, cancer, smoking, and alcohol consumption. A statistically significant value was defined as a p-value of less than 0.05.For testing the proportional hazard assumption in the Cox model, first we used a visual inspection of the log minus log curve. Second, a time-dependent Cox regression analysis was additionally performed to investigate whether the time-dependent covariate was not significant.The statistical analysis was performed using the Statistical Package for the Social Sciences, version 22.0 .This study enrolled 323 older adults aged ≥65 years. Their mean age was 76.5 ± 6.6 years and their mean survival time was 37.1 ± 20.4 months; death was reported in 96 (29.7%) cases. IVtPA treatment was performed in 13 patients (4.0%), and the mean time to IVtPA treatment was 68.8 ± 30.5 min. Stent retriever treatment was performed in 20 patients (6.2%), and the mean time to stent retriever treatment was 132.7 ± 60.0 min. IVtPA with stent retriever treatment was performed in three patients (0.9%). The general characteristics of the expired and surviving groups are shown in p < 0.001).The association between the selected risk factors and all-cause mortality was assessed through univariate analysis . Table 2The results of this study showed that the factors that increase the mortality rate in the elderly after ischemic stroke were age, initial NIHSS score at admission (indicator of stroke severity), high Cr levels, and a significantly reduced ALT level (less than 10 U/L). It is noteworthy that laboratory tests at diagnosis have a clear correlation with mortality, even though statistically controlled confounding factors are known to be risk factors. Survival analysis using the multivariate Cox proportional hazard analysis revealed that elderly individuals with a significantly reduced ALT level (less than 10 U/L) had a significantly higher mortality rate after ischemic stroke; this difference in mortality rate was observed shortly after the onset and increased over time.The Totaled Health Risks in Vascular Events (THRIVE) and Acute Stroke Registry and Analysis of Lausanne (ASTRAL) are models for predicting mortality outcomes using acute ischemic stroke states . THRIVE The TOAST classification and tentorial location were not associated with mortality. However, in hemispheric localization, the proportion of the bilateral injury group was higher in the expired group; in the univariate analysis, the unilateral injury group had a lower mortality rate than the bilateral injury group. This could be attributed to the difference in severity according to the extent of the infarction area.The post-hoc test results for the four BMI categories in our study showed a significant difference in mortality between the overweight and underweight groups; there were more expired cases in the latter. Previous studies have shown that BMI and mortality are inversely related. Elderly individuals with a higher BMI had a lower mortality rate than those with an underweight BMI, which was interpreted as sarcopenia. Thus, the mortality risk due to frailty in patients who are underweight is higher than that in those who are overweight ,27.Thrombolytic treatment includes IVtPA treatment and stent retriever treatment. Only 9.3% of the subjects included in this study were included. It is known that the survival rate of thrombolytic treatment may vary depending on the treatment time, but in this study, the sample size was too small for a subgroup analysis, so it could be concluded ,29.Recent evidence suggests that high blood pressure and blood pressure variability are important factors in predicting the prognosis of acute stroke. In particular, it is known that systolic blood pressure at admission and systolic blood pressure variability increase the risk of cerebral hemorrhage or symptomatic hemorrhagic transformation, and adversely affect mortality and functional outcome ,31,32. AThere is strong evidence that stroke outcomes are strongly influenced by various factors related to metabolic homogeneity, inflammatory reactions, and perfusion disorders ,34,35,36In our study, the laboratory findings of the two groups showed that the proportion of a significantly reduced ALT level (less than 10 U/L), reduced albumin level (less than 3.5 g/dL), and reduced Hb level (less than 11 g/dL) was significantly higher in the expired group than in the surviving group. Furthermore, Cr, ESR levels, and NLR were significantly higher in the expired group. Albumin and Hb levels reflect the whole-body nutritional status, high ESR and NLR indicates systemic inflammatory response, and high Cr indicates renal dysfunction. In previous research, all of these factors were found to be strongly related to mortality. For the prognosis of inflammatory response and stroke, ficolin-1 is also a strong prognostic, but it was not included in this retrospective study ,21,22,35Significantly reduced serum ALT is an independent risk factor for mortality in the elderly population ,4,6,7,8.The accumulation of damage in the body’s organ system is the cause of death from frailty. Most people who are afflicted with diseases will recover without dying. Frail people, on the other hand, are more vulnerable to other illnesses and take longer to recover, and their organ damage continues to expand over time, ultimately leading to death. . RehabilThis study had some limitations. As the cause of mortality was not investigated, it is not possible to determine whether it was the cause of the ischemic stroke. Therefore, when referring to mortality, it is considered as mortality caused by the all-causative cause. As this study was a retrospective study, information on the modified Rankin scale or NIHSS at discharge was difficult to control and was not included. In addition, as previously mentioned, ficolin-1, which is associated with inflammatory reactions, was not a test widely distributed in the general clinical sites, and thus could not be investigated because of limitations in retrospective design. Although a clear mechanism has not been identified yet, if a prospective design study including compelling evidence related to the prognosis of stroke is conducted, it will be helpful to improve the algorithm for the prognosis of ischemic cerebral infarction in the future. In addition, a limitation of this study is that the subgroup analysis for thrombolytic treatment was not progressed because of the small sample size. In the future, it will be necessary to use cohort studies rather than cross-sectional studies to determine the association between a significantly reduced ALT level, frailty, and mortality. In order to evaluate the efficacy of rehabilitation in patients with a significantly reduced ALT level, further research is required.In conclusion, a significantly reduced ALT level at diagnosis (less than 10 U/L) is an independent risk factor that increases the mortality rate in the elderly after ischemic stroke.