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Critical Care (London, England) Nov 2017Cefepime is a widely used antibiotic with neurotoxicity attributed to its ability to cross the blood-brain barrier and exhibit concentration-dependent ϒ-aminobutyric... (Review)
Review
BACKGROUND
Cefepime is a widely used antibiotic with neurotoxicity attributed to its ability to cross the blood-brain barrier and exhibit concentration-dependent ϒ-aminobutyric acid (GABA) antagonism. Neurotoxic symptoms include depressed consciousness, encephalopathy, aphasia, myoclonus, seizures, and coma. Data suggest that up to 15% of ICU patients treated with cefepime may experience these adverse effects. Risk factors include renal dysfunction, excessive dosing, preexisting brain injury, and elevated serum cefepime concentrations. We aimed to characterize the clinical course of cefepime neurotoxicity and response to interventions.
METHODS
A librarian-assisted search identified publications describing cefepime-associated neurotoxicity from January 1980 to February 2016 using the CINAHL and MEDLINE databases. Search terms included cefepime, neurotoxicity, encephalopathy, seizures, delirium, coma, non-convulsive status epilepticus, myoclonus, confusion, aphasia, agitation, and death. Two reviewers independently assessed identified articles for eligibility and used the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) for data reporting.
RESULTS
Of the 123 citations identified, 37 (representing 135 patient cases) were included. Patients had a median age of 69 years, commonly had renal dysfunction (80%) and required intensive care (81% of patients with a reported location). All patients exhibited altered mental status, with reduced consciousness (47%), myoclonus (42%), and confusion (42%) being the most common symptoms. All 98 patients (73% of cohort) with electroencephalography had abnormalities, including non-convulsive status epilepticus (25%), myoclonic status epilepticus (7%), triphasic waves (40%), and focal sharp waves (39%). As per Food and Drug Administration (FDA)-approved dosing guidance, 48% of patients were overdosed; however, 26% experienced neurotoxicity despite appropriate dosing. Median cefepime serum and cerebrospinal fluid (CSF) concentrations were 45 mg/L (n = 21) and 13 mg/L (n = 4), respectively. Symptom improvement occurred in 89% of patients, and 87% survived to hospital discharge. The median delay from starting the drug to symptom onset was 4 days, and resolution occurred a median of 2 days after the intervention, which included cefepime discontinuation, antiepileptic administration, or hemodialysis.
CONCLUSIONS
Cefepime-induced neurotoxicity is challenging to recognize in the critically ill due to widely varying symptoms that are common in ICU patients. This adverse reaction can occur despite appropriate dosing, usually resolves with drug interruption, but may require additional interventions such as antiepileptic drug administration or dialysis.
Topics: Anti-Bacterial Agents; Cefepime; Cephalosporins; Consciousness Disorders; Drug-Related Side Effects and Adverse Reactions; Humans; Neurotoxicity Syndromes; Seizures
PubMed: 29137682
DOI: 10.1186/s13054-017-1856-1 -
Neurological Sciences : Official... Feb 2022The aim of this meta-analysis was to evaluate the evidence on the effectiveness of music therapy in the recovery of language function in post-stroke aphasia, compared... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of this meta-analysis was to evaluate the evidence on the effectiveness of music therapy in the recovery of language function in post-stroke aphasia, compared with conventional therapy or no therapy.
METHODS
We searched studies that explored the effect of music therapy on language function in post-stroke aphasia and published in PubMed, Embase, the Cochrane Library, Web of Science, CINAHL, ProQuest Digital Dissertations, and ClinicalTrials.gov from inception to March 2021. Six reviewers independently screened out eligible studies, extracted data, and evaluated the methodological quality. Results were pooled using mean difference (MD) with 95% confidence interval (CI). Heterogeneity was assessed by the chi-square test and I statistic.
RESULTS
Six studies were included in this meta-analysis involving 115 patients. The methodological quality of these studies ranged from poor to excellent. There was significant mean difference in functional communication for post-stroke aphasia by 1.45 (95% CI: 0.24, 2.65; P = 0.02, from poor to excellent evidence), in repetition by 6.49 (95% CI: 0.97, 12.00; P = 0.02, from acceptable to excellent evidence), and in naming by 11.44 (95% CI: 1.63, 21.26; P = 0.02, from acceptable to excellent evidence). But there was no significant difference in comprehension for post-stroke aphasia by 7.21 (95% CI: - 10.88, 25.29; P = 0.43, from acceptable to excellent evidence).
CONCLUSIONS
Music therapy can improve functional communication, repetition, and naming in patients with post-stroke aphasia, but did not significantly improve comprehension.
TRIAL REGISTRATION
CRD42021251526.
Topics: Aphasia; Comprehension; Humans; Language; Music Therapy; Stroke
PubMed: 34816318
DOI: 10.1007/s10072-021-05743-9 -
European Journal of Physical and... Feb 2021Speech difficulties, such as dysarthria or aphasia, in addition to motor impairments are frequently seen in post-stroke patients. (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Speech difficulties, such as dysarthria or aphasia, in addition to motor impairments are frequently seen in post-stroke patients.
EVIDENCE ACQUISITION
Literature searches with the keywords: "stroke" and "dysarthria" and "diagnosis" and "stroke" and "dysarthria" and "assessment" were conducted using PubMed, EMBASE, Cochrane Library, and Web of Science databases to perform the systematic review about the methods used to measure the severity of dysarthria in subjects post-stroke. The search was performed by two authors from 15 January to 22 February 2020. The research identified a total of 402 articles for the search using the keywords "stroke" and "dysarthria," and "diagnosis" and 84 references for the search using the keywords "stroke" and "dysarthria" and "assessment." Sixty-nine selected articles were analyzed by the reviewers. Thirty-seven publications met the inclusion criteria and were included in the systematic review. Thirty-two articles were excluded for several reasons: 1) 12 involved individuals with aphasia or other speech problems different from dysarthria; 2) 12 examined different topics from our aim; and 3) eight did not include post-stroke cases.
EVIDENCE SYNTHESIS
The systematic review identified methods for measuring the severity of post-stroke dysarthria. The meta-analysis showed the acoustic parameters affected in dysarthria secondary to stroke and the differences in these parameters after speech therapy.
CONCLUSIONS
The alternating and sequential motion rate (AMR- Pə, AMR-Tə, AMR-Kə, and SMR-PəTəKə) and maximum phonation time were significantly improved after speech rehabilitation.
Topics: Dysarthria; Humans; Speech Therapy; Stroke Rehabilitation
PubMed: 32519528
DOI: 10.23736/S1973-9087.20.06242-5 -
The Cochrane Database of Systematic... Jun 2016Aphasia is an acquired language impairment following brain damage that affects some or all language modalities: expression and understanding of speech, reading, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Aphasia is an acquired language impairment following brain damage that affects some or all language modalities: expression and understanding of speech, reading, and writing. Approximately one third of people who have a stroke experience aphasia.
OBJECTIVES
To assess the effects of speech and language therapy (SLT) for aphasia following stroke.
SEARCH METHODS
We searched the Cochrane Stroke Group Trials Register (last searched 9 September 2015), CENTRAL (2015, Issue 5) and other Cochrane Library Databases (CDSR, DARE, HTA, to 22 September 2015), MEDLINE (1946 to September 2015), EMBASE (1980 to September 2015), CINAHL (1982 to September 2015), AMED (1985 to September 2015), LLBA (1973 to September 2015), and SpeechBITE (2008 to September 2015). We also searched major trials registers for ongoing trials including ClinicalTrials.gov (to 21 September 2015), the Stroke Trials Registry (to 21 September 2015), Current Controlled Trials (to 22 September 2015), and WHO ICTRP (to 22 September 2015). In an effort to identify further published, unpublished, and ongoing trials we also handsearched the International Journal of Language and Communication Disorders (1969 to 2005) and reference lists of relevant articles, and we contacted academic institutions and other researchers. There were no language restrictions.
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing SLT (a formal intervention that aims to improve language and communication abilities, activity and participation) versus no SLT; social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions); or another SLT intervention (differing in duration, intensity, frequency, intervention methodology or theoretical approach).
DATA COLLECTION AND ANALYSIS
We independently extracted the data and assessed the quality of included trials. We sought missing data from investigators.
MAIN RESULTS
We included 57 RCTs (74 randomised comparisons) involving 3002 participants in this review (some appearing in more than one comparison). Twenty-seven randomised comparisons (1620 participants) assessed SLT versus no SLT; SLT resulted in clinically and statistically significant benefits to patients' functional communication (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.49, P = 0.01), reading, writing, and expressive language, but (based on smaller numbers) benefits were not evident at follow-up. Nine randomised comparisons (447 participants) assessed SLT with social support and stimulation; meta-analyses found no evidence of a difference in functional communication, but more participants withdrew from social support interventions than SLT. Thirty-eight randomised comparisons (1242 participants) assessed two approaches to SLT. Functional communication was significantly better in people with aphasia that received therapy at a high intensity, high dose, or over a long duration compared to those that received therapy at a lower intensity, lower dose, or over a shorter period of time. The benefits of a high intensity or a high dose of SLT were confounded by a significantly higher dropout rate in these intervention groups. Generally, trials randomised small numbers of participants across a range of characteristics (age, time since stroke, and severity profiles), interventions, and outcomes.
AUTHORS' CONCLUSIONS
Our review provides evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, reading, writing, and expressive language compared with no therapy. There is some indication that therapy at high intensity, high dose or over a longer period may be beneficial. HIgh-intensity and high dose interventions may not be acceptable to all.
Topics: Aphasia; Humans; Language Therapy; Randomized Controlled Trials as Topic; Social Support; Speech Therapy; Stroke
PubMed: 27245310
DOI: 10.1002/14651858.CD000425.pub4 -
International Journal of Stroke :... Oct 2023Information about cognitive functioning is vital in the management of stroke, but the literature is mostly based on data from individuals older than 50 years of age... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Information about cognitive functioning is vital in the management of stroke, but the literature is mostly based on data from individuals older than 50 years of age who make up the majority of the stroke population. As cognitive functioning is subject to change due to aging, it is unclear whether such cognitive impairment patterns from the general stroke literature apply to the growing population of younger people with a stroke.
AIM
The aim of the study was to conduct a systematic review and meta-analysis of the proportion and severity of cognitive impairment in young-stroke patients.
SUMMARY OF REVIEW
MEDLINE, Embase, PsycINFO, and Web of Science were systematically searched up to 11 October 2022. Studies were included if they reported on a population of young-stroke patients, evaluated cognitive functioning as an outcome measure, and reported original data. We estimated the pooled prevalence rates for cognitive impairment and for aphasia. In addition, we calculated the pooled estimates for the severity of impairment per cognitive domain in the chronic phase (defined as >6 months post-stroke). Six hundred thirty-five articles were identified, of which 29 were eligible for inclusion. The pooled prevalence of cognitive impairment was 44% ( = 10; 95% confidence interval (CI): 34-54%) and of aphasia 22% ( = 13; 95% CI: 12-39%). Young-stroke patients in the chronic phase performed worse than stroke-free healthy age-appropriate controls across all cognitive domains examined, with Hedges' g effect sizes ranging from -0.49 to -1.64.
CONCLUSION
Around half of all young-stroke patients present with cognitive impairment and around a quarter with aphasia. Our data suggest that patterns of impairment in young-stroke patients follow those in the general stroke literature.
Topics: Humans; Young Adult; Stroke; Cognitive Dysfunction; Cognition; Aphasia
PubMed: 36765436
DOI: 10.1177/17474930231159267 -
Transplantation and Cellular Therapy Jun 2022Chimeric antigen receptor (CAR) T cell therapy is a novel therapy for patients with relapsed or refractory hematologic malignancies. Most CAR T cell therapy recipients... (Review)
Review
Clinical Presentation, Risk Factors, and Outcomes of Immune Effector Cell-Associated Neurotoxicity Syndrome Following Chimeric Antigen Receptor T Cell Therapy: A Systematic Review.
Chimeric antigen receptor (CAR) T cell therapy is a novel therapy for patients with relapsed or refractory hematologic malignancies. Most CAR T cell therapy recipients will experience clinical features of the immune effector cell-associated neurotoxicity syndrome (ICANS), a potentially life-threatening condition. Here we describe the clinical, biological, and radiological findings associated with ICANS in adults with hematologic malignancies treated with CAR T cell therapy, as well as the acute and long-term outcomes of ICANS. A literature search of Ovid Medline, Embase, PubMed, Scopus, Web of Science Core Collection, Cochrane Library, and Google Scholar was conducted from each database's inception through February 1, 2022, using search terms reflecting CAR T cell therapy and ICANS. We included studies that enrolled adults (age ≥18 years) who received CAR T cell therapy as management for hematologic malignancies and reported the clinical presentation, predictors, and/or acute or long-term outcomes of ICANS. Two reviewers independently extracted data following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) reporting guidelines. Quality was assessed using the Joanna Briggs Institute critical appraisal tool for cohort studies. Of the 2928 studies screened, 23 observational studies (10 prospective, 11 retrospective, 1 mixed design, and 1 cross-sectional) with a total of 1666 participants met our eligibility criteria and were included in our review. The most common hematologic malignancies were diffuse large B cell lymphoma, acute lymphocytic leukemia, non-Hodgkin lymphoma, and chronic lymphocytic leukemia. ICANS onset was most often associated with the presence and severity of cytokine release syndrome, as well as with C-reactive protein and ferritin levels. Aphasia was the most common ICANS-related symptom reported, although the neurologic manifestations of ICANS were highly variable. Neuroimaging studies (magnetic resonance imaging or computed tomography) were often normal in cases of ICANS; however, electroencephalography often showed generalized background slowing, abnormal rhythmic, and periodic discharge patterns. The pooled mean (± SD) onset of ICANS was 6.4 ± 3.2 days, with a pooled mean duration of 8.3 ± 10.5 days. Two of the 23 studies (9%) reported 5 ICANS-related deaths among 233 participants. A subset of patients experienced persistent neurocognitive complaints at ≥1-year after CAR T cell therapy. The clinical presentation, onset, severity, long-term sequelae, and grading system of ICANS are variable. Future studies should consider using a consensus grading/reporting scale that would permit cross-trial comparisons of the safety profile of various CAR T cell products and enable the development of interventions to mitigate or manage these neurotoxicities. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc. This systematic review was conducted according to a published protocol (PROSPERO CRD42020207864) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and Synthesis without Meta-Analysis (SWiM) in systematic review reporting guidelines (Supplementary Table S1) [15,16].
Topics: Adult; Cell- and Tissue-Based Therapy; Cross-Sectional Studies; Hematologic Neoplasms; Humans; Immunotherapy, Adoptive; Neurotoxicity Syndromes; Prospective Studies; Receptors, Chimeric Antigen; Retrospective Studies; Risk Factors
PubMed: 35288347
DOI: 10.1016/j.jtct.2022.03.006 -
Frontiers in Neurology 2021Melodic intonation therapy (MIT) is one of the most studied speech and language therapy (SLT) approaches for patients with non-fluent aphasia, although the...
Melodic intonation therapy (MIT) is one of the most studied speech and language therapy (SLT) approaches for patients with non-fluent aphasia, although the methodological quality of the studies has been rated as low in previous reviews. The aim of this study is to update current evidence on the possible efficacy of MIT for the treatment of non-fluent post-stroke aphasia. A systematic review and meta-analysis. We selected randomized clinical trials (RCT) that included adult patients over 18 years of age with non-fluent post-stroke aphasia, whose intervention was MIT vs. no therapy or other therapy. We excluded non-RCT studies, mixed populations including patients with aphasia of non-stroke etiology, studies with no availability of post-stroke aphasia-specific data, and incomplete studies. Three sections of communicative ability were analyzed as outcomes: functional communication, expressive language (naming and repetition), and comprehension. We identified a total of four eligible RCTs involving 94 patients. Despite the heterogeneity in the psychometric tests employed among the trials, a significant effect of MIT on functional communication (evaluated by the Communication Activity Log) was found (SMD 1.47; 95% CI 0.39-2.56). In addition, a positive effect of MIT on expressive language (repetition) was found (SMD 0.45; 95% CI 0.01-0.90). No significant effects on comprehension measurements were found, despite a lack of significant statistical heterogeneity. This systematic review and meta-analysis shows a significant effect of MIT on improving functional communication and on repetition tasks. Future larger RCT specifically addressing those outcomes should provide the definite evidence on the efficacy of MIT on post-stroke aphasia recovery. PROSPERO-URL https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020144604.
PubMed: 34421802
DOI: 10.3389/fneur.2021.700115 -
Stroke Mar 2022Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND PURPOSE
Optimizing speech and language therapy (SLT) regimens for maximal aphasia recovery is a clinical research priority. We examined associations between SLT intensity (hours/week), dosage (total hours), frequency (days/week), duration (weeks), delivery (face to face, computer supported, individual tailoring, and home practice), content, and language outcomes for people with aphasia.
METHODS
Databases including MEDLINE and Embase were searched (inception to September 2015). Published, unpublished, and emerging trials including SLT and ≥10 individual participant data on aphasia, language outcomes, and time post-onset were selected. Patient-level data on stroke, language, SLT, and trial risk of bias were independently extracted. Outcome measurement scores were standardized. A statistical inferencing, one-stage, random effects, network meta-analysis approach filtered individual participant data into an optimal model examining SLT regimen for overall language, auditory comprehension, naming, and functional communication pre-post intervention gains, adjusting for a priori-defined covariates (age, sex, time poststroke, and baseline aphasia severity), reporting estimates of mean change scores (95% CI).
RESULTS
Data from 959 individual participant data (25 trials) were included. Greatest gains in overall language and comprehension were associated with >20 to 50 hours SLT dosage (18.37 [10.58-26.16] Western Aphasia Battery-Aphasia Quotient; 5.23 [1.51-8.95] Aachen Aphasia Test-Token Test). Greatest clinical overall language, functional communication, and comprehension gains were associated with 2 to 4 and 9+ SLT hours/week. Greatest clinical gains were associated with frequent SLT for overall language, functional communication (3-5+ days/week), and comprehension (4-5 days/week). Evidence of comprehension gains was absent for SLT ≤20 hours, <3 hours/week, and ≤3 days/week. Mixed receptive-expressive therapy, functionally tailored, with prescribed home practice was associated with the greatest overall gains. Relative variance was <30%. Risk of trial bias was low to moderate; low for meta-biases.
CONCLUSIONS
Greatest language recovery was associated with frequent, functionally tailored, receptive-expressive SLT, with prescribed home practice at a greater intensity and duration than reports of usual clinical services internationally. These exploratory findings suggest critical therapeutic ranges, informing hypothesis-testing trials and tailoring of clinical services. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018110947.
Topics: Aphasia; Humans; Language Therapy; Network Meta-Analysis; Stroke; Stroke Rehabilitation
PubMed: 34847708
DOI: 10.1161/STROKEAHA.121.035216 -
The Cochrane Database of Systematic... 2003It is thought that approximately 6% of children have speech and language difficulties of which the majority will not have any other significant developmental... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It is thought that approximately 6% of children have speech and language difficulties of which the majority will not have any other significant developmental difficulties. Whilst most children's difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialisation, behaviour and school attainment.
OBJECTIVES
To examine the effectiveness of speech and language interventions for children with primary speech and language delay/disorder.
SEARCH STRATEGY
The following databases were searched: The Cochrane Controlled Trials Register (Cochrane Library, CENTRAL: 2002/3), CINAHL (1982 - July 2002), EMBASE (1980 - Sept Week 4 2002), ERIC (1965 - 2002), MEDLINE (1966 - Sept Week 3 2002), PsycINFO (1872 - 2002/10 Week 2), The National Research Register (2002/3). In addition to this references were taken from reviews of the literature and reference lists from articles.
SELECTION CRITERIA
The review considered randomised controlled trials of speech and language therapy interventions for children or adolescents with primary speech and language delay/disorder.
DATA COLLECTION AND ANALYSIS
Titles and abstracts were identified and assessed for relevance, before the full text version was obtained of all potentially relevant articles. The data were categorised depending on the nature of the control group and considered in terms of the effects of intervention on expressive and receptive phonology, syntax and vocabulary. The outcomes used in the analysis were dependent on the focus of the study with only the primary effects of therapy being considered in this review.
MAIN RESULTS
The results of twenty-five studies were used in the meta-analysis. The results suggest that speech and language therapy is effective for children with phonological (SMD=0.44, 95%CI: 0.01,0.86) or vocabulary difficulties (SMD=0.89, 95%CI: 0.21,1.56), but that there is less evidence that interventions are effective for children with receptive difficulties (SMD=-0.04, 95%CI: -0.64,0.56). Mixed findings were found concerning the effectiveness of expressive syntax interventions (n=233; SMD=1.02, 95%CI: 0.04-2.01). No significant differences were shown between clinician administered intervention and intervention implemented by trained parents, and studies did not show a difference between the effects of group and individual interventions (SMD=0.01, 95%CI: -0.26,1.17). The use of normal language peers in therapy was shown to have a positive effect on therapy outcome (SMD=2.29, 95%CI: 1.11,3.48).
REVIEWER'S CONCLUSIONS
The review shows that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The evidence for expressive syntax difficulties is more mixed, and there is a need for further research to investigate intervention for receptive language difficulties. There is a large degree of heterogeneity in the results, and the sources of this need to be investigated.
Topics: Adolescent; Aphasia; Child; Dysarthria; Humans; Language Development Disorders; Language Therapy; Randomized Controlled Trials as Topic; Speech Disorders; Speech Therapy
PubMed: 12918003
DOI: 10.1002/14651858.CD004110 -
Archives of Physical Medicine and... Dec 2010To describe the effects of communication partner training on persons with aphasia and their communication partners. Specifically the systematic review addressed 3... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To describe the effects of communication partner training on persons with aphasia and their communication partners. Specifically the systematic review addressed 3 clinical questions regarding the impact of partner training on language, communication activity and participation, psychosocial adjustment, and quality of life for adults with aphasia and their communication partners.
DATA SOURCES
Twenty-three terms were used to search 12 electronic databases (eg, PubMed, CINAHL, PsychINFO, PsychArticles, CSA Linguistics and Language Behavior Abstracts, Social Sciences Citation Index [Web of Science], SUMSearch, TRIP, EMBASE, REHABDATA, National Library for Health, Cochrane Database of Systematic Reviews) and the journal "Aphasiology." References from all relevant articles were hand-searched.
STUDY SELECTION
Two reviewers independently applied inclusion criteria to select potential relevant articles from the titles and abstracts of references retrieved by the literature search. The full text of the remaining articles was reviewed by a 5-member panel, resulting in a corpus of 31 studies that met the final inclusion criteria.
DATA EXTRACTION
Two independent reviewers extracted the descriptive data related to the participants, the intervention, the outcome measures, and the results.
DATA SYNTHESIS
The 5-member review team by consensus classified the studies using the American Academy of Neurology system for classification of evidence (2004).
CONCLUSIONS
Evidence shows that communication partner training is effective in improving communication activities and/or participation of the communication partner and is probably effective in improving communication activities and/or participation of persons with chronic aphasia when they are interacting with trained communication partners. There is insufficient evidence to make recommendations related to the impact of partner training on persons with acute aphasia or the impact of training on language impairment, psychosocial adjustment, or quality of life for either the person with aphasia or the communication partner.
Topics: Aphasia; Humans; Interpersonal Relations; Quality of Life
PubMed: 21112422
DOI: 10.1016/j.apmr.2010.08.026