Exercise and risk of stroke in male physicians

Age-period-cohort analysis of ischemic stroke deaths attributable to physical inactivity in different income regions

This study assessed the global and regional burden of IS (ischemic stroke) deaths due to LPA (low physical activity) from 1990 to 2019, analyzed regional, sex, and age differences in ASMR (age-standardized mortality rate), and provided a comprehensive understanding of the impact of age, period, and cohort on low physical activity related ischemic stroke ASMR. We conducted an APC (age-period-cohort) analysis of the global and four World Bank income level regions' IS mortality data attributed to LPA from 1990 to 2019, using the GBD2019 database, and the results showed that the global net drift of the Ischemic stroke age-standardized mortality attributable to low physical activity was - 1.085%[95% CI: - 1.168, - 1.003].The ASMR drop is most pronounced in the high-income zone, with a net drift of - 2.473% [95% CI: - 2.759, - 2.187] across the four income groups. The influence of age on mortality is increasing in the worldwide old population, while the period and cohort effects are decreasing. We also performed a Joinpoint regression analysis, which revealed that the specific time of considerable drop in ASMR of IS in the global LPA population was 2002-2007, with an APC of -2.628%. The specific period of considerable drop in ASMR in high-income regions with the highest variation was 1999-2007, with an APC = - 4.726%. The global burden of public health deaths caused by LPA is diminishing, with the most notable progress observed in high-income regions. However, in low and lower-middle income areas, the situation continues to deteriorate. Within the global elderly population, the effects of age on mortality is increasing, while the effects of period and cohort are diminishing. These trends vary across income levels, highlighting the necessity for enhanced international collaboration to formulate context-specific public health strategies aimed at enhancing cardiovascular health on a global, regional, and national scale.

The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.

The preconditioning effect of different exercise training modes on middle cerebral artery occlusion induced-behavioral deficit in senescent rats

Introduction

Brain abilities decrease after brain stroke in elderly. The neuroprotective effect of exercise training has been proved in clinical trials and animal experiment. Nevertheless, it is not still clear what kind of exercise has greater protective effect. The present study aimed at investigating pre-conditioning effect of endurance, resistance, and concurrent training on learning ability, anxiety, and spatial memory in aged rats following stroke strength with middle cerebral artery occlusion.

Method

We used 50 male Wistar rats (age = 24 months) that were assigned randomly in five groups; 1: sham group, 2: Control group 3: Endurance training 4: Resistance training, and 5: concurrent training. The exercise training groups received training for four weeks. Following training, middle cerebral artery occlusion was applied to induce cerebral ischemia. Using the elevated plus maze, shuttle box test, and Morris water maze, neurocognitive functions were tested in the sample rats.

Results

It was found that resistance training did not affect spatial memory in the acquisition phase, while concurrent training and endurance training enhanced spatial memory in the acquisition phase. On the contrary, spatial memory was improved by resistance training in the retention phase, while concurrent and endurance exercises did not affect spatial memory in the retention phase. Passive avoidance learning ability at acquisition phase was more in resistance group compared to the endurance and concurrent training in shuttle box test, but in retention phase was similar between training groups. Unlike endurance and concurrent training, resistance training reduced anxiety in senescent rats.

Conclusion

All three exercise types alleviated aversive learning and memory impairment induced by stroke in senescent rats. Notably, the resistance training showed a greater protective effect compared to the other two training methods.

Prioritization of neurologic rehabilitation interventions by ELECTRE-III analysis in subacute stroke patients

BACKGROUND

Elimination and Choice Translating Reality (ELECTRE) III is a commonly used multicriteria decision-making (MCDM) method when alternatives are being prioritized in health sciences. The selection of the rehabilitation approach is the key factor to improve the upper extremity functions of stroke patients. Thus, choosing a reasonably good treatment approach will directly reduce the patient's cost to the government and caregivers, while also improving quality of life. The aim of our study was to prioritize the six different methods used in the rehabilitation of stroke patients with mild or moderate upper extremity dysfunction, using one of the MCDM methods based on experts' opinions.

METHODS

A three-stage face-to-face interview across Turkey, based on the ELECTRE-III method, was conducted with 18 physiotherapists specializing in the rehabilitation of mild or moderate stroke-induced upper extremity disorders.

RESULTS

According to ELECTRE-III, Circuit Class Therapy (CCT) is the best choice for treating upper extremity functional loss in general. It is also the best alternative in both the ascending and descending distillation processes of ELECTRE-III. On the other hand, Bobath neurodevelopmental treatment (NDT) has a similar success level according to ascending distillation. Mirror therapy and constraint-induced movement therapy are the third-best methods in the analysis. However, robotic rehabilitation is the least preferable treatment method according to the experts' judgments.

CONCLUSIONS

The results showed that rehabilitation interventions such as Bobath-NDT and proprioceptive neuromuscular facilitation, which are frequently used in developing countries, are still useful, and CCT is the most appropriate intervention for the transition from conventional methods to innovative models in these countries.

Antiplatelet agents and anticoagulants for hypertension

BACKGROUND

The main complications of elevated systemic blood pressure (BP), coronary heart disease, ischaemic stroke, and peripheral vascular disease, are related to thrombosis rather than haemorrhage. Therefore, it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated BP.

OBJECTIVES

To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with elevated BP, including elevations in systolic or diastolic BP alone or together. To assess the effects of antiplatelet agents on total deaths or major thrombotic events or both in these patients versus placebo or other active treatment. To assess the effects of oral anticoagulants on total deaths or major thromboembolic events or both in these patients versus placebo or other active treatment.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to January 2021: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 12), Ovid MEDLINE (from 1946), and Ovid Embase (from 1974). The World Health Organization International Clinical Trials Registry Platform and the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) were searched for ongoing trials.  SELECTION CRITERIA: RCTs in patients with elevated BP were included if they were ≥ 3 months in duration and compared antithrombotic therapy with control or other active treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for inclusion criteria, our prespecified outcomes, and sources of bias. They assessed the risks and benefits of antiplatelet agents and anticoagulants by calculating odds ratios (OR), accompanied by the 95% confidence intervals (CI). They assessed risks of bias and applied GRADE criteria.  MAIN RESULTS: Six trials (61,015 patients) met the inclusion criteria and were included in this review. Four trials were primary prevention (41,695 patients; HOT, JPAD, JPPP, and TPT), and two secondary prevention (19,320 patients, CAPRIE and Huynh). Four trials (HOT, JPAD, JPPP, and TPT) were placebo-controlled and two studies (CAPRIE and Huynh) included active comparators. Four studies compared acetylsalicylic acid (ASA) versus placebo and found no evidence of a difference for all-cause mortality (OR 0.97, 95% CI 0.87 to 1.08; 3 studies, 35,794 participants; low-certainty evidence). We found no evidence of a difference for cardiovascular mortality (OR 0.98, 95% CI 0.82 to 1.17; 3 studies, 35,794 participants; low-certainty evidence). ASA reduced the risk of all non-fatal cardiovascular events (OR 0.63, 95% CI 0.45 to 0.87; 1 study (missing data in 3 studies), 2540 participants; low-certainty evidence) and the risk of all cardiovascular events (OR 0.86, 95% CI 0.77 to 0.96; 3 studies, 35,794 participants; low-certainty evidence). ASA increased the risk of major bleeding events (OR 1.77, 95% CI 1.34 to 2.32; 2 studies, 21,330 participants; high-certainty evidence). One study (CAPRIE; ASA versus clopidogrel) included patients diagnosed with hypertension (mean age 62.5 years, 72% males, 95% Caucasians, mean follow-up: 1.91 years). It showed no evidence of a difference for all-cause mortality (OR 1.02, 95% CI 0.91 to 1.15; 1 study, 19,143 participants; high-certainty evidence) and for cardiovascular mortality (OR 1.08, 95% CI 0.94 to 1.26; 1 study, 19,143 participants; high-certainty evidence). ASA probably reduced the risk of non-fatal cardiovascular events (OR 1.10, 95% CI 1.00 to 1.22; 1 study, 19,143 participants; high-certainty evidence) and the risk of all cardiovascular events (OR 1.08, 95% CI 1.00 to 1.17; 1 study, 19,143 participants; high-certainty evidence) when compared to clopidogrel. Clopidogrel increased the risk of major bleeding events when compared to ASA (OR 1.35, 95% CI 1.14 to 1.61; 1 study, 19,143 participants; high-certainty evidence). In one study (Huynh; ASA verus warfarin) patients with unstable angina or non-ST-segment elevation myocardial infarction, with prior coronary artery bypass grafting (CABG) were included (mean age 68 years, 79.8% males, mean follow-up: 1.1 year). There was no evidence of a difference for all-cause mortality (OR 0.98, 95% CI 0.06 to 16.12; 1 study, 91 participants; low-certainty evidence). Cardiovascular mortality, non-fatal cardiovascular events, and all cardiovascular events were not available. There was no evidence of a difference for major bleeding events (OR 0.13, 95% CI 0.01 to 2.60; 1 study, 91 participants; low-certainty evidence).  AUTHORS' CONCLUSIONS: There is no evidence that antiplatelet therapy modifies mortality in patients with elevated BP for primary prevention. ASA reduced the risk of cardiovascular events and increased the risk of major bleeding events.  Antiplatelet therapy with ASA probably reduces the risk of non-fatal and all cardiovascular events when compared to clopidogrel. Clopidogrel increases the risk of major bleeding events compared to ASA in patients with elevated BP for secondary prevention.  There is no evidence that warfarin modifies mortality in patients with elevated BP for secondary prevention.  The benefits and harms of the newer drugs glycoprotein IIb/IIIa inhibitors, clopidogrel, prasugrel, ticagrelor, and non-vitamin K antagonist oral anticoagulants for patients with high BP have not been studied in clinical trials. Further RCTs of antithrombotic therapy including newer agents and complete documentation of all benefits and harms are required in patients with elevated BP.

Machine learning predicts clinically significant health related quality of life improvement after sensorimotor rehabilitation interventions in chronic stroke

Health related quality of life (HRQOL) reflects individuals perceived of wellness in health domains and is often deteriorated after stroke. Precise prediction of HRQOL changes after rehabilitation interventions is critical for optimizing stroke rehabilitation efficiency and efficacy. Machine learning (ML) has become a promising outcome prediction approach because of its high accuracy and easiness to use. Incorporating ML models into rehabilitation practice may facilitate efficient and accurate clinical decision making. Therefore, this study aimed to determine if ML algorithms could accurately predict clinically significant HRQOL improvements after stroke sensorimotor rehabilitation interventions and identify important predictors. Five ML algorithms including the random forest (RF), k-nearest neighbors (KNN), artificial neural network, support vector machine and logistic regression were used. Datasets from 132 people with chronic stroke were included. The Stroke Impact Scale was used for assessing multi-dimensional and global self-perceived HRQOL. Potential predictors included personal characteristics and baseline cognitive/motor/sensory/functional/HRQOL attributes. Data were divided into training and test sets. Tenfold cross-validation procedure with the training data set was used for developing models. The test set was used for determining model performance. Results revealed that RF was effective at predicting multidimensional HRQOL (accuracy: 85%; area under the receiver operating characteristic curve, AUC-ROC: 0.86) and global perceived recovery (accuracy: 80%; AUC-ROC: 0.75), and KNN was effective at predicting global perceived recovery (accuracy: 82.5%; AUC-ROC: 0.76). Age/gender, baseline HRQOL, wrist/hand muscle function, arm movement efficiency and sensory function were identified as crucial predictors. Our study indicated that RF and KNN outperformed the other three models on predicting HRQOL recovery after sensorimotor rehabilitation in stroke patients and could be considered for future clinical application.

Walking and Activeness: The First Step toward the Prevention of Strokes and Mental Illness

Physical activity, especially routine walking, is an imperative factor for the prevention of strokes, mental illness, and cardiovascular diseases (CVDs). The NIH (National Institute of Health) has also acknowledged walking as the most important factor of the stroke rehabilitation program. Many research studies are presented by physicians and researchers in the literature that highlight the positive impacts of walking on human health (physical and mental). This paper has the objective of studying the impact of regular walking, especially on mental illness, CVDs, and strokes. The C-reactive protein (CRP), P-selectin protein, and homocysteine biomarkers are considered to decide the improvement in the health of an individual with respect to CVDs and strokes. The other parameters considered for the recommendations of physicians and healthcare experts for mental health are PSS (perceived stress score) and ESS (Epworth sleepiness score) that control mental illness. The values are measured for the participating subjects before participating in the walking activity and after the end of the walking schedule to see the impact on individuals. The overall mental and physical health of an individual contributes to the chances of occurrence of CVDs, mental illness, and strokes in individuals aged between 40 years and 55 years, as per the study presented in this paper. The results show that the PSS and ESS scores are improved after the walking activity. Eventually, it improved recovery from many kinds of mental illness and also reduced the chances of strokes. Similarly, the levels of the biomarkers that determine the chances of an individual having CVD or stroke also improved. Walking can impact our overall health in many ways, however, in this paper, the focus is given to ailments, such as strokes, CVDs, and mental illness. The results show that stress and improper sleepiness can impact mental health negatively. The research outcome is measured by adding walking in a routine life so that every individual can get rid of many physical and mental ailments. The results presented in the paper reveal that the 90-day walking program has created a good impact on the health of individuals by improving their physical and mental health.

Is High-Intensity Interval Training Suitable to Promote Neuroplasticity and Cognitive Functions after Stroke?

Stroke-induced cognitive impairments affect the long-term quality of life. High-intensity interval training (HIIT) is now considered a promising strategy to enhance cognitive functions. This review is designed to examine the role of HIIT in promoting neuroplasticity processes and/or cognitive functions after stroke. The various methodological limitations related to the clinical relevance of studies on the exercise recommendations in individuals with stroke are first discussed. Then, the relevance of HIIT in improving neurotrophic factors expression, neurogenesis and synaptic plasticity is debated in both stroke and healthy individuals (humans and rodents). Moreover, HIIT may have a preventive role on stroke severity, as found in rodents. The potential role of HIIT in stroke rehabilitation is reinforced by findings showing its powerful neurogenic effect that might potentiate cognitive benefits induced by cognitive tasks. In addition, the clinical role of neuroplasticity observed in each hemisphere needs to be clarified by coupling more frequently to cellular/molecular measurements and behavioral testing.

Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial

Background

Our group developed a rehabilitation robot to assist with repetitive, active reaching movement of a paretic upper extremity. The robot is equipped with a servo motor-controlled arm-weight support and works in conjunction with neuromuscular electrical stimulation and vibratory stimulation to facilitate agonist-muscle contraction. In this before-and-after pilot study, we assessed the feasibility of applying the robot to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.

Methods

We enrolled 6 patients with chronic stroke and hemiparesis who, while sitting and without assistance, could reach 10 cm both sagitally and vertically (from a starting position located 10 cm forward from the patient’s navel level) with the affected upper extremity. The patients were assigned to receive reaching exercise intervention with the robot (Yaskawa Electric Co., Ltd. Fukuoka, Japan) for 2 weeks at 15 min/day in addition to regular occupational therapy for 40 min/day. Outcomes assessed before and after 2 weeks of intervention included the upper extremity component of the Fugl-Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and, during reaching movement, kinematic analysis.

Results

None of the patients experienced adverse events. The mean score of UE-FMA increased from 44.8 [SD 14.4] to 48.0 [SD 14.4] (p = 0.026, r = 0.91), and both the shoulder–elbow and wrist–hand scores increased after 2-week intervention. An increase was also observed in ARAT score, from mean 29.8 [SD 16.3] to 36.2 [SD 18.1] (p = 0.042, r = 0.83). Kinematic analysis during the reaching movement revealed a significant increase in active range of motion (AROM) at the elbow, and movement time tended to decrease. Furthermore, trajectory length for the wrist (“hand path”) and the acromion (“trunk compensatory movement”) showed a decreasing trend.

Conclusions

This robot-assisted modality is feasible and our preliminary findings suggest it improved motor control and motor function of the hemiparetic upper extremity in patients with chronic stroke. Training with this robot might induce greater AROM for the elbow and decrease compensatory trunk movement, thus contributing to movement efficacy and efficiency.

Trial registration UMIN Clinical Trial Registry, as UMIN000018132, on June 30, 2015. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000020398

An Age-Period-Cohort Analysis of Stroke Mortality Attributable to Low Physical Activity in China and Japan: Data from the GBD Study 1990-2016

Stroke is the first and fourth leading cause of death in China and Japan, respectively. Physical inactivity was suggested to be one of the most important risk factors for stroke mortality. Therefore, this study aimed to assess long-term trends in stroke mortality attributable to low physical activity (LPA) in China and Japan during the period 1990–2016. Mortality data were obtained from the Global Burden of Disease Study 2016 (GBD 2016) and were analyzed with an age-period-cohort method. The age-standardized mortality rates (ASMRs) showed declining trends for LPA-attributable stroke mortality. The overall net drift per year was −1.3% for Chinese men, −2.9% for Chinese women, −3.9% for Japanese men, and −5.6% for Japanese women. In both countries, the local drift values were below zero in all age groups. The longitudinal age curves of LPA-attributable stroke mortality were higher in men than in women in all age groups. The period and cohort rate ratios showed similar downward patterns for both sexes, with a faster decline for women than for men. However, the physically active population is still small in both countries. Therefore, policymakers should further promote physical activity as one of the most recommended effective strategies in stroke prevention.

Eight-Section Brocade Exercises Improve the Sleep Quality and Memory Consolidation and Cardiopulmonary Function of Older Adults With Atrial Fibrillation-Associated Stroke

Purpose: Poor sleep quality is harmful for everyone and potentially even more harmful for older adults with atrial fibrillation-associated stroke (AFAS). This study aims to explore the effects of eight-section brocade (ESB) on sleep quality, memory, and cardiopulmonary function in the older adults with AFAS. Methods: Older adults with AFAS and sleep disorders were recruited and divided into the ESB (EG, n = 85) and control groups (CG, general exercise, n = 85). EG patients received 60 min ESB exercises 5 times a week for 12 weeks; CG patients received normal exercise. Pittsburgh sleep quality index (PSQI) scores (poor sleepers ≥8 and normal sleepers < 8), memory for word pairs (poor memory ≤ 7 and normal memory > 7), left ventricular posterior wall (LVPW) thickness, and maximum ventilation (MV, to evaluate cardiopulmonary function) values were measured. The correlation between sleep and memory quality was analyzed using PSQI scores and word pairs via the Pearson correlation coefficients test. Adjusted Cox models were used to explore an interaction between PSQI and ESB exercise. Results: After 12-week exercise intervention, ESB improved sleep quality, latency, duration, disturbance and daytime dysfunction when compared to conventional exercise. In similar cases, the MV values in the EG were also higher than that in the CG (p = 0.009). ESB intervention could not affect the cardiac structure and left ventricular ejection fraction. Compared with the CG, the ESB intervention reduced PSQI scores and increased memorized word pairs (p < 0.001 for poor and normal sleepers in both unadjusted and adjusted analysis, p = 0.012 and 0.003 for poor and normal memory). The test of Pearson correlation coefficients showed that PSQI scores were strongly associated with the number of word pairs in both unadjusted and adjusted analyses (p < 0.0001). Conclusion: Eight-section brocade exercise improved sleep quality and memory consolidation and cardiopulmonary function by reducing PSQI scores, increasing word pairs and MV values in the older adults with AFAS.

Relationship between Circadian Variation in Ictus of Aneurysmal Subarachnoid Hemorrhage and Physical Activity

OBJECTIVE

The circadian pattern of the onset time of aneurysmal subarachnoid hemorrhage (aSAH) has been reported by various authors. However, the effect of the degree of physical exertion on the circadian pattern has not been studied in detail. Therefore, we conducted this study to investigate the effect of physical exertion on the circadian pattern of aSAH.

METHODS

Of the 335 patients presenting with aSAH from January 2012 to December 2017, 234 patients with identifiable onset time and metabolic equivalent (MET) values were enrolled. The onset time of aSAH was divided into 4-hour intervals. The patient's physical exertion was then assessed on a scale between 1 and 8 METs using generally accepted MET values, and categorized into two groups-light exertion (1 to 4 METs) and moderate to heavy exertion (5 to 8 METs)-to determine the effect of the degree of physical exertion on the onset time distribution of aSAH. Multivariate analysis was used to calculate the odds ratio (OR) between the two groups to determine the effect of the degree of physical exertion on each set of time periods.

RESULTS

There was a definite bimodal onset pattern that peaked at 08:00-12:00 hours followed by 16:00-20:00 hours (p <0.001). MET values at all time intervals were found to be significantly higher than the night time (00:00-04:00 hours) values (p<0.031). The MET value distribution showed a unimodal pattern that slightly differed from the bimodal distribution of the onset time of aSAH. There were no significant differences in the ORs of each time interval according to the degree of the MET value.

CONCLUSION

This study reaffirmed that aSAH occurs in a bimodal pattern, especially showing the highest prevalence in the morning. Although aSAH could be related to daily activity, there were no significant changes in diurnal variations affected by the degree of physical exertion.

Promoting Physical Activity in a Primary Care Practice: Overcoming the Barriers

Along with proper diet and avoidance of tobacco use, physical activity is extremely important to maintain and improve overall health of the individual and population. Despite evidence for the cost-effectiveness of physical activity counseling in primary care, only one-third of patients report that they received physical activity counseling by their primary care physician (PCP). Both PCPs and patients face numerous barriers to addressing insufficient physical activity. To assist patients in overcoming their barriers to regular physical activity, the PCP should assess and address the patient's specific barriers to physical activity and counsel patients about the most common general barriers, such as lack of time, knowledge, and motivation. Numerous benefits and barriers are present, and the PCP should understand them and use the information to better counsel patients regarding the benefit of and need for regular physical activity. Brief counseling is an efficient, effective, and cost-effective means to increase physical activity and to bring considerable clinical benefits to various patient populations.

Current advances in ischemic stroke research and therapies

With more than 795,000 cases occurring every year, stroke has become a major problem in the United States across all demographics. Stroke is the leading cause of long-term disability and is the fifth leading cause of death in the US. Ischemic stroke represents 87% of total strokes in the US, and is currently the main focus of stroke research. This literature review examines the risk factors associated with ischemic stroke, changes in cell morphology and signaling in the brain after stroke, and the advantages and disadvantages of in vivo and in vitro ischemic stroke models. Classification systems for stroke etiology are also discussed briefly, as well as current ischemic stroke therapies and new therapeutic strategies that focus on the potential of stem cells to promote stroke recovery.

Exercise for stroke prevention

We review evidence concerning exercise for stroke prevention. Plausible biological reasons suggest that exercise would be important in preventing stroke. While definitive randomised controlled trials evaluating the impact of physical activity (PA) and exercise on preventing stroke and mortality are lacking, observational studies, small randomised controlled trials and meta-analyses have provided evidence that PA and exercise favourably modify stroke risk factors, including hypertension, dyslipidaemia, diabetes, sedentary lifestyle, obesity, excessive alcohol consumption and tobacco use. It is, therefore, important to understand the factors associated with poststroke PA/exercise and cardiorespiratory fitness. Positively associated factors include self-efficacy, social support and quality of patients' relationships with health professionals. Negatively associated factors include logistical barriers, medical comorbidities, stroke-related deficits, negative exercise beliefs, fear of falling, poststroke fatigue, arthropathy/pain and depression. Definitive research is needed to specify efficacious behavioural approaches to increase poststroke exercise. Effective techniques probably include physician endorsement of exercise programmesto patients, enhancement of patient-professional relationships, providing patients an exercise rationale, motivational interviewing, collaborative goal-setting with patients, addressing logistical concerns, social support in programsmes, structured exercise programming, individualised behavioural instruction, behavioural diary recording, reviewing behavioural consequences of exercise efforts, reinforcing successful exercise performance. Exercise programming without counselling may increase short-term activity; simple advice or information-giving is probably ineffective. Older patients or those with cognitive impairment may need increased structure, with emphasis on behaviour per se, versus self-regulation skills. We support the latest American Heart Association/American Stroke Association guidelines (2014) recommending PA and exercise for stroke prevention, and referral to behaviourally oriented programmes to improve PA and exercise.

Estimated effects of air pollution and space-time-activity on cardiopulmonary outcomes in healthy adults: A repeated measures study

BACKGROUND

Exposure to air pollution is known to affect both short and long-term outcomes of the cardiopulmonary system; however, findings on short-term outcomes have been inconsistent and often from isolated and long-term rather than coexisting and short-term exposures, and among susceptible/unhealthy rather than healthy populations.

AIMS

We aimed to investigate separately the annual, daily and daily space-time-activity-weighted effect of ambient air pollution, as well as confounding or modification by other environmental (including noise) or space-time-activity (including total daily physical activity) exposures, on cardiopulmonary outcomes in healthy adults.

METHODS

Participants (N=57: 54% female) had indicators of cardiopulmonary outcomes [blood pressure (BP), pulse (HR) and heart rate variability (HRV {SDNN}), and lung function (spirometry {FEV₁, FVC, SUM})] measured on four different mornings (at least five days apart) in a clinical setting between 2011 and 2014. Spatiotemporal ESCAPE-LUR models were used to estimate daily and annual air pollution exposures (including PM₁₀, PM_Coarse, but not Ozone {derived from closest station}) at participant residential and occupational addresses. Participants' time-activity diaries indicated time spent at either address to allow daily space-time-activity-weighted estimates, and capture total daily physical activity (total-PA {as metabolic-equivalents-of-task, METs}), in the three days preceding health measurements. Multivariate-adjusted linear mixed-effects models (using either annual or daily estimates) were adjusted for possible environmental confounders or mediators including levels of ambient noise and greenness. Causal mediation analysis was also performed separately considering these factors as well as total-PA. All presented models are controlled by age, height, sex and season.

RESULTS

An increase in 5μg/m³ of daily space-time-activity-weighted PM_Coarse exposure was statistically significantly associated with a 4.1% reduction in total heart rate variability (SDNN; p=0.01), and remained robust after adjusting for suspected confounders [except for occupational-address noise (β=-2.7, p=0.20)]. An increase in 10ppb of annual mean Ozone concentration at the residential address was statistically significantly associated with an increase in diastolic BP of 6.4mmHg (p<0.01), which lost statistical significance when substituted with daily space-time-activity-weighted estimates. As for pulmonary function, an increase in 10μg/m³ of annual mean PM₁₀ concentration at the residential address was significantly associated with a 0.3% reduction in FVC (p<0.01) and a 0.5% reduction in SUM (p<0.04), for which again significance was lost when substituted for daily space-time-activity-weighted estimates These associations with pulmonary function remained robust after adjusting for suspected confounders, including annual Ozone, as well as total-PA and bioaerosol (pollen and fungal spore) levels (but not residential-neighborhood greenness {β=-0.22, p=0.09; β=-0.34, p=0.15, respectively}). Multilevel mediation analysis indicated that the proportion mediated as a direct effect on cardiopulmonary outcomes by suspected confounders (including total-PA, residential-neighborhood greenness, and occupational-address noise level) from primary exposures (including PM₁₀, PM_Coarse, and O₃) was not statistically significant.

CONCLUSION

Our findings suggest that increased daily space-time-activity-weighted PM_Coarse exposure levels significantly adversely affect cardiac autonomic modulation (as reduced total HRV) among healthy adults. Additionally, increased annual levels at the residential address of Ozone and PM₁₀ significantly increase diastolic blood pressure and reduce lung function, respectively, among healthy adults. These associations typically remained robust when adjusting for suspected confounders. Occupational-address noise and residential-neighborhood greenness levels, however, were seen as mediators of cardiovascular and pulmonary outcomes, respectively. Total daily physical activity was not seen as a mediator of any of the studied outcomes, which supports the promotion of active mobility within cities.

Comparison of proximal versus distal upper-limb robotic rehabilitation on motor performance after stroke: a cluster controlled trial

This study examined the treatment efficacy of proximal-emphasized robotic rehabilitation by using the InMotion ARM (P-IMT) versus distal-emphasized robotic rehabilitation by using the InMotion WRIST (D-IMT) in patients with stroke. A total of 40 patients with stroke completed the study. They received P-IMT, D-IMT, or control treatment (CT) for 20 training sessions. Primary outcomes were the Fugl-Meyer Assessment (FMA) and Medical Research Council (MRC) scale. Secondary outcomes were the Motor Activity Log (MAL) and wrist-worn accelerometers. The differences on the distal FMA, total MRC, distal MRC, and MAL quality of movement scores among the 3 groups were statistically significant (P = 0.02 to 0.05). Post hoc comparisons revealed that the D-IMT group significantly improved more than the P-IMT group on the total MRC and distal MRC. Furthermore, the distal FMA and distal MRC improved more in the D-IMT group than in the CT group. Our findings suggest that distal upper-limb robotic rehabilitation using the InMotion WRIST system had superior effects on distal muscle strength. Further research based on a larger sample is needed to confirm long-term treatment effects of proximal versus distal upper-limb robotic rehabilitation.

Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration

BACKGROUND

There is inconclusive evidence from observational studies to suggest that people who eat a diet rich in antioxidant vitamins (carotenoids, vitamins C, and E) or minerals (selenium and zinc) may be less likely to develop age-related macular degeneration (AMD).

OBJECTIVES

To determine whether or not taking antioxidant vitamin or mineral supplements, or both, prevent the development of AMD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 2), MEDLINE Ovid (1946 to 29 March 2017), Embase Ovid (1947 to 29 March 2017), AMED (Allied and Complementary Medicine Database) (1985 to 29 March 2017), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/); searched 29 March 2017, the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 29 March 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 29 March 2017 and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 29 March 2017. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing an antioxidant vitamin or mineral supplement (alone or in combination) to control.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed risk of bias in the included studies and extracted data. One author entered data into RevMan 5; the other author checked the data entry. We pooled data using a fixed-effect model. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included a total of five RCTs in this review with data available for 76,756 people. The trials were conducted in Australia, Finland, and the USA, and investigated vitamin C, vitamin E, beta-carotene, and multivitamin supplements. All trials were judged to be at low risk of bias.Four studies reported the comparison of vitamin E with placebo. Average treatment and follow-up duration ranged from 4 to 10 years. Data were available for a total of 55,614 participants. There was evidence that vitamin E supplements do not prevent the development of any AMD (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.06; high-certainty evidence), and may slightly increase the risk of late AMD (RR 1.22, 95% CI 0.89 to 1.67; moderate-certainty evidence) compared with placebo. Only one study (941 participants) reported data separately for neovascular AMD and geographic atrophy. There were 10 cases of neovascular AMD (RR 3.62, 95% CI 0.77 to 16.95; very low-certainty evidence), and four cases of geographic atrophy (RR 2.71, 95% CI 0.28 to 26.0; very low-certainty evidence). Two trials reported similar numbers of adverse events in the vitamin E and placebo groups. Another trial reported excess of haemorrhagic strokes in the vitamin E group (39 versus 23 events, hazard ratio 1.74, 95% CI 1.04 to 2.91, low-certainty evidence).Two studies reported the comparison of beta-carotene with placebo. These studies took place in Finland and the USA. Both trials enrolled men only. Average treatment and follow-up duration was 6 years and 12 years. Data were available for a total of 22,083 participants. There was evidence that beta-carotene supplements did not prevent any AMD (RR 1.00, 95% CI 0.88 to 1.14; high-certainty evidence) nor have an important effect on late AMD (RR 0.90, 95% CI 0.65 to 1.24; moderate-certainty evidence). Only one study (941 participants) reported data separately for neovascular AMD and geographic atrophy. There were 10 cases of neovascular AMD (RR 0.61, 95% CI 0.17 to 2.15; very low-certainty evidence) and 4 cases of geographic atrophy (RR 0.31 95% CI 0.03 to 2.93; very low-certainty evidence). Beta-carotene was associated with increased risk of lung cancer in people who smoked.One study reported the comparison of vitamin C with placebo, and multivitamin (Centrum Silver) versus placebo. This was a study in men in the USA with average treatment duration and follow-up of 8 years for vitamin C and 11 years for multivitamin. Data were available for a total of 14,236 participants. AMD was assessed by self-report followed by medical record review. There was evidence that vitamin C supplementation did not prevent any AMD (RR 0.96, 95% CI 0.79 to 1.18; high-certainty evidence) or late AMD (RR 0.94, 0.61 to 1.46; moderate-certainty evidence). There was a slight increased risk of any AMD (RR 1.21, 95% CI 1.02 to 1.43; moderate-certainty evidence) and late AMD (RR 1.22, 95% CI 0.88 to 1.69; moderate-certainty evidence) in the multivitamin group. Neovascular AMD and geographic atrophy were not reported separately. Adverse effects were not reported but there was possible increased risk of skin rashes in the multivitamin group.Adverse effects were not consistently reported in these eye studies, but there is evidence from other large studies that beta-carotene increases the risk of lung cancer in people who smoke or who have been exposed to asbestos.None of the studies reported quality of life or resource use and costs.

AUTHORS' CONCLUSIONS

Taking vitamin E or beta-carotene supplements will not prevent or delay the onset of AMD. The same probably applies to vitamin C and the multivitamin (Centrum Silver) investigated in the one trial reported to date. There is no evidence with respect to other antioxidant supplements, such as lutein and zeaxanthin. Although generally regarded as safe, vitamin supplements may have harmful effects, and clear evidence of benefit is needed before they can be recommended. People with AMD should see the related Cochrane Review on antioxidant vitamin and mineral supplements for slowing the progression of AMD, written by the same review team.

How to design clinical rehabilitation trials for the upper paretic limb early post stroke?

BACKGROUND

The impact of spontaneous neurobiological recovery is still neglected in designing rehabilitation trials early post stroke. We aimed to investigate the impact of the timing of randomization and prognostic stratification on the required sample sizes that are needed to reveal significant intervention effects on upper limb function at 26 weeks after first-ever ischemic stroke.

METHOD

Sample size calculations were based on a cohort study of 159 patients, using the Fugl-Meyer Assessment Upper Extremity and Action Research Arm Test as outcome measures (power = 80 %; two-tailed alpha = 0.05). We investigated different scenarios: random sampling of patients within five time intervals (stroke onset to 1, 3, 5, 8 and 12 weeks post stroke), and within stratified groups according to the presence or absence of voluntary extension of the thumb and/or two or more fingers at intake.

RESULTS

The heterogeneity between outcome scores of patients, and subsequently the required sample sizes, increased from the first to the fifth time interval. Compared to the whole group, the sample sizes for both stratified groups (i.e., patients with and without Voluntary Finger Extension (VFE)) were lower. The required sample sizes for the patient group without VFE markedly increased when the time interval was broadened from 1 to 12 weeks post stroke, as opposed to the decrease seen for the group of patients with VFE.

CONCLUSION

These results are fundamental for designing upper limb trials early post stroke. To prevent type II error, future upper limb trials should randomize patients at a fixed moment early post stroke and stratify patients according to their potential neurobiological recovery.

TRIAL REGISTRATION

Netherlands Trial Registry, www.trialregister.nl , NTR1424 , registered on 27 August 2008.

Secondary Prevention of Ischemic Cerebrovascular Disease. What Is the Evidence?

Patients who had a transient ischemic attack or stroke are at increased risk of experiencing recurrent cerebrovascular events. For this reason, secondary prevention of ischemic cerebrovascular disease is essential. Several modifiable, lifestyle-associated risk factors have been implicated, such as physical activity, smoking, and alcohol consumption. Established and emerging vascular risk factors are associated with an increased risk of stroke. Pharmacologic treatment, including the use of antiplatelet, antihypertensive, and lipid-lowering agents, has also been shown to reduce the risk of secondary cerebrovascular events. Surgical intervention, either open or endovascular, may be the preferred therapeutic option in well-defined subsets of patients. It is important to establish specific measures for the early detection and prevention of recurrent cerebrovascular disease. Therefore, further research and greater awareness in this field are needed.

Risk-factor profile for the incidence of subarachnoid and intracerebral haemorrhage, cerebral infarction, and unspecified stroke during 21 years' follow-up in men

Aims: To study the risk-factor profile for the incidence of non-fatal and fatal stroke among middle-aged men according to the stroke subtypes subarachnoid or intracerebral haemorrhage, cerebral infarction, and unspecified stroke. Methods: The study design is a prospective cohort study. A total of 16,209 men aged 40—49 years resident in Oslo were screened for cardiovascular disease risk factors in 1972—73. Of these, 14,403 men had no cardiovascular symptoms or diseases or diabetes. The incidence of stroke after 21 years of follow-up of all men was extracted from hospital records and linkage to Statistics Norway. Results: A total of 429 non-fatal and 107 fatal stroke events were registered. Case fatality within 28 days (number and percentage of cases) was 51% (41, 7.7%) for subarachnoid haemorrhage, 39% (67, 12.6%) for cerebral haemorrhage, 10% (246, 46.3%) for cerebral infarct, and 19% (177, 33.4%) for unspecified stroke. Risk of stroke (not subarachnoid haemorrhage) increased with the presence of symptoms or a history of cardiovascular disease or diabetes. In multivariate analysis of men without CVD or diabetes, high blood pressure was a risk factor for all subtypes of stroke; furthermore, daily smoking was a risk factor for all subtypes except subarachnoid haemorrhage. Serum cholesterol and glucose concentrations and height (inverse association) were independently associated with cerebral infarction. Smoking was a significantly stronger predictor of fatal than non-fatal events. Conclusions: The risk-factor profile differed according to the underlying subtype of stroke. Cerebral infarction clearly shared with myocardial infarction the classical risk factors, including non-fasting glucose concentration.

Social Cognitive Theory in Diabetes Exercise Research: An Integrative Literature Review

PURPOSE

This integrative review critically examined the literature on diabetes research using Social Cognitive Theory (SCT) to determine its predictive ability in explaining exercise behavior and to identify key interventions that enhance exercise initiation and maintenance.

METHODS

Literature published between 1985 and 2002 was searched using the following keywords: SCT, self-efficacy, diabetes mellitus, non-insulin-dependent diabetes mellitus, insulin-dependent diabetes mellitus, physical activity, and exercise. The databases searched were CINAHL, Medline, and PsychInfo. Of the 38 articles retrieved from databases, 13 were reviewed.

RESULTS

A statistically significant relationship between self-efficacy and exercise behavior was found in correlational studies. Results from the predictive study support the predictability of self-efficacy for exercise behavior. Mixed results were found for the predictive ability of outcome expectancies for exercise behavior. Self-efficacy was predictive of exercise initiation and maintenance over time. The evidence for successful interventions to increase self-efficacy and exercise behavior over time was inconclusive.

CONCLUSIONS

To better understand exercise behavior and to develop effective exercise interventions, a microanalytic, theory-driven approach to studying exercise behavior is needed. Several suggestions are offered to strengthen exercise self-efficacy.

Obtaining Accelerometer Data in a National Cohort of Black and White Adults

PURPOSE

The objective of this study is to report methodological details and feasibility of conducting an accelerometer ancillary study in a large US cohort being followed for stroke and cognitive decline.

METHODS

Reasons for Geographic and Racial Differences in Stroke is a national population-based study of 30,239 blacks and whites, age ≥45 yr, enrolled January 2003 to October 2007. Baseline evaluations were conducted through computer-assisted telephone interview and an in-home visit. Participants are followed by computer-assisted telephone interview every 6 months. Starting with May 2009 follow-up, contingent on accelerometer availability, participants were invited to wear an accelerometer for 7 d. Device inventory was 1150. Accelerometer, instructions, log sheet, and stamped addressed return envelope were mailed to consenting participants. Postcard acknowledgement and reminders and two calls or less were made to encourage compliance.

RESULTS

Between May 2009 and January 2013, 20,076 were invited to participate; 12,146 (60.5%) consented. Participation rates by race-sex groups were similar: black women, 58.6%; black men, 59.6%; white women, 62.3%; and white men, 60.5%. The mean age of the 12,146 participants to whom devices were shipped was 63.5 ± 8.7 yr. Return rate was 92%. Of 11,174 returned, 1187 were not worn and 14 had device malfunction, and of 9973 with data, 8096 (81.2%) provided usable data, defined as ≥4 d of 10+ h of wear time, ranging from 74.4% among black women to 85.2% among white men.

CONCLUSIONS

Using mail and telephone methods, it is feasible to obtain objective measures of physical activity from a sizeable proportion of a national cohort of adults, with similar participation rates among blacks and whites. Linked with the clinical health information collected through follow-up, these data will allow future analyses on the association between objectively measured sedentary time, physical activity, and health outcomes.

Exercise Modulates Oxidative Stress and Inflammation in Aging and Cardiovascular Diseases

Despite the wealth of epidemiological and experimental studies indicating the protective role of regular physical activity/exercise training against the sequels of aging and cardiovascular diseases, the molecular transducers of exercise/physical activity benefits are not fully identified but should be further investigated in more integrative and innovative approaches, as they bear the potential for transformative discoveries of novel therapeutic targets. As aging and cardiovascular diseases are associated with a chronic state of oxidative stress and inflammation mediated via complex and interconnected pathways, we will focus in this review on the antioxidant and anti-inflammatory actions of exercise, mainly exerted on adipose tissue, skeletal muscles, immune system, and cardiovascular system by modulating anti-inflammatory/proinflammatory cytokines profile, redox-sensitive transcription factors such as nuclear factor kappa B, activator protein-1, and peroxisome proliferator-activated receptor gamma coactivator 1-alpha, antioxidant and prooxidant enzymes, and repair proteins such as heat shock proteins, proteasome complex, oxoguanine DNA glycosylase, uracil DNA glycosylase, and telomerase. It is important to note that the effects of exercise vary depending on the type, intensity, frequency, and duration of exercise as well as on the individual's characteristics; therefore, the development of personalized exercise programs is essential.

Secondhand Smoke Exposure and Stroke: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

INTRODUCTION

Stroke is a major public health concern worldwide given the associated morbidity and mortality. Smoking is a risk factor for stroke, but the relationship between secondhand smoke (SHS) exposure and stroke has been inconsistent to date. The aim of the current study was to examine the association of SHS exposure and risk of stroke and its subtypes (ischemic and hemorrhagic stroke) among nonsmokers.

METHODS

Demographic and clinical characteristics were compared by SHS exposure status for African American and white nonsmokers aged ≥45 years in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study in 2014. Hazard ratios (HRs) and corresponding 95% CIs were calculated by Cox proportional hazards models to assess the relationship between SHS exposure and stroke risk.

RESULTS

Of the 21,743 participants (38% African American, 45% male), SHS exposure in the past year was reported by 23%. Compared with those without SHS exposure, exposed participants were more likely to be female, white, younger, and reside with a smoker (all p<0.001). A total of 428 incident strokes were observed from April 2003 to March 2012 during a mean follow-up of 5.6 years. The risk of overall stroke was increased 30% among those with SHS exposure after adjustment for other stroke risk factors (95% CI=2%, 67%). This relationship appeared to be driven by ischemic strokes.

CONCLUSIONS

SHS exposure is independently associated with an increased risk of stroke. Future studies are needed to confirm these findings and examine the role of long-term effects of SHS exposure on stroke outcomes.

Physical Exercise as a Diagnostic, Rehabilitation, and Preventive Tool: Influence on Neuroplasticity and Motor Recovery after Stroke

Stroke remains a leading cause of adult motor disabilities in the world and accounts for the greatest number of hospitalizations for neurological disease. Stroke treatments/therapies need to promote neuroplasticity to improve motor function. Physical exercise is considered as a major candidate for ultimately promoting neural plasticity and could be used for different purposes in human and animal experiments. First, acute exercise could be used as a diagnostic tool to understand new neural mechanisms underlying stroke physiopathology. Indeed, better knowledge of stroke mechanisms that affect movements is crucial for enhancing treatment/rehabilitation effectiveness. Secondly, it is well established that physical exercise training is advised as an effective rehabilitation tool. Indeed, it reduces inflammatory processes and apoptotic marker expression, promotes brain angiogenesis and expression of some growth factors, and improves the activation of affected muscles during exercise. Nevertheless, exercise training might also aggravate sensorimotor deficits and brain injury depending on the chosen exercise parameters. For the last few years, physical training has been combined with pharmacological treatments to accentuate and/or accelerate beneficial neural and motor effects. Finally, physical exercise might also be considered as a major nonpharmacological preventive strategy that provides neuroprotective effects reducing adverse effects of brain ischemia. Therefore, prestroke regular physical activity may also decrease the motor outcome severity of stroke.

Vigorous exercise training improves reactivity of cerebral arterioles and reduces brain injury following transient focal ischemia

OBJECTIVE

Our objective was to examine whether vigorous exercise training (VExT) could influence nitric oxide synthase (NOS)-dependent vasodilation and transient focal ischemia-induced brain injury. Rats were divided into sedentary (SED) or VExT groups.

MATERIALS AND METHODS

Exercise was carried out 5 days/week for a period of 8-10 weeks. First, we measured responses of pial arterioles to an eNOS-dependent (ADP), an nNOS-dependent (NMDA) and a NOS-independent (nitroglycerin) agonist in SED and VExT rats. Second, we measured infarct volume in SED and VExT rats following middle cerebral artery occlusion (MCAO). Third, we measured superoxide levels in brain tissue of SED and VExT rats under basal and stimulated conditions.

RESULTS

We found that eNOS- and nNOS-dependent, but not NOS-independent vasodilation, was increased in VExT compared to SED rats, and this could be inhibited with L-NMMA in both groups. In addition, we found that VExT reduced infarct volume following MCAO when compared to SED rats. Further, superoxide levels were similar in brain tissue from SED and VExT rats under basal and stimulated conditions.

CONCLUSIONS

We suggest that VExT potentiates NOS-dependent vascular reactivity and reduces infarct volume following MCAO via a mechanism that appears to be independent of oxidative stress, but presumably related to an increase in the contribution of nitric oxide.

Effects of long-term exercise on spatial learning, memory ability, and cortical capillaries in aged rats

Background

This study aimed to determine the effects of long-term running exercise on spatial learning, spatial memory, and cortical capillaries in aged rats.

Material/Methods

Fourteen-month-old female and male Sprague-Dawley rats were randomly divided into an exercised group (EG) and a non-exercised group (NG). The EG rats were trained on treadmill running for 4 or 14 months. The NG rats were housed under identical conditions without running. Spatial learning and memory were assessed with the Morris water maze. The cortical capillary parameters were quantitatively investigated using immunohistochemical and stereological methods.

Results

The escaped latencies of the EG were significantly different from those of the NG in 18-month-old females and 28-month-old males (p<0.05). However, 28-month-old females and 18-month-old males showed no differences in escape latency between the EG and NG (p>0.05). In 28-month-old female rats, stereological techniques showed significant differences between the EG and NG in the cortical capillary volume (median, 22.55 vs. 11.42, p<0.05) and the cortical capillary surface area (median, 7474.13 vs. 3935.90, p<0.05). In 28-month-old male rats, the EG had a significantly longer total cortical capillary length (median, 530.35 vs. 156.27, p<0.05), significantly larger cortical capillary volume (median, 16.47 vs. 3.65, p<0.01), and a significantly larger cortical capillary total surface area (median, 7885.79 vs. 1957.16, p<0.01) compared with the NG group.

Conclusions

These data demonstrate that exercise improved spatial learning, memory capacity and cortical capillaries in aged rats.

Physical activity and risk of bleeding in elderly patients taking anticoagulants

BACKGROUND

Although the possibility of bleeding during anticoagulant treatment may limit patients from taking part in physical activity, the association between physical activity and anticoagulation-related bleeding is uncertain.

OBJECTIVES

To determine whether physical activity is associated with bleeding in elderly patients taking anticoagulants.

PATIENTS/METHODS

In a prospective multicenter cohort study of 988 patients aged ≥ 65 years receiving anticoagulants for venous thromboembolism, we assessed patients' self-reported physical activity level. The primary outcome was the time to a first major bleeding, defined as fatal bleeding, symptomatic bleeding in a critical site, or bleeding causing a fall in hemoglobin or leading to transfusions. The secondary outcome was the time to a first clinically relevant non-major bleeding. We examined the association between physical activity level and time to a first bleeding by using competing risk regression, accounting for death as a competing event. We adjusted for known bleeding risk factors and anticoagulation as a time-varying covariate.

RESULTS

During a mean follow-up of 22 months, patients with a low, moderate, and high physical activity level had an incidence of major bleeding of 11.6, 6.3, and 3.1 events per 100 patient-years and an incidence of clinically relevant non-major bleeding of 14.0, 10.3, and 7.7 events per 100 patient-years, respectively. A high physical activity level was significantly associated with a lower risk of major bleeding (adjusted sub-hazard ratio 0.40, 95% confidence interval 0.22-0.72). There was no association between physical activity and non-major bleeding.

CONCLUSIONS

A high level of physical activity is associated with a decreased risk of major bleeding in elderly patients receiving anticoagulant therapy.

Autophagy suppression by exercise pretreatment and p38 inhibition is neuroprotective in cerebral ischemia

Autophagy is a degradative mechanism for cellular proteins and organelles, but its role in the nervous system is still not clear. In the present study, we found that exercise pretreatment and p38 inhibition had influence on autophagic process after cerebral ischemia, contributing to their neuroprotective effects. We examined the levels of p62 and phosphorylated ERK1/2 as an autophagic marker and cell-survival marker respectively after cerebral ischemic injury. The brain infarction volume after ischemia was measured as well. Both treadmill training pretreatment and p38 inhibition decreased the degradation of p62, promoted the phosphorylation of ERK1/2, and alleviated the brain infarction, indicating that these treatments could provide neuroprotection in cerebral ischemic injury via autophagy suppression.

Exercise pretreatment promotes mitochondrial dynamic protein OPA1 expression after cerebral ischemia in rats

Exercise training is a neuroprotective strategy in cerebral ischemic injury, but the underlying mechanisms are not yet clear. In the present study, we investigated the effects of treadmill exercise pretreatment on the expression of mitochondrial dynamic proteins. We examined the expression of OPA1/DLP1/MFF/Mfn1/Mfn2, which regulatesmitochondrial fusion and fission, and cytochrome C oxidase subunits (COX subunits), which regulatemitochondrial functions, after middle cerebral artery occlusion (MCAO) in rats. T2-weighted magnetic resonance imaging (MRI) was evaluated as indices of brain edema after ischemia as well. Treadmill training pretreatment increased the expression levels of OPA1 and COXII/III/IV and alleviated brain edema, indicating that exercise pretreatment provided neuroprotection in cerebral ischemic injury via the regulation of mitochondrial dynamics and functions.

Neuroprotection against transient cerebral ischemia by exercise pre-conditioning in rats

There is increasing evidence that physical activity is associated with decreased stroke risk and incidence. The purpose of this study was to determine whether increased levels of physical activity could reduce brain damage in rats subjected to transient or permanent middle cerebral artery (MCA) occlusion. Adult male Sprague-Dawley rats (three months old, n=36) exercised on a treadmill, which required repetitive locomotor movement, for 30 min each day for three weeks. Then, using an intraluminal filament, stroke was induced by either 2-h MCA occlusion followed by two days of reperfusion or by MCA occlusion for two days without reperfusion. Brain damage was determined by evaluating neurologic deficits and brain infarction. In rat with transient MCA occlusion, pre-ischemic motor activity significantly (p<0.01) reduced neurologic deficits and infarct volume in the frontoparietal cortex and the dorsolateral striatum. In contrast, the same exercise procedure did not produce neuroprotection in the permanently MCA-occluded stroke. In addition to decreasing stroke risk and incidence, physical activity also reduces brain damage after stroke. Although we cannot completely rule out a neuroprotective effect on ischemic episode, our study suggests that a major neuroprotection is conferred during reperfusion for rats that have undergone exercise pre-conditioning. This exercise-induced endogenous neuroprotection may be an effective strategy to ameliorate ischemia/reperfusion brain injury from stroke.

Physical activity frequency and risk of incident stroke in a national US study of blacks and whites

BACKGROUND AND PURPOSE

Regular physical activity (PA) is an important recommendation for stroke prevention. We compared the associations of self-reported PA with incident stroke in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.

METHODS

REGARDS recruited 30 239 US blacks (42%) and whites, aged ≥45 years with follow-up every 6 months for stroke events. Excluding those with prior stroke, analysis involved 27 348 participants who reported their frequency of moderate to vigorous intensity PA at baseline according to 3 categories: none (physical inactivity), 1 to 3×, and ≥4× per week. Stroke and transient ischemic attack cases were identified during an average of 5.7 years of follow-up. Cox proportional hazards models were constructed to examine whether self-reported PA was associated with risk of incident stroke.

RESULTS

Physical inactivity was reported by 33% of participants and was associated with a hazard ratio of 1.20 (95% confidence intervals, 1.02-1.42; P=0.035). Adjustment for demographic and socioeconomic factors did not affect hazard ratio, but further adjustment for traditional stroke risk factors (diabetes mellitus, hypertension, body mass index, alcohol use, and smoking) partially attenuated this risk (hazard ratio, 1.14 [0.95-1.37]; P=0.17). There was no significant association between PA frequency and risk of stroke by sex groups, although there was a trend toward increased risk for men reporting PA 0 to 3× a week compared with ≥4× a week.

CONCLUSIONS

Self-reported low PA frequency is associated with increased risk of incident stroke. Any effect of PA is likely to be mediated through reducing traditional risk factors.

Association of physical activity level and stroke outcomes in men and women: a meta-analysis

OBJECTIVE

The protective effect of physical activity (PA) on risk of stroke remains controversial as a result of lack of insight into the sources of heterogeneity between studies. We performed a comprehensive meta-analysis of studies to (1) quantify the association between PA level and risk of stroke outcomes and (2) test the hypothesis that the association of PA level with stroke outcomes will be similar between men and women. The outcome measures are stroke incidence, stroke mortality, or both.

METHODS

Cohort studies were identified by searching MEDLINE and EMBASE (from 1986 to 2005) and meta-analysis conducted according to meta-analysis of Observational Studies in Epidemiology (MOOSE) group recommendations. Data were reported as pooled relative risk (RR) and 95% confidence intervals (CI) using random-effects models to assess the association of stroke outcomes with PA level. Heterogeneity was investigated, and sensitivity analysis was performed. Stratified analysis by gender was performed.

RESULTS

Of 992 articles, 13 satisfied all eligibility criteria and were studied. Compared with low PA, moderate PA caused an 11% reduction in risk of stroke outcome (RR = 0.89, 95% CI 0.86-0.93, p < 0.01) and high PA a 19% reduction (RR = 0.81, CI 0.77-0.84, p < 0.01). Among the men, results showed a 12% reduction in risk associated with moderate PA (RR = 0.88, CI 0.82-0.94, p < 0.01) and 19% reduction for high PA (RR = 0.81, CI 0.75-0.87, p < 0.01). Among the women, results showed a 24% reduction in risk for high PA (RR = 0.76, CI 0.64-.89, p < 0.01). There was, however, no significant risk reduction associated with a moderate PA level in women.

CONCLUSIONS

Increased PA level appears beneficial in reduction of risk of stroke and related outcomes. However, higher levels of PA may be required in women to achieve as significant a risk reduction as in men. An exercise regimen tailored to women to improve related physiological mechanisms will likely be beneficial.

Influence of exercise training on ischemic brain injury in type 1 diabetic rats

While exercise training (ExT) appears to influence cerebrovascular function during type 1 diabetes (T1D), it is not clear whether this beneficial effect extends to protecting the brain from ischemia-induced brain injury. Thus our goal was to examine whether modest ExT could influence transient focal ischemia-induced brain injury along with nitric oxide synthase (NOS)-dependent dilation of cerebral (pial) arterioles during T1D. Sprague-Dawley rats were divided into four groups: nondiabetic sedentary, nondiabetic ExT, diabetic (streptozotocin; 50 mg/kg ip) sedentary, and diabetic ExT. In the first series of studies, we measured infarct volume in all groups of rats following right MCA occlusion for 2 h, followed by 24 h of reperfusion. In a second series of studies, a craniotomy was performed over the parietal cortex, and we measured responses of pial arterioles to an endothelial NOS (eNOS)-dependent, a neuronal NOS (nNOS)-dependent, and a NOS-independent agonist in all groups of rats. We found that sedentary diabetic rats had significantly larger total, cortical, and subcortical infarct volumes following ischemia-reperfusion than sedentary nondiabetic, nondiabetic ExT, and diabetic ExT rats. Infarct volumes were similar in sedentary nondiabetic, ExT nondiabetic, and ExT diabetic rats. In contrast, ExT did not alter infarct size in nondiabetic compared with sedentary nondiabetic rats. In addition, ExT diabetic rats had impaired eNOS- and nNOS-dependent, but not NOS-independent, vasodilation that was restored by ExT. Thus ExT of T1D rats lessened ischemic brain injury following middle cerebral artery occlusion and restored impaired eNOS- and nNOS-dependent vascular function. Since the incidence of ischemic stroke is increased during T1D, we suggest that our finding are significant in that modest ExT may be a viable preventative therapeutic approach to lessen ischemia-induced brain injury that may occur in T1D subjects.

Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration

BACKGROUND

There is inconclusive evidence from observational studies to suggest that people who eat a diet rich in antioxidant vitamins (carotenoids, vitamins C and E) or minerals (selenium and zinc) may be less likely to develop age-related macular degeneration (AMD).

OBJECTIVES

To examine the evidence as to whether or not taking antioxidant vitamin or mineral supplements prevents the development of AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 12), MEDLINE (January 1950 to January 2012), EMBASE (January 1980 to January 2012), Open Grey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 January 2012.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing an antioxidant vitamin and/or mineral supplement (alone or in combination) to control.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed risk of bias in the included studies and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We pooled data using a fixed-effect model.

MAIN RESULTS

We included four RCTs in this review; 62,520 people were included in the analyses. The trials were conducted in Australia, Finland and the USA and investigated vitamin E and beta-carotene supplements. Overall the quality of the evidence was high. People who took these supplements were not at decreased (or increased) risk of developing AMD. The pooled risk ratio for any antioxidant supplement in the prevention of any AMD was 0.98 (95% confidence interval 0.89 to 1.08) and for advanced AMD was 1.05 (95% CI 0.80 to 1.39). Similar results were seen when the analyses were restricted to beta-carotene and alpha-tocopherol alone.

AUTHORS' CONCLUSIONS

There is accumulating evidence that taking vitamin E or beta-carotene supplements will not prevent or delay the onset of AMD. There is no evidence with respect to other antioxidant supplements, such as vitamin C, lutein and zeaxanthin, or any of the commonly marketed multivitamin combinations. Although generally regarded as safe, vitamin supplements may have harmful effects and clear evidence of benefit is needed before they can be recommended. People with AMD should see the related Cochrane review 'Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration' written by the same review team.

Physical activity and risk of cardiovascular disease--a meta-analysis of prospective cohort studies

In order to update and improve available evidence on associations of physical activity (PA) with cardiovascular disease (CVD) by applying meta-analytic random effects modeling to data from prospective cohort studies, using high quality criteria of study selection, we searched the PubMed database from January 1980 to December 2010 for prospective cohort studies of PA and incident CVD, distinguishing occupational PA and leisure time PA, coronary heart disease (CHD) and stroke, respectively. Inclusion criteria were peer-reviewed English papers with original data, studies with large sample size (n ≥ 1,000) and substantial follow-up (≥ 5 years), available data on major confounders and on estimates of relative risk (RR) or hazard ratio (HR), with 95% confidence intervals (CI). We included 21 prospective studies in the overall analysis, with a sample size of more than 650,000 adults who were initially free from CVD, and with some 20,000 incident cases documented during follow-up. Among men, RR of overall CVD in the group with the high level of leisure time PA was 0.76 (95% CI 0.70-0.82, p < 0.001), compared to the reference group with low leisure time PA, with obvious dose-response relationship. A similar effect was observed among women (RR = 0.73, 95% CI 0.68-0.78, p < 0.001). A strong protective effect of occupational PA was observed for moderate level in both men (RR = 0.89, 95% CI 0.82-0.97, p = 0.008) and women (RR = 0.83, 95% CI 0.67-1.03, p = 0.089). No publication bias was observed. Our findings suggest that high level of leisure time PA and moderate level of occupational PA have a beneficial effect on cardiovascular health by reducing the overall risk of incident coronary heart disease and stroke among men and women by 20 to 30 percent and 10 to 20 percent, respectively. This evidence from high quality studies supports efforts of primary and secondary prevention of CVD in economically advanced as well as in rapidly developing countries.

Antiplatelet agents and anticoagulants for hypertension

BACKGROUND

Elevated systemic blood pressure results in high intravascular pressure but the main complications, coronary heart disease (CHD), ischaemic strokes and peripheral vascular disease (PVD), are related to thrombosis rather than haemorrhage. Some complications related to elevated blood pressure, heart failure or atrial fibrillation, are themselves associated with stroke and thromboembolism. Therefore it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated blood pressure.

OBJECTIVES

To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with high blood pressure, including those with elevations in both systolic and diastolic blood pressure, isolated elevations of either systolic or diastolic blood pressure, to address the following hypotheses: (i) antiplatelet agents reduce total deaths and/or major thrombotic events when compared to placebo or other active treatment; and (ii) oral anticoagulants reduce total deaths and/or major thromboembolic events when compared to placebo or other active treatment.

SEARCH METHODS

Electronic databases (MEDLINE, EMBASE, DARE, CENTRAL, Hypertension Group specialised register) were searched up to January 2011. The reference lists of papers resulting from the electronic searches and abstracts from national and international cardiovascular meetings were hand-searched to identify missed or unpublished studies. Relevant authors of studies were contacted to obtain further data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with elevated blood pressure were included if they were of at least 3 months in duration and compared antithrombotic therapy with control or other active treatment.

DATA COLLECTION AND ANALYSIS

Data were independently collected and verified by two reviewers. Data from different trials were pooled where appropriate.

MAIN RESULTS

Four trials with a combined total of 44,012 patients met the inclusion criteria and are included in this review. Acetylsalicylic acid (ASA) did not reduce stroke or 'all cardiovascular events' compared to placebo in primary prevention patients with elevated blood pressure and no prior cardiovascular disease. In one large trial ASA taken for 5 years reduced myocardial infarction (ARR 0.5%, NNT 200), increased major haemorrhage (ARI 0.7%, NNT 154), and did not reduce all cause mortality or cardiovascular mortality. In one trial there was no significant difference between ASA and clopidogrel for the composite endpoint of stroke, myocardial infarction or vascular death. In two small trials warfarin alone or in combination with ASA did not reduce stroke or coronary events. The ATC meta-analysis of antiplatelet therapy for secondary prevention in patients with elevated blood pressure reported an absolute reduction in vascular events of 4.1% as compared to placebo. Data on the 10,600 patients with elevated blood pressure from the 29 individual trials included in the ATC meta-analysis was requested but could not be obtained.

AUTHORS' CONCLUSIONS

Antiplatelet therapy with ASA for primary prevention in patients with elevated blood pressure provides a benefit, reduction in myocardial infarction, which is negated by a harm of similar magnitude, increase in major haemorrhage.The benefit of antiplatelet therapy for secondary prevention in patients with elevated blood pressure is many times greater than the harm.Benefit has not been demonstrated for warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure. Ticlopidine, clopidogrel and newer antiplatelet agents such as prasugrel and ticagrelor have not been sufficiently evaluated in patients with high blood pressure. Newer antithrombotic oral drugs such as dabigatran, rivaroxaban, apixaban and endosaban are yet to be tested in patients with high blood pressure.Further trials of antithrombotic therapy including with newer agents and complete documentation of all benefits and harms are required in patients with elevated blood pressure.

Physical activity in the prevention and treatment of stroke

The role of physical activity in the prevention of stroke is of great interest due to the high mortality and significant impact of stroke-related morbidity on the individual and on healthcare resources. The use of physical activity as a therapeutic strategy to maximise functional recovery in the rehabilitation of stroke survivors has a growing evidence base. This narrative review examines the existing literature surrounding the use of exercise and physical therapy in the primary and secondary prevention of stroke. It explores the effect of gender, exercise intensities and the duration of observed benefit. It details the most recent evidence for physical activity in improving functional outcome in stroke patients. The review summaries the current guidelines and recommendations for exercise therapy and highlights areas in which further research and investigation would be useful to determine optimal exercise prescription for effective prevention and rehabilitation in stroke.

Physical activity and functional outcomes from cerebral vascular events in men

BACKGROUND AND PURPOSE

In studies enrolling patients with stroke, higher levels of prestroke physical activity are associated with better functional outcomes. However, prospective studies evaluating this association are sparse. Using a cohort of initially healthy men, we aimed to prospectively assess the association between physical activity and functional outcomes from cerebral vascular events.

METHODS

We conducted a prospective cohort study among 21 794 men enrolled in the Physician's Health Study who provided information on physical activity at baseline and who did not have a history of stroke or transient ischemic attack (TIA). Baseline levels of physical activity were categorized as: vigorous exercise<1, 1, 2 to 4, and ≥5 times/week. Possible functional outcomes included TIA and stroke with modified Rankin Scale score of 0 to 1, 2 to 3, or 5 to 6. Multinomial logistic regression was used to determine the association between physical activity and functional outcomes from cerebral vascular events.

RESULTS

After a mean of 20.2 years of follow-up, 761 TIAs, 1146 ischemic strokes, 221 hemorrhagic strokes, and 11 strokes of unknown type occurred. Compared with men who did not experience a stroke or TIA and who exercise vigorously<1 time/week, men who exercise vigorously≥5 times/week had adjusted relative risk (95% CIs) of 0.67 (0.53-0.86) for TIA, 0.84 (0.61-1.14) for stroke with modified Rankin Scale score 0 to 1, 0.85 (0.67-1.08) for modified Rankin Scale score 2 to 3, and 1.12 (0.78-1.60) for modified Rankin Scale score 5 to 6 after total stroke. Other levels of physical activity did not have a significant impact on the risk of our outcomes.

CONCLUSIONS

Physical activity before TIA or stroke does not appear to influence functional outcomes after cerebral vascular events.

Vascular effects of exercise: endothelial adaptations beyond active muscle beds

Endothelial adaptations to exercise training are not exclusively conferred within the active muscle beds. Herein, we summarize key studies that have evaluated the impact of chronic exercise on the endothelium of vasculatures perfusing nonworking skeletal muscle, brain, viscera, and skin, concluding with discussion of potential mechanisms driving these endothelial adaptations.

Independent and joint associations of physical activity and fitness on stroke in men

INTRODUCTION

Recent studies have demonstrated that physical activity (PA) and cardiorespiratory fitness (CRF) are independent predictors of stroke in men. The combined associations of these 2 factors are not well established.

OBJECTIVE

To investigate the independent and joint associations of PA and CRF with fatal, nonfatal, and total stroke in a group of men.

METHODS

The current analyses included 45 689 men aged 18 to 100 years who completed baseline sessions between 1970 and 2001. All participants had no known myocardial infarction, stroke, or cancer. Physical activity was measured by questionnaire, and CRF was assessed from a maximal treadmill exercise test. The National Death Index for fatal stroke and mail-back surveys for nonfatal stroke were used to ascertain cases. Cox regression analyses were used to estimate the risk of stroke outcomes.

RESULTS

There were 619 cases over 800 582 person-years of observation. Significant inverse associations were observed between CRF and fatal, nonfatal, and total strokes after adjustment for age and examination year (P for trend < 0.05 for each). No associations were found between PA and any of the 3 outcomes after adjusting for other covariates and CRF. Joint associations of 9 PA fitness groups showed less risk for total stroke in the moderate and high fitness categories.

CONCLUSION

These findings suggest that CRF is an independent predictor of incident stroke in asymptomatic men.