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Mead G, Graham C, Lundström E, Hankey GJ, Hackett ML, Billot L, Näsman P, Forbes J, Dennis M. Individual patient data meta-analysis of the effects of fluoxetine on functional outcomes after acute stroke. Int J Stroke 2024:17474930241242628. [PMID: 38497332 DOI: 10.1177/17474930241242628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Three large randomized controlled trials of fluoxetine for stroke recovery have been performed. We performed an individual patient data meta-analysis (IPDM) on the combined data. METHODS Fixed effects meta-analyses were performed on the combined data set, for the primary outcome (modified Rankin scale (mRS) at 6 months), and secondary outcomes common to the individual trials. As a sensitivity analysis, summary statistics from each trial were created and combined. FINDINGS The three trials recruited a combined total of 5907 people (mean age 69.5 years (SD 12.3), 2256 (38%) females, 2-15 days post-stroke) from Australia, New Zealand, United Kingdom, Sweden, and Vietnam; and randomized them to fluoxetine 20 mg daily or matching placebo for 6 months. Data on 5833 (98.75%) were available at 6 months. The adjusted ordinal comparison of mRS was similar in the two groups (common OR 0.96, 95% CI 0.87 to 1.05, p = 0.37). There were no statistically significant interactions between the minimization variables (baseline probability of being alive and independent at 6 months, time to treatment, motor deficit, or aphasia) and pre-specified subgroups (including age, pathological type, inability to assess mood, proxy or patient consent, baseline depression, country). Fluoxetine increased seizure risk (2.64% vs 1.8%, p = 0.03), falls with injury (6.26% vs 4.51%, p = 0.03), fractures (3.15% vs 1.39%, p < 0.0001) and hyponatremia (1.22% vs 0.61%, p = 0.01) but reduced new depression (10.05% vs 13.42%, p < 0.0001). At 12 months, there was no difference in adjusted mRS (n = 5760; common OR 0.98, 95% CI 0.89 to 1.07). Sensitivity analyses gave the same results. INTERPRETATION Fluoxetine 20 mg daily for 6 months did not improve functional recovery. It increased seizures, falls with injury, and bone fractures but reduced depression frequency at 6 months.
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Affiliation(s)
- Gillian Mead
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Catriona Graham
- Wellcome Trust Clinical Research Facility at the Western General Hospital, Edinburgh, UK
| | - Erik Lundström
- Neurology, Department of Medical Sciences, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Graeme J Hankey
- Centre for Neuromuscular and Neurological Disorders, UWA Medical School, The University of Western Australia, Perth, WA, Australia
- Perron Institute for Neurological and Translational Science, Perth, WA, Australia
| | - Maree L Hackett
- The George Institute for Global Health, Barangaroo, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- University of Central Lancashire, Preston, UK
| | - Laurent Billot
- Faculty of Medicine and Health, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Per Näsman
- KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Martin Dennis
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Vahlberg BM, Eriksson S, Holmbäck U, Lundström E. Factors associated with changes in walking performance in individuals 3 months after stroke or TIA: secondary analyses from a randomised controlled trial of SMS-delivered training instructions in Sweden. BMJ Open 2024; 14:e078180. [PMID: 38443081 DOI: 10.1136/bmjopen-2023-078180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVES This study aimed to identify factors related to changes in walking performance in individuals 3 months after a stroke or TIA. DESIGN Cross-sectional study with post hoc analysis of a randomised controlled study. SETTING University Hospital, Sweden. PARTICIPANTS 79 individuals, 64 (10) years, 37% women, who were acutely hospitalised because of stroke or TIA between November 2016 and December 2018. Inclusion criteria were patients aged 18 or above and the major eligibility criterion was the ability to perform the 6 min walking test. INTERVENTION The intervention group received standard care plus daily mobile phone text messages (short message service) with instructions to perform regular outdoor walking and functional leg exercises in combination with step counting and training diaries. The control group received standard care. OUTCOME MEASURES Multivariate analysis was performed and age, sex, group allocation, comorbidity, baseline 6 min walk test, body mass index (BMI), cognition and chair-stand tests were entered as possible determinants for changes in the 6 min walk test. RESULTS Multiple regression analyses showed that age (standardised beta -0.33, 95% CI -3.8 to -1.05, p<0.001), sex (-0.24, 95% CI -66.9 to -8.0, p=0.014), no comorbidity (-0.16, 95% CI -55.5 to 5.4, p=0.11), baseline BMI (-0.29, 95% CI -8.1 to -1.6, p=0.004), baseline 6 min walk test (-0.55, 95% CI -0.5 to -0.3, p<0.001) were associated with changes in 6 min walk test 3 months after the stroke event. The regression model described 36% of the variance in changes in the 6 min walk test. CONCLUSIONS Post hoc regression analyses indicated that younger age, male sex, lower BMI and shorter 6 min walk test at baseline and possible no comorbidity contributed to improvement in walking performance at 3 months in patients with a recent stroke or TIA. These factors may be important when planning secondary prevention actions. TRIAL REGISTRATION NUMBER NCT02902367.
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Affiliation(s)
- Birgit Maria Vahlberg
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Staffan Eriksson
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research, Uppsala University, Uppsala, Sweden
| | - Ulf Holmbäck
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
| | - Erik Lundström
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
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Fresnais D, Ihle-Hansen H, Lundström E, Andersson ÅG, Fure B. Cerebrovascular Hemodynamics in Cognitive Impairment and Dementia: A Systematic Review and Meta-Analysis of Transcranial Doppler Studies. Dement Geriatr Cogn Disord 2023; 52:277-295. [PMID: 38008061 PMCID: PMC10911167 DOI: 10.1159/000535422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023] Open
Abstract
INTRODUCTION Transcranial Doppler (TCD) sonography is a noninvasive tool for measuring cerebrovascular hemodynamics. Studies have reported alterations in cerebrovascular hemodynamics in normal aging, mild cognitive impairment (MCI), and dementia, as well as in different etiologies of dementia. This systematic review and meta-analysis was designed to investigate the relationship between cerebral blood velocity (CBv) and pulsatility index (PI) in the middle cerebral artery (MCA) in persons with MCI and dementia. METHODS A systematic literature search was conducted in Pubmed, Embase, Cochrane Library, Epistemonikos, PsychINFO, and CINAHL. The search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After screening of 33,439 articles, 86 were reviewed in full-text, and 35 fulfilled the inclusion criteria. RESULTS CBv was significantly lower and PI significantly higher in MCA in vascular dementia (VaD) and Alzheimer's disease (AD) compared to cognitively normal (CN) older persons. Also, CBv was lower in MCI compared to CN. There were no significant differences in CBv in MCA in AD compared with VaD, although PI was higher in VaD compared to AD. CONCLUSION Alterations in cerebrovascular hemodynamics are seen in AD, VaD, and MCI. While PI was slightly higher in VaD compared to AD, the reduction in CBv appears to be equally pronounced across neurodegenerative and vascular etiologies of dementia.
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Affiliation(s)
- David Fresnais
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Orebro, Sweden
- Department of Internal Medicine, Central Hospital Karlstad, Karlstad, Sweden
| | | | - Erik Lundström
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
- Department of Neurology, Academic University Hospital Uppsala, Uppsala, Sweden
| | - Åsa G Andersson
- Department of Geriatrics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Orebro, Sweden
| | - Brynjar Fure
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Orebro, Sweden
- Department of Internal Medicine, Central Hospital Karlstad, Karlstad, Sweden
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Hu X, Liv P, Lundström E, Norström F, Lindahl O, Borg K, Sunnerhagen KS. Study protocol for a randomized, controlled, multicentre, pragmatic trial with Rehabkompassen®-a digital structured follow-up tool for facilitating patient-tailored rehabilitation in persons after stroke. Trials 2023; 24:650. [PMID: 37803460 PMCID: PMC10559468 DOI: 10.1186/s13063-023-07673-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Stroke is a leading cause of disability among adults worldwide. A timely structured follow-up tool to identify patients' rehabilitation needs and develop patient-tailored rehabilitation regimens to decrease disability is largely lacking in current stroke care. The overall purpose of this study is to evaluate the effectiveness of a novel digital follow-up tool, Rehabkompassen®, among persons discharged from acute care settings after a stroke. METHODS This multicentre, parallel, open-label, two-arm pragmatic randomized controlled trial with an allocation ratio of 1:1 will be conducted in Sweden. A total of 1106 adult stroke patients will have follow-up visits in usual care settings at 3 and 12 months after stroke onset. At the 3-month follow-up, participants will have a usual outpatient visit without (control group, n = 553) or with (intervention group, n = 553) the Rehabkompassen® tool. All participants will receive the intervention at the 12-month follow-up visit. Feedback from the end-users (patient and health care practitioners) will be collected after the visits. The primary outcomes will be the patients' independence and social participation at the 12-month visits. Secondary outcomes will include end-users' satisfaction, barriers and facilitators for adopting the instrument, other stroke impacts, health-related quality of life and the cost-effectiveness of the instrument, calculated by incremental cost per quality-adjusted life year (QALY). DISCUSSION The outcomes of this trial will inform clinical practice and health care policy on the role of the Rehabkompassen® digital follow-up tool in the post-acute continuum of care after stroke. TRIAL REGISTRATION ClinicalTrials.gov NCT04915027. Registered on 4 June 2021. ISRCTN registry ISRCTN63166587. Registered on 21 August 2023.
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Affiliation(s)
- Xiaolei Hu
- Department of Community Medicine and Rehabilitation, Umeå University, Neuro-Head-Hals-Centrum, University Hospital of Umeå, Umeå, 901 87, Sweden.
| | - Per Liv
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Erik Lundström
- Department of Medical Sciences, Neurology, Uppsala University, Akademiska Sjukhuset, Uppsala, Sweden
| | - Fredrik Norström
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Olof Lindahl
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Kristian Borg
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden
| | - Katharina S Sunnerhagen
- Department of Neuroscience and Physiology, Gothenburg University, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abzhandadze T, Lundström E, Buvarp D, Eriksson M, Quinn TJ, Sunnerhagen KS. Development of a Swedish short version of the Montreal Cognitive Assessment for cognitive screening in patients with stroke. J Rehabil Med 2023; 55:jrm4442. [PMID: 37309231 DOI: 10.2340/jrm.v55.4442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 04/19/2023] [Indexed: 06/14/2023] Open
Abstract
OBJECTIVE The primary objective was to develop a Swedish short version of the Montreal Cognitive Assessment (s-MoCA-SWE) for use with patients with stroke. Secondary objectives were to identify an optimal cut-off value for the s-MoCA-SWE to screen for cognitive impairment and to compare its sensitivity with that of previously developed short forms of the Montreal Cognitive Assessment. DESIGN Cross-sectional study. SUBJECTS/PATIENTS Patients admitted to stroke and rehabilitation units in hospitals across Sweden. METHODS Cognition was screened using the Montreal Cognitive Assessment. Working versions of the s-MoCA-SWE were developed using supervised and unsupervised algorithms. RESULTS Data from 3,276 patients were analysed (40% female, mean age 71.5 years, 56% minor stroke at admission). The suggested s-MoCA-SWE comprised delayed recall, visuospatial/executive function, serial 7, fluency, and abstraction. The aggregated scores ranged from 0 to 16. A threshold for impaired cognition ≤ 12 had a sensitivity of 97.41 (95% confidence interval, 96.64-98.03) and positive predictive value of 90.30 (95% confidence interval 89.23-91.27). The s-MoCA-SWE had a higher absolute sensitivity than that of other short forms. CONCLUSION The s-MoCA-SWE (threshold ≤ 12) can detect post-stroke cognitive issues. The high sensitivity makes it a potentially useful "rule-out" tool that may eliminate severe cognitive impairment in people with stoke.
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Affiliation(s)
- Tamar Abzhandadze
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg; Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg.
| | - Erik Lundström
- Department of Medical Sciences, Neurology, Akademiska Sjukhuset, Uppsala
| | - Dongni Buvarp
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg
| | - Marie Eriksson
- Department of Statistics, USBE, Umeå University, Umeå, Sweden
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg; Neurocare, Rehabilitation Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Buvarp D, Viktorisson A, Axelsson F, Lehto E, Lindgren L, Lundström E, Sunnerhagen KS. Physical Activity Trajectories and Functional Recovery After Acute Stroke Among Adults in Sweden. JAMA Netw Open 2023; 6:e2310919. [PMID: 37126346 PMCID: PMC10152305 DOI: 10.1001/jamanetworkopen.2023.10919] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Importance The optimum level and timing of poststroke physical activity interventions to enhance functional recovery remain unclear. Objective To assess the level of physical activity in the first 6 months after stroke among individuals with similar physical activity patterns over time and to investigate the association between physical activity trajectories and functional recovery at 6 months after stroke. Design, Setting, and Participants This cohort study obtained data from the Efficacy of Fluoxetine-a Randomized Controlled Trial in Stroke, which was conducted in 35 stroke and rehabilitation centers across Sweden from October 2014 to June 2019. Adult participants (aged >18 years) were recruited between 2 and 15 days after stroke onset and followed up for 6 months. Participants who withdrew or were lost to follow-up were excluded from the longitudinal analysis. Data analyses were performed between August 15 and October 28, 2022. Exposures Physical activity was assessed at 1 week, 1 month, 3 months, and 6 months. Multiple factors associated with physical activity trajectories were investigated. Association of the distinct trajectories with functional recovery was assessed in multivariable logistic regression. Main Outcomes and Measures The primary outcomes were the distinct physical activity trajectories over time, which were identified using group-based trajectory modeling. The secondary outcome was the functional recovery at 6 months after stroke, which was assessed using the modified Rankin Scale. Results Of the 1367 included participants (median [IQR] age, 72 years [65-79] years; 844 males [62%]), 2 distinct trajectory groups were identified: increaser (n = 720 [53%]) and decreaser (647 [47%]). The increaser group demonstrated a significant increase in physical activity level (mean difference, 0.27; linear slope β1 = 0.46; P < .001) and sustained it at light intensity from 1 week to 6 months, whereas the decreaser group showed a decline in physical activity and eventually became inactive (mean difference, -0.26; linear slope β1 = 1.81; P < .001). Male participants and those with normal cognition had higher odds of being in the increaser group, regardless of stroke severity. Increasing physical activity and sustaining it at light intensity were associated with a good functional outcome at 6 months (adjusted odds ratio, 2.54; 99% CI, 1.72-3.75; P < .001). Conclusions ad Relevance Results of this study suggest that increased physical activity was associated with functional recovery 6 months after stroke. Interventions targeting individuals with decreasing physical activity in the subacute phase of stroke may play a role in improved functional outcomes.
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Affiliation(s)
- Dongni Buvarp
- Rehabilitation Medicine Research Group, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sweden
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Adam Viktorisson
- Rehabilitation Medicine Research Group, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sweden
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Felix Axelsson
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Elias Lehto
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Linnea Lindgren
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Erik Lundström
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Katharina S Sunnerhagen
- Rehabilitation Medicine Research Group, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sweden
- Sahlgrenska University Hospital, Gothenburg, Sweden
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Lindvall E, Franzon K, Lundström E, Kilander L. The impact of stroke on the ability to live an independent life at old age: a community-based cohort study of Swedish men. BMC Geriatr 2023; 23:126. [PMID: 36879184 PMCID: PMC9990268 DOI: 10.1186/s12877-023-03817-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 02/10/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Few studies with controls from the same cohort have investigated the impact of stroke on the ability to live an independent life at old age. We aimed to analyze how great an impact being a stroke survivor would have on cognition and disability. We also analyzed the predictive value of baseline cardiovascular risk factors. METHODS We included 1147 men, free from stroke, dementia, and disability, from the Uppsala Longitudinal Study of Adult Men, between 69-74 years of age. Follow-up data were collected between the ages of 85-89 years and were available for 481 of all 509 survivors. Data on stroke diagnosis were obtained through national registries. Dementia was diagnosed through a systematic review of medical charts and in accordance with the current diagnostic criteria. The primary outcome, preserved functions, was a composite outcome comprising four criteria: no dementia, independent in personal activities of daily living, ability to walk outside unassisted, and not living in an institution. RESULTS Among 481 survivors with outcome data, 64 (13%) suffered a stroke during the follow-up. Only 31% of stroke cases, compared to 72% of non-stroke cases (adjusted OR 0.20 [95% CI 0.11-0.37]), had preserved functions. The chance of being free of dementia was 60% lower in the stroke group, OR 0.40 [95% CI 0.22-0.72]. No cardiovascular risk factors were independently able to predict preserved functions among stroke cases. CONCLUSION Stroke has long lasting consequences for many aspects of disability at very high age.
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Affiliation(s)
- Elias Lindvall
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala Academic Hospital, Neurological Reception, Sjukhusvägen, 75185, Uppsala, Sweden.
| | - Kristin Franzon
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
| | - Erik Lundström
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala Academic Hospital, Neurological Reception, Sjukhusvägen, 75185, Uppsala, Sweden
| | - Lena Kilander
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden
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Nielsen PB, Skj⊘th F, Dun AR, Lilja M, Rahman I, Larsen TB, S⊘gaard M, Halvorsen S, Lundström E, Coleman CI, Fast T, Rivera M. PERSISTENCE OF REDUCED DOSE DOACS AND WARFARIN: A MULTINATIONAL COHORT STUDY OF INDIVIDUALS WITH INCIDENT AF. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00562-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Tay J, Mårtensson B, Markus HS, Lundström E. Does fluoxetine reduce apathetic and depressive symptoms after stroke? An analysis of the Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke trial data set. Int J Stroke 2023; 18:285-295. [PMID: 36050815 PMCID: PMC9940155 DOI: 10.1177/17474930221124760] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Apathy is a common and disabling symptom after stroke with no proven treatments. Selective serotonin reuptake inhibitors are widely used to treat depressive symptoms post-stroke but whether they reduce apathetic symptoms is unknown. We determined the effect of fluoxetine on post-stroke apathy in a post hoc analysis of the EFFECTS (Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke) trial. METHODS EFFECTS enrolled patients ⩾18 years between 2 and 15 days after stroke onset. Participants were randomly assigned to receive oral fluoxetine 20 mg once daily or matching placebo for 6 months. The Montgomery-Åsberg Depression Rating Scale (MADRS) was administered at baseline and 6 months. Individual items on this scale were divided into those reflecting symptoms of apathy and depression. Symptoms were compared between fluoxetine and placebo groups. RESULTS Of 1500 participants enrolled, complete MADRS data were available for 1369. The modified intention-to-treat population included 681 patients in the fluoxetine group and 688 in the placebo group. Confirmatory factor analysis revealed that apathetic, depressive, and anhedonic symptoms were dissociable. Apathy scores increased in both fluoxetine and placebo groups (both p ⩽ 0.00001). In contrast, fluoxetine was associated with a reduction in depressive scores (p = 0.002). CONCLUSION Post-stroke apathetic and depressive symptoms respond differently to fluoxetine treatment. Our analysis suggests fluoxetine is ineffective in preventing post-stroke apathy.
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Affiliation(s)
- Jonathan Tay
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Björn Mårtensson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Hugh S Markus, Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Neurology R3, Box 83, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK.
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
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Nielsen PB, Skj⊘th F, Dun AR, Lilja M, Rahman I, Larsen TB, S⊘gaard M, Halvorsen S, Lundström E, Coleman CI, Fast T, Rivera M. COMPARATIVE EFFECTIVENESS AND SAFETY OUTCOMES OF REDUCED DOSE DOACS VS WARFARIN: A MULTINATIONAL COHORT STUDY OF INDIVIDUALS WITH AF. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00495-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Roaldsen MB, Eltoft A, Wilsgaard T, Christensen H, Engelter ST, Indredavik B, Jatužis D, Karelis G, Kõrv J, Lundström E, Petersson J, Putaala J, Søyland MH, Tveiten A, Bivard A, Johnsen SH, Mazya MV, Werring DJ, Wu TY, De Marchis GM, Robinson TG, Mathiesen EB, Valente M, Chen A, Sharobeam A, Edwards L, Blair C, Christensen L, Ægidius K, Pihl T, Fassel-Larsen C, Wassvik L, Folke M, Rosenbaum S, Gharehbagh SS, Hansen A, Preisler N, Antsov K, Mallene S, Lill M, Herodes M, Vibo R, Rakitin A, Saarinen J, Tiainen M, Tumpula O, Noppari T, Raty S, Sibolt G, Nieminen J, Niederhauser J, Haritoncenko I, Puustinen J, Haula TM, Sipilä J, Viesulaite B, Taroza S, Rastenyte D, Matijosaitis V, Vilionskis A, Masiliunas R, Ekkert A, Chmeliauskas P, Lukosaitis V, Reichenbach A, Moss TT, Nilsen HY, Hammer-Berntzen R, Nordby LM, Weiby TA, Nordengen K, Ihle-Hansen H, Stankiewiecz M, Grotle O, Nes M, Thiemann K, Særvold IM, Fraas M, Størdahl S, Horn JW, Hildrum H, Myrstad C, Tobro H, Tunvold JA, Jacobsen O, Aamodt N, Baisa H, Malmberg VN, Rohweder G, Ellekjær H, Ildstad F, Egstad E, Helleberg BH, Berg HH, Jørgensen J, Tronvik E, Shirzadi M, Solhoff R, Van Lessen R, Vatne A, Forselv K, Frøyshov H, Fjeldstad MS, Tangen L, Matapour S, Kindberg K, Johannessen C, Rist M, Mathisen I, Nyrnes T, Haavik A, Toverud G, Aakvik K, Larsson M, Ytrehus K, Ingebrigtsen S, Stokmo T, Helander C, Larsen IC, Solberg TO, Seljeseth YM, Maini S, Bersås I, Mathé J, Rooth E, Laska AC, Rudberg AS, Esbjörnsson M, Andler F, Ericsson A, Wickberg O, Karlsson JE, Redfors P, Jood K, Buchwald F, Mansson K, Gråhamn O, Sjölin K, Lindvall E, Cidh Å, Tolf A, Fasth O, Hedström B, Fladt J, Dittrich TD, Kriemler L, Hannon N, Amis E, Finlay S, Mitchell-Douglas J, McGee J, Davies R, Johnson V, Nair A, Robinson M, Greig J, Halse O, Wilding P, Mashate S, Chatterjee K, Martin M, Leason S, Roberts J, Dutta D, Ward D, Rayessa R, Clarkson E, Teo J, Ho C, Conway S, Aissa M, Papavasileiou V, Fry S, Waugh D, Britton J, Hassan A, Manning L, Khan S, Asaipillai A, Fornolles C, Tate ML, Chenna S, Anjum T, Karunatilake D, Foot J, VanPelt L, Shetty A, Wilkes G, Buck A, Jackson B, Fleming L, Carpenter M, Jackson L, Needle A, Zahoor T, Duraisami T, Northcott K, Kubie J, Bowring A, Keenan S, Mackle D, England T, Rushton B, Hedstrom A, Amlani S, Evans R, Muddegowda G, Remegoso A, Ferdinand P, Varquez R, Davis M, Elkin E, Seal R, Fawcett M, Gradwell C, Travers C, Atkinson B, Woodward S, Giraldo L, Byers J, Cheripelli B, Lee S, Marigold R, Smith S, Zhang L, Ghatala R, Sim CH, Ghani U, Yates K, Obarey S, Willmot M, Ahlquist K, Bates M, Rashed K, Board S, Andsberg G, Sundayi S, Garside M, Macleod MJ, Manoj A, Hopper O, Cederin B, Toomsoo T, Gross-Paju K, Tapiola T, Kestutis J, Amthor KF, Heermann B, Ottesen V, Melum TA, Kurz M, Parsons M, Valente M, Chen A, Sharobeam A, Edwards L, Blair C. Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2023; 22:117-126. [PMID: 36549308 DOI: 10.1016/s1474-4422(22)00484-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT. METHODS TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890). FINDINGS From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64). INTERPRETATION In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT. FUNDING Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.
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Affiliation(s)
- Melinda B Roaldsen
- Department of Clinical Research, University Hospital of North Norway, Tromsø, Norway
| | - Agnethe Eltoft
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Department of Community Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stefan T Engelter
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Neurology and Neurorehabilitation, University of Basel, Basel, Switzerland; University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Bent Indredavik
- Department of Medicine, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway; Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dalius Jatužis
- Faculty of Medicine, Vilnius University, Center of Neurology, Vilnius, Lithuania
| | - Guntis Karelis
- Department of Neurology and Neurosurgery, Riga East University Hospital, Riga, Latvia; Rīga Stradiņš University, Riga, Latvia
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu, Tartu, Estonia
| | - Erik Lundström
- Department of Medicine and Neurology, Uppsala University, Uppsala, Sweden
| | - Jesper Petersson
- Department of Neurology, Lund University, Institute for Clinical Sciences Lund, Lund, Sweden
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mary-Helen Søyland
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway; Department of Neurology, Hospital of Southern Norway, Kristiansand, Norway
| | - Arnstein Tveiten
- Department of Neurology, Hospital of Southern Norway, Kristiansand, Norway
| | - Andrew Bivard
- Department of Medicine, Royal Melbourne Hospital, Melbourne Brain Centre, Melbourne, VIC, Australia
| | - Stein Harald Johnsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Michael V Mazya
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - David J Werring
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Neurology, University of Basel, Basel, Switzerland
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ellisiv B Mathiesen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
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Ball EL, Shah M, Ross E, Sutherland R, Squires C, Mead GE, Wardlaw JM, Quinn TJ, Religa D, Lundström E, Cheyne J, Shenkin SD. Predictors of post-stroke cognitive impairment using acute structural MRI neuroimaging: A systematic review and meta-analysis. Int J Stroke 2022; 18:543-554. [PMID: 35924821 DOI: 10.1177/17474930221120349] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stroke survivors are at an increased risk of developing post-stroke cognitive impairment and post-stroke dementia; those at risk could be identified by brain imaging routinely performed at stroke onset. AIM This systematic review aimed to identify features which are associated with post-stroke cognitive impairment (including dementia) on magnetic resonance imaging (MRI) performed at stroke diagnosis. SUMMARY OF REVIEW We searched the literature from inception to January 2022 and identified 10,284 records. We included studies that performed MRI at the time of stroke (0-30 days after a stroke) and assessed cognitive outcome at least 3 months after stroke. We synthesized findings from 26 papers, comprising 27 stroke-populations (N = 13,114, average age range = 40-80 years, 19-62% female). When data were available, we pooled unadjusted (ORu) and adjusted (ORa) odds ratios.We found associations between cognitive outcomes and presence of cerebral atrophy (three studies, N = 453, ORu = 2.48, 95% CI = 1.15-4.62), presence of microbleeds (two studies, N = 9151, ORa = 1.36, 95% CI = 1.08-1.70), and increasing severity of white matter hyperintensities (three studies, N = 704, ORa = 1.26, 95% CI = 1.06-1.49). Increasing cerebral small vessel disease score was associated with cognitive outcome following unadjusted analysis only (two studies, N = 499, ORu = 1.34, 95%CI = 1.12-1.61; three studies, N = 950, ORa = 1.23, 95% CI = 0.96-1.57). Associations remained after controlling for pre-stroke cognitive impairment. We did not find associations between other stroke features and cognitive outcome, or there were insufficient data. CONCLUSION Acute stroke MRI features may enable healthcare professionals to identify patients at risk of post-stroke cognitive problems. However, there is still substantial uncertainty about the prognostic utility of acute MRI for this.
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Affiliation(s)
- Emily L Ball
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Mahnoor Shah
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Eilidh Ross
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | | | | | - Gillian E Mead
- Ageing and Health Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Dorota Religa
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Erik Lundström
- Neurology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Susan D Shenkin
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Ageing and Health Research Group, Usher Institute, The University of Edinburgh, Edinburgh, UK.,Advanced Care Research Centre, Usher Institute, The University of Edinburgh, Edinburgh, UK
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13
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Hua X, Wu S, Legg LA, Rudberg AS, Hackett ML, Tilney R, Lindgren L, Kutlubaev MA, Hsieh CF, Barugh AJ, Hankey GJ, Lundström E, Dennis M, Mead GE. Selective Serotonin Reuptake Inhibitors for Stroke Recovery. Stroke 2022. [PMID: 35994683 DOI: 10.1161/strokeaha.121.038149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (X.H., S.W.)
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (X.H., S.W.)
| | - Lynn A Legg
- NHS Greater Glasgow and Clyde Health Board, Paisley, United Kingdom (L.A.L.)
| | - Ann-Sofie Rudberg
- Division of Neurology, Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden (A.-S.R.)
| | - Maree L Hackett
- Mental Health, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.L.H.)
| | - Russel Tilney
- Department of Medicine, Mater Dei Hospital, Msida, Malta (R.T.)
| | - Linnea Lindgren
- Department of Medical Sciences, Neurology, Uppsala University, Sweden (L.L., E.L.)
| | - Mansur A Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russian Federation (M.A.K.)
| | - Cheng-Fang Hsieh
- Division of Geriatrics and Gerontology, Departments of Internal Medicine and Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan (C.-F.H.)
| | - Amanda J Barugh
- Department of Geriatric Medicine (A.J.B.), University of Edinburgh, United Kingdom
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia (G.J.H.)
| | - Erik Lundström
- Department of Medical Sciences, Neurology, Uppsala University, Sweden (L.L., E.L.)
| | - Martin Dennis
- Centre for Clinical Brain Sciences (M.D., G.E.M.), University of Edinburgh, United Kingdom
| | - Gillian E Mead
- Centre for Clinical Brain Sciences (M.D., G.E.M.), University of Edinburgh, United Kingdom
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14
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Chye A, Hackett ML, Hankey GJ, Lundström E, Almeida OP, Gommans J, Dennis M, Jan S, Mead GE, Ford AH, Beer CE, Flicker L, Delcourt C, Billot L, Anderson CS, Stibrant Sunnerhagen K, Yi Q, Bompoint S, Nguyen TH, Lung T. Repeated Measures of Modified Rankin Scale Scores to Assess Functional Recovery From Stroke: AFFINITY Study Findings. J Am Heart Assoc 2022; 11:e025425. [PMID: 35929466 PMCID: PMC9496315 DOI: 10.1161/jaha.121.025425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Function after acute stroke using the modified Rankin Scale (mRS) is usually assessed at a point in time. The analytical implications of serial mRS measurements to evaluate functional recovery over time is not completely understood. We compare repeated‐measures and single‐measure analyses of the mRS from a randomized clinical trial. Methods and Results Serial mRS data from AFFINITY (Assessment of Fluoxetine in Stroke Recovery), a double‐blind placebo randomized clinical trial of fluoxetine following stroke (n=1280) were analyzed to identify demographic and clinical associations with functional recovery (reduction in mRS) over 12 months. Associations were identified using single‐measure (day 365) and repeated‐measures (days 28, 90, 180, and 365) partial proportional odds logistic regression. Ninety‐five percent of participants experienced a reduction in mRS after 12 months. Functional recovery was associated with age at stroke <70 years; no prestroke history of diabetes, coronary heart disease, or ischemic stroke; prestroke history of depression, a relationship partner, living with others, independence, or paid employment; no fluoxetine intervention; ischemic stroke (compared with hemorrhagic); stroke treatment in Vietnam (compared with Australia or New Zealand); longer time since current stroke; and lower baseline National Institutes of Health Stroke Scale & Patient Health Questionnaire‐9 scores. Direction of associations was largely concordant between single‐measure and repeated‐measures models. Association strength and variance was generally smaller in the repeated‐measures model compared with the single‐measure model. Conclusions Repeated‐measures may improve trial precision in identifying trial associations and effects. Further repeated‐measures stroke analyses are required to prove methodological value. Registration URL: http://www.anzctr.org.au; Unique identifier: ACTRN12611000774921.
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Affiliation(s)
- Alexander Chye
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia
| | - Maree L Hackett
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia.,The University of Central Lancashire Preston Lancashire United Kingdom
| | - Graeme J Hankey
- Medical School Faculty of Health and Medical Sciences, The University of Western Australia Perth Western Australia Australia.,Department of Neurology Sir Charles Gairdner Hospital Perth Western Australia Australia
| | - Erik Lundström
- Department of Neuroscience Neurology, Uppsala University Uppsala Sweden
| | - Osvaldo P Almeida
- Medical School University of Western Australia Perth Western Australia Australia
| | - John Gommans
- Hawke's Bay Hospital, Hastings Hawke's Bay New Zealand
| | - Martin Dennis
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh Scotland United Kingdom
| | - Stephen Jan
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia
| | - Gillian E Mead
- Usher Institute University of Edinburgh Edinburgh Scotland United Kingdom
| | - Andrew H Ford
- Medical School University of Western Australia Perth Western Australia Australia
| | | | - Leon Flicker
- Medical School University of Western Australia Perth Western Australia Australia
| | - Candice Delcourt
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia.,Faculty of Medicine University of New South Wales Sydney New South Wales Australia.,Department of Clinical Medicine, Faculty of Medicine Health and Human Sciences, Macquarie University Macquarie Park New South Wales Australia
| | - Laurent Billot
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia
| | - Craig S Anderson
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia.,Faculty of Medicine University of New South Wales Sydney New South Wales Australia.,Neurology Department Royal Prince Alfred Hospital Sydney New South Wales Australia.,The George Institute for Global Health at Peking University Health Science Center Beijing People's Republic of China
| | - Katharina Stibrant Sunnerhagen
- Institute of Neuroscience and Physiology-Clinical Neuroscience The Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
| | - Qilong Yi
- Canadian Blood Services and University of Toronto Toronto Canada
| | - Severine Bompoint
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia
| | - Thang Huy Nguyen
- Cerebrovascular Disease Department The People's Hospital 115 Ho Chi Min City Vietnam
| | - Thomas Lung
- The George Institute for Global Health University of New South Wales Sydney New South Wales Australia.,Faculty of Medicine and Health The University of Sydney Sydney Australia
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15
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Eltoft A, Wilsgaard T, Roaldsen MB, Søyland MH, Lundström E, Petersson J, Indredavik B, Putaala J, Christensen H, Kõrv J, Jatužis D, Engelter ST, De Marchis GM, Werring DJ, Robinson T, Tveiten A, Mathiesen EB. Statistical analysis plan for the randomized controlled trial Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST). Trials 2022; 23:421. [PMID: 35590386 PMCID: PMC9118782 DOI: 10.1186/s13063-022-06301-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with wake-up ischemic stroke are frequently excluded from thrombolytic treatment due to unknown symptom onset time and limited availability of advanced imaging modalities. The Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST) is a randomized controlled trial of intravenous tenecteplase 0.25 mg/kg and standard care versus standard care alone (no thrombolysis) in patients who wake up with acute ischemic stroke and can be treated within 4.5 h of wakening based on non-contrast CT findings. OBJECTIVE To publish the detailed statistical analysis plan for TWIST prior to unblinding. METHODS The TWIST statistical analysis plan is consistent with the Consolidating Standard of Reporting Trials (CONSORT) statement and provides clear and open reporting. DISCUSSION Publication of the statistical analysis plan serves to reduce potential trial reporting bias and clearly outlines the pre-specified analyses. TRIAL REGISTRATION ClinicalTrials.gov NCT03181360 . EudraCT Number 2014-000096-80 . WHO ICRTP registry number ISRCTN10601890 .
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Affiliation(s)
- Agnethe Eltoft
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway. .,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Melinda B Roaldsen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Clinical Research, University Hospital of North Norway, Tromsø, Norway
| | - Mary-Helen Søyland
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Neurology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
| | - Bent Indredavik
- Department of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu and Tartu University Hospital, Tartu, Estonia
| | - Dalius Jatužis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Stefan T Engelter
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Thompson Robinson
- College of Life Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Arnstein Tveiten
- Department of Neurology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Ellisiv B Mathiesen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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16
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Hu X, Jonzén K, Lindahl OA, Karlsson M, Norström F, Lundström E, Sunnerhagen KS. Evaluating Rehabkompassen® - A Digital Graphic Follow-up Tool for Identifying Rehabilitation Needs Among People With Stroke: A Randomized Clinical Feasibility Study (Preprint). JMIR Hum Factors 2022; 9:e38704. [PMID: 35904867 PMCID: PMC9377427 DOI: 10.2196/38704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 12/01/2022] Open
Abstract
Background Stroke is a leading cause of disability among adults, with heavy social and economic burden worldwide. A cost-effective solution is urgently needed to facilitate the identification of individual rehabilitation needs and thereby provide tailored rehabilitations to reduce disability among people who have had a stroke. A novel digital graphic follow-up tool Rehabkompassen has recently been developed to facilitate capturing the multidimensional rehabilitation needs of people who have had a stroke. Objective The aim of this study was to evaluate the feasibility and acceptability of conducting a definitive trial to evaluate Rehabkompassen as a digital follow-up tool among people who have had a stroke in outpatient clinical settings. Methods This pilot study of Rehabkompassen was a parallel, open-label, 2-arm prospective, proof-of-concept randomized controlled trial (RCT) with an allocation ratio of 1:1 in a single outpatient clinic. Patients who have had a stroke within the 3 previous months, aged ≥18 years, and living in the community were included. The trial compared usual outpatient visits with Rehabkompassen (intervention group) and without Rehabkompassen (control group) at the 3-month follow-up as well as usual outpatient visit with Rehabkompassen at the 12-month follow-up. Information on the recruitment rate, delivery, and uptake of Rehabkompassen; assessment and outcome measures completion rates; the frequency of withdrawals; the loss of follow-up; and satisfaction scores were obtained. The key outcomes were evaluated in both groups. Results In total, 28 patients (14 control, 14 Rehabkompassen) participated in this study, with 100 patients screened. The overall recruitment rate was 28% (28/100). Retention in the trial was 86% (24/28) at the 12-month follow-up. All participants used the tool as planned during their follow-ups, which provided a 100% (24/24) task completion rate of using Rehabkompassen and suggested excellent feasibility. Both patient- and physician-participants reported satisfaction with the instrument (19/24, 79% and 2/2, 100%, respectively). In all, 2 (N=2, 100%) physicians and 18 (N=24, 75%) patients were willing to use the tool in the future. Furthermore, modified Rankin Scale as the primary outcome and various stroke impacts as secondary outcomes were both successfully collected and compared in this study. Conclusions This study demonstrated the high feasibility and adherence of the study protocol as well as the high acceptability of Rehabkompassen among patients who have had a stroke and physicians in an outpatient setting in comparison to the predefined criterion. The information collected in this feasibility study combined with the amendments of the study protocol may improve the future definitive RCT. The results of this trial support the feasibility and acceptability of conducting a large definitive RCT. Trial Registration ClinicalTrials.gov NCT04915027; https://clinicaltrials.gov/ct2/show/NCT04915027
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Affiliation(s)
- Xiaolei Hu
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Karolina Jonzén
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Olof A Lindahl
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Marcus Karlsson
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Fredrik Norström
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Erik Lundström
- Department of Medical Sciences, Neurology, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
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Borota L, Libard S, Fahlström M, Latini F, Lundström E. Correction to: Complete functional recovery in a child after endovascular treatment of basilar artery occlusion caused by spontaneous dissection: a case report. Childs Nerv Syst 2022; 38:1613. [PMID: 35015111 PMCID: PMC9546512 DOI: 10.1007/s00381-022-05444-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ljubisa Borota
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden.
| | - Sylwia Libard
- Department of Pathology, Uppsala University, Uppsala, Sweden
| | - Markus Fahlström
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | - Francesco Latini
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
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18
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Legg LA, Rudberg AS, Hua X, Wu S, Hackett ML, Tilney R, Lindgren L, Kutlubaev MA, Hsieh CF, Barugh AJ, Hankey GJ, Lundström E, Dennis M, Mead GE. Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery. Cochrane Database Syst Rev 2021; 11:CD009286. [PMID: 34780067 PMCID: PMC8592088 DOI: 10.1002/14651858.cd009286.pub4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) might theoretically reduce post-stroke disability by direct effects on the brain. This Cochrane Review was first published in 2012 and last updated in 2019. OBJECTIVES To determine if SSRIs are more effective than placebo or usual care at improving outcomes in people less than 12 months post-stroke, and to determine whether treatment with SSRIs is associated with adverse effects. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched 7 January 2021), Cochrane Controlled Trials Register (CENTRAL, Issue 7 of 12, 7 January 2021), MEDLINE (1946 to 7 January 2021), Embase (1974 to 7 January 2021), CINAHL (1982 to 7 January 2021), PsycINFO (1985 to 7 January 2021), and AMED (1985 to 7 January 2021). PsycBITE had previously been searched (16 July 2018). We searched clinical trials registers. SELECTION CRITERIA We included randomised controlled trials (RCTs) recruiting stroke survivors within the first year. The intervention was any SSRI, at any dose, for any period, and for any indication. The comparator was usual care or placebo. Studies reporting at least one of our primary (disability score or independence) or secondary outcomes (impairments, depression, anxiety, quality of life, fatigue, cognition, healthcare cost, death, adverse events and leaving the study early) were included in the meta-analysis. The primary analysis included studies at low risk of bias. DATA COLLECTION AND ANALYSIS We extracted data on demographics, stroke type and, our pre-specified outcomes, and bias sources. Two review authors independently extracted data. We used mean difference (MD) or standardised mean differences (SMDs) for continuous variables, and risk ratios (RRs) for dichotomous variables, with 95% confidence intervals (CIs). We assessed bias risks and applied GRADE criteria. MAIN RESULTS We identified 76 eligible studies (13,029 participants); 75 provided data at end of treatment, and of these two provided data at follow-up. Thirty-eight required participants to have depression to enter. The duration, drug, and dose varied. Six studies were at low risk of bias across all domains; all six studies did not need participants to have depression to enter, and all used fluoxetine. Of these six studies, there was little to no difference in disability between groups SMD -0.0; 95% CI -0.05 to 0.05; 5 studies, 5436 participants, high-quality evidence) or in independence (RR 0.98; 95% CI 0.93 to 1.03; 5 studies, 5926 participants; high-quality evidence) at the end of treatment. In the studies at low risk of bias across all domains, SSRIs slightly reduced the average depression score (SMD 0.14 lower, 95% CI 0.19 lower to 0.08 lower; 4 studies; 5356 participants, high-quality evidence) and there was a slight reduction in the proportion with depression (RR 0.75, 95% CI 0.65 to 0.86; 3 studies, 5907 participants, high-quality evidence). Cognition was slightly better in the control group (MD -1.22, 95% CI -2.37 to -0.07; 4 studies, 5373 participants, moderate-quality evidence). Only one study (n = 30) reported neurological deficit score (SMD -0.39, 95% CI -1.12 to 0.33; low-quality evidence). SSRIs resulted in little to no difference in motor deficit (SMD 0.03, -0.02 to 0.08; 6 studies, 5518 participants, moderate-quality evidence). SSRIs slightly increased the proportion leaving the study early (RR 1.57, 95% CI 1.03 to 2.40; 6 studies, 6090 participants, high-quality evidence). SSRIs slightly increased the outcome of a seizure (RR 1.40, 95% CI 1.00 to 1.98; 6 studies, 6080 participants, moderate-quality evidence) and a bone fracture (RR 2.35, 95% CI 1.62 to 3.41; 6 studies, 6080 participants, high-quality evidence). One study at low risk of bias across all domains reported gastrointestinal side effects (RR 1.71, 95% CI 0.33, to 8.83; 1 study, 30 participants). There was no difference in the total number of deaths between SSRI and placebo (RR 1.01, 95% CI 0.82 to 1.24; 6 studies, 6090 participants, moderate quality evidence). SSRIs probably result in little to no difference in fatigue (MD -0.06; 95% CI -1.24 to 1.11; 4 studies, 5524 participants, moderate-quality of evidence), nor in quality of life (MD 0.00; 95% CI -0.02 to 0.02, 3 studies, 5482 participants, high-quality evidence). When all studies, irrespective of risk of bias, were included, SSRIs reduced disability scores but not the proportion independent. There was insufficient data to perform a meta-analysis of outcomes at end of follow-up. Several small ongoing studies are unlikely to alter conclusions. AUTHORS' CONCLUSIONS There is high-quality evidence that SSRIs do not make a difference to disability or independence after stroke compared to placebo or usual care, reduced the risk of future depression, increased bone fractures and probably increased seizure risk.
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Affiliation(s)
- Lynn A Legg
- NHS Greater Glasgow and Clyde Health Board, Paisley, UK
| | - Ann-Sofie Rudberg
- Division of Neurology, Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden
| | - Xing Hua
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Maree L Hackett
- Professor, Program Head, Mental Health, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Russel Tilney
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Linnea Lindgren
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Mansur A Kutlubaev
- Department of Neurology, Neurosurgery and Medical Genetics, Bashkir State Medical University, Ufa, Russian Federation
| | - Cheng-Fang Hsieh
- Division of Geriatrics and Gerontology, Department of Internal Medicine and Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Amanda J Barugh
- Department of Geriatric Medicine, University of Edinburgh, Edinburgh, UK
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences,, The University of Western Australia, Perth, Australia
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Gillian E Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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19
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Vahlberg BM, Lundström E, Eriksson S, Holmback U, Cederholm T. Potential effects on cardiometabolic risk factors and body composition by short message service (SMS)-guided training after recent minor stroke or transient ischaemic attack: post hoc analyses of the STROKEWALK randomised controlled trial. BMJ Open 2021; 11:e054851. [PMID: 34663672 PMCID: PMC8524288 DOI: 10.1136/bmjopen-2021-054851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES To evaluate effects of mobile phone text-messaging exercise instructions on body composition, cardiometabolic risk markers and self-reported health at 3 months after stroke. DESIGN Randomised controlled intervention study with per-protocol analyses. SETTING University Hospital in Sweden. PARTICIPANTS Seventy-nine patients (mean (SD) age 64 (10) years, 37% female) ≥18 years with good motor function (modified Rankin Scale ≤2) and capable to perform 6 min walking test at hospital discharge were randomised to either intervention (n=40) or control group (n=39). Key exclusion criteria: subarachnoid bleeding, uncontrolled hypertension, severe psychiatric problems or cognitive limitations. INTERVENTIONS The intervention group received beyond standard care, daily mobile phone instructional text messages to perform regular outdoor walking and functional leg exercises. The control group received standard care. MAIN OUTCOME MEASURES Fat mass and fat-free mass were estimated by bioelectric impedance analysis. Cardiometabolic risk factors like blood lipids, glycated haemoglobin and blood glucose were analysed at baseline and after 3 months. RESULTS Both groups changed favourably in fat-free mass (1.83 kg, 95% CI 0.77 to 2.89; p=0.01, effect size (ES)=0.63 vs 1.22 kg, 95% CI 0.39 to 2.0; p=0.05, ES=0.54) and fat mass (-1.30 kg, 95% CI -2.45 to -0.14; p=0.029, ES=0.41 vs -0.76 kg, 95% CI -1.74 to 0.22; p=0.123, ES=0.28). Also, many cholesterol related biomarkers improved; for example, total cholesterol -0.65 mmol/L, 95% CI -1.10 to -0.2; p=0.06, ES: 0.5 vs -1.1 mmol/L, 95% CI -1.47 to -0.56; p>0.001, ES=0.8. However, there were no between-group differences. At 3 months, 94% and 86%, respectively, reported very good/fairly good health in the text messaging and control groups. CONCLUSIONS No clear effect of 3 months daily mobile phone delivered training instructions was detected on body composition, cardiovascular biochemical risk factors or self-perceived health. Further research is needed to evaluate secondary prevention efforts in larger populations after recent stroke. TRIAL REGISTRATION NUMBER NCT02902367.
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Affiliation(s)
- Birgit Maria Vahlberg
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
| | - Erik Lundström
- Department of Neuroscience, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
| | - Staffan Eriksson
- Centre for Clinical Research, Eskilstuna, Sweden
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Ulf Holmback
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
| | - Tommy Cederholm
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
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Ball EL, Sutherland R, Squires C, Mead GE, Religa D, Lundström E, Cheyne J, Wardlaw JM, Quinn TJ, Shenkin SD. Predicting post-stroke cognitive impairment using acute CT neuroimaging: A systematic review and meta-analysis. Int J Stroke 2021; 17:618-627. [PMID: 34569865 PMCID: PMC9260488 DOI: 10.1177/17474930211045836] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Identifying whether acute stroke patients are at risk of cognitive decline could
improve prognostic discussions and management. Structural computed tomography
neuroimaging is routine in acute stroke, and may identify those at risk of post-stroke
dementia or post-stroke cognitive impairment (PSCI). Aim To systematically review the literature to identify which stroke or pre-stroke features
on brain computed tomography scans, performed at the time of stroke, are associated with
post-stroke dementia or PSCI. Summary of review We searched electronic databases to December 2020. We included studies reporting acute
stroke brain computed tomography, and later diagnosis of a cognitive syndrome. We
created summary estimates of size of unadjusted association between computed tomography
features and cognition. Of 9536 citations, 28 studies (41 papers) were eligible
(N = 7078, mean age 59.8–78.6 years). Cognitive outcomes were post-stroke dementia (10
studies), PSCI (17 studies), and one study analyzed both. Fifteen studies (N = 2952)
reported data suitable for meta-analyses. White matter lesions (WML) (six studies,
N = 1054, OR = 2.46, 95% CI = 1.25–4.84), cerebral atrophy (four studies, N = 558,
OR = 2.80, 95% CI = 1.21–6.51), and pre-existing stroke lesions (three studies, N = 352,
OR = 2.38, 95% CI = 1.06–5.32) were associated with post-stroke dementia. WML (four
studies, N = 473, OR = 3.46, 95% CI = 2.17–5.52) were associated with PSCI. Other
computed tomography features were either not associated with cognitive outcome, or there
were insufficient data. Conclusions Cognitive impairment following stroke is of great concern to patients and carers.
Features seen on visual assessment of acute stroke computed tomography brain scans are
strongly associated with cognitive outcomes. Clinicians should consider when and how
this information should be discussed with stroke survivors.
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Affiliation(s)
- Emily L Ball
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gillian E Mead
- Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Dorota Religa
- Division of Clinical Geriatrics, Karolinska Institutet, Stockholm, Sweden
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Susan D Shenkin
- Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
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21
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Lundström E, Isaksson E, Greilert Norin N, Näsman P, Wester P, Mårtensson B, Norrving B, Wallén H, Borg J, Hankey GJ, Hackett ML, Mead GE, Dennis MS, Sunnerhagen KS. Effects of Fluoxetine on Outcomes at 12 Months After Acute Stroke: Results From EFFECTS, a Randomized Controlled Trial. Stroke 2021; 52:3082-3087. [PMID: 34465201 DOI: 10.1161/strokeaha.121.034705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
[Figure: see text].
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Affiliation(s)
| | - Eva Isaksson
- Uppsala University, Sweden (E.I.).,Department of Clinical Neuroscience, Neurology (E.I.), Karolinska Institutet, Stockholm.,Department of Neurology, Danderyd Hospital, Stockholm, Sweden (E.I.)
| | - Nina Greilert Norin
- Department of Clinical Sciences, Danderyd Hospital (N.G.N.), Karolinska Institutet, Stockholm
| | - Per Näsman
- Centre for Safety Research, KTH Royal Institute of Technology, Stockholm, Sweden (P.N.)
| | - Per Wester
- Department of Clinical Sciences (P.W.), Karolinska Institutet, Stockholm.,Department of Public Health & Clinical Medicine, Umeå University, Sweden (P.W.)
| | - Björn Mårtensson
- Department of Clinical Neurosciences (B.M.), Karolinska Institutet, Stockholm
| | - Bo Norrving
- Department of Clinical Sciences, Neurology, Lund University, Sweden (B.N.)
| | - Håkan Wallén
- Department of Clinical Sciences (H.W.), Karolinska Institutet, Stockholm
| | - Jörgen Borg
- Department of Neuroscience, NeurologyDepartment of Clinical Sciences (J.B.).,Department of Clinical Sciences (J.B.), Karolinska Institutet, Stockholm
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth (G.J.H.).,Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia (G.J.H.)
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales Sydney (M.L.H.).,The University of Central Lancashire, United Kingdom (M.L.H.)
| | - Gillian E Mead
- University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (G.E.M., M.S.D.)
| | - Martin S Dennis
- University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (G.E.M., M.S.D.)
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology-Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.S.)
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22
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Hankey GJ, Hackett ML, Almeida OP, Flicker L, Mead GE, Dennis MS, Etherton-Beer C, Ford AH, Billot L, Jan S, Lung T, Lundström E, Sunnerhagen KS, Anderson CS, Thang-Nguyen H, Gommans J, Yi Q. Twelve-Month Outcomes of the AFFINITY Trial of Fluoxetine for Functional Recovery After Acute Stroke: AFFINITY Trial Steering Committee on Behalf of the AFFINITY Trial Collaboration. Stroke 2021; 52:2502-2509. [PMID: 34015940 DOI: 10.1161/strokeaha.120.033070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The AFFINITY trial (Assessment of Fluoxetine in Stroke Recovery) reported that oral fluoxetine 20 mg daily for 6 months after acute stroke did not improve functional outcome and increased the risk of falls, bone fractures, and seizures. After trial medication was ceased at 6 months, survivors were followed to 12 months post-randomization. This preplanned secondary analysis aimed to determine any sustained or delayed effects of fluoxetine at 12 months post-randomization. METHODS AFFINITY was a randomized, parallel-group, double-blind, placebo-controlled trial in adults (n=1280) with a clinical diagnosis of stroke in the previous 2 to 15 days and persisting neurological deficit who were recruited at 43 hospital stroke units in Australia (n=29), New Zealand (4), and Vietnam (10) between 2013 and 2019. Participants were randomized to oral fluoxetine 20 mg once daily (n=642) or matching placebo (n=638) for 6 months and followed until 12 months after randomization. The primary outcome was function, measured by the modified Rankin Scale, at 6 months. Secondary outcomes for these analyses included measures of the modified Rankin Scale, mood, cognition, overall health status, fatigue, health-related quality of life, and safety at 12 months. RESULTS Adherence to trial medication was for a mean 167 (SD 48) days and similar between randomized groups. At 12 months, the distribution of modified Rankin Scale categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio, 0.93 [95% CI, 0.76-1.14]; P=0.46). Compared with placebo, patients allocated fluoxetine had fewer recurrent ischemic strokes (14 [2.18%] versus 29 [4.55%]; P=0.02), and no longer had significantly more falls (27 [4.21%] versus 15 [2.35%]; P=0.08), bone fractures (23 [3.58%] versus 11 [1.72%]; P=0.05), or seizures (11 [1.71%] versus 8 [1.25%]; P=0.64) at 12 months. CONCLUSIONS Fluoxetine 20 mg daily for 6 months after acute stroke had no delayed or sustained effect on functional outcome, falls, bone fractures, or seizures at 12 months poststroke. The lower rate of recurrent ischemic stroke in the fluoxetine group is most likely a chance finding. Registration: URL: http://www.anzctr.org.au/; Unique identifier: ACTRN12611000774921.
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Affiliation(s)
- Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia (G.J.H., O.P.A., L.F.).,Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia (G.J.H.)
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.L.H., S.J., T.L., C.S.A.).,The University of Central Lancashire, Preston, England (M.L.H.)
| | - Osvaldo P Almeida
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia (G.J.H., O.P.A., L.F.)
| | - Leon Flicker
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia (G.J.H., O.P.A., L.F.).,Royal Perth Hospital, Perth, Western Australia, Australia (L.F.)
| | - Gillian E Mead
- University of Edinburgh, Royal Infirmary, Scotland (G.E.M., M.S.D.)
| | - Martin S Dennis
- University of Edinburgh, Royal Infirmary, Scotland (G.E.M., M.S.D.)
| | | | - Andrew H Ford
- The University of Western Australia, Perth, Western Australia, Australia (C.E.-B., A.H.F.)
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, Sydney, New South Wales, Australia (L.B.).,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia (L.B., T.L., C.S.A.)
| | - Stephen Jan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.L.H., S.J., T.L., C.S.A.)
| | - Thomas Lung
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.L.H., S.J., T.L., C.S.A.).,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia (L.B., T.L., C.S.A.)
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden (E.L.)
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology-Clinical Neuroscience, The Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.S.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.L.H., S.J., T.L., C.S.A.).,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia (L.B., T.L., C.S.A.).,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia (C.S.A.)
| | - Huy Thang-Nguyen
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China (C.S.A.)
| | - John Gommans
- Department of Neurology, The People's Hospital 115, Ho Chi Minh city, Vietnam (H.T.-N.)
| | - Qilong Yi
- Hawke's Bay Hospital, Hastings, New Zealand (J.G.)
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Abzhandadze T, Lundström E, Buvarp D, Eriksson M, Quinn TJ, Sunnerhagen KS. Development of a short-form Swedish version of the Montreal Cognitive Assessment (s-MoCA-SWE): protocol for a cross-sectional study. BMJ Open 2021; 11:e049035. [PMID: 33941639 PMCID: PMC8098968 DOI: 10.1136/bmjopen-2021-049035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Short forms of the Montreal Cognitive Assessment (MoCA) have allowed quick cognitive screening. However, none of the available short forms has been created or validated in a Swedish sample of patients with stroke.The aim is to develop a short-form Swedish version of the MoCA (s-MoCA-SWE) in a sample of patients with acute and subacute stroke. The specific objectives are: (1) to identify a subgroup of MoCA items that have the potential to form the s-MoCA-SWE; (2) to determine the optimal cut-off value of s-MoCA-SWE for predicting cognitive impairment and (3) and to compare the psychometric properties of s-MoCA-SWE with those of previously developed MoCA short forms. METHODS AND ANALYSIS This is a statistical analysis protocol for a cross-sectional study. The study sample will comprise patients from Väststroke, a local stroke registry from Gothenburg, Sweden and Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS), a randomised controlled trial in Sweden. The s-MoCA-SWE will be developed by using exploratory factor analysis and the boosted regression tree algorithm. The cut-off value of s-MoCA-SWE for impaired cognition will be determined based on binary logistic regression analysis. The psychometric properties of s-MoCA-SWE will be compared with those of other MoCA short forms by using cross-tabulation and area under the receiving operating characteristic curve analyses. ETHICS AND DISSEMINATION The Väststroke study has received ethical approval from the Regional Ethical Review Board in Gothenburg (346-16) and the Swedish Ethical Review Authority (amendment 2019-04299). The handling of data generated within the framework of quality registers does not require written informed consent from patients. The EFFECTS study has received ethical approval from the Stockholm Ethics Committee (2013/1265-31/2 on 30 September 2013). All participants provided written consent. Results will be published in an international, peer-reviewed journal, presented at conferences and communicated to clinical practitioners in local meetings and seminars.
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Affiliation(s)
- Tamar Abzhandadze
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Akademiska Sjukhuset, Uppsala, Sweden
| | - Dongni Buvarp
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marie Eriksson
- Department of Statistics, USBE, Umeå University, Umeå, Sweden
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Neurocare, Sahlgrenska University Hospital, Gothenburg, Sweden
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Vahlberg B, Lundström E, Eriksson S, Holmbäck U, Cederholm T. Effects on walking performance and lower body strength by short message service guided training after stroke or transient ischemic attack (The STROKEWALK Study): a randomized controlled trial. Clin Rehabil 2021; 35:276-287. [PMID: 32942914 PMCID: PMC7874373 DOI: 10.1177/0269215520954346] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/11/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate whetherdaily mobile-phone delivered messages with training instructions during three months increase physical activity and overall mobility in patients soon after stroke or transient ischemic attack. DESIGN Randomised controlled trial with intention-to-treat analyses. SETTING University hospital. Data collection from November 2016 until December2018. SUBJECTS Seventy-nine patients (mean (SD) age 63.9 (10.4) years, 29 were women) were allocated to either intervention (n = 40) or control group (n = 39). Participants had to be independent (modified Ranking Scale ⩽2) and able to perform the six-minute walking test at discharge from the hospital. INTERVENTIONS The intervention group received standard care and daily mobile phone instructional text messages to perform regular outdoor walking and functional leg exercises. The control group received standard care; that is, primary care follow-up. MAIN MEASURES Walking performance by six-minute walking test (m), lower body strength by five times chair-stand test (s), the short physical performance battery (0-12 points) and 10-metres walk test (m/s) were assessed at baseline and after three months. RESULTS The estimated median difference in the six-minute walking test was in favour of the intervention group by 30 metres (95% CI, 55 to 1; effect size 0.64; P = 0.037) and in the chair-stand test by 0.88 seconds (95% CI, 0.02 to 1.72; effect size 0.64; P = 0.034). There were no differences between groups on the short physical performance battery or in 10-metres walking time. CONCLUSIONS Three months of daily mobile phone text messages with guided training instructions improved composite mobility measures; that is, walking performanceand lower body strength. CLINICAL TRIAL REGISTRY The study is registered with ClinicalTrials.gov, number NCT02902367.
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Affiliation(s)
- Birgit Vahlberg
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Staffan Eriksson
- Department of Neuroscience, Physiotherapy, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research, Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Sweden
| | - Ulf Holmbäck
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
| | - Tommy Cederholm
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
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Hedlund F, Leighs A, Barber PA, Lundström E, Wu TY, Ranta A. Trends in stroke reperfusion treatment and outcomes in New Zealand. Intern Med J 2020; 50:1367-1372. [DOI: 10.1111/imj.14682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/15/2019] [Accepted: 10/20/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Fredrik Hedlund
- Department of Medicine University of Otago Wellington New Zealand
- Department of Neuroscience, Neurology Uppsala University Uppsala Sweden
| | - Andrew Leighs
- Department of Medicine University of Otago Wellington New Zealand
| | - P. Alan Barber
- Department of Medicine University of Auckland Auckland New Zealand
| | - Erik Lundström
- Department of Neuroscience, Neurology Uppsala University Uppsala Sweden
| | - Teddy Y. Wu
- Department of Neurology Christchurch Hospital Christchurch New Zealand
| | - Annemarei Ranta
- Department of Medicine University of Otago Wellington New Zealand
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Isaksson E, Wester P, Laska AC, Näsman P, Lundström E. Validation of the Simplified Modified Rankin Scale Questionnaire. Eur Neurol 2020; 83:493-499. [PMID: 33027792 DOI: 10.1159/000510721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/05/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The modified Rankin scale (mRS) is the most common assessment tool for measuring overall functional outcome in stroke studies. The traditional way of using mRS face-to-face is time- and cost-consuming. The aim of this study was to test the validity of the Swedish translation of the simplified modified Rankin scale questionnaire (smRSq) as compared with the mRS assessed face-to-face 6 months after a stroke. METHODS Within the ongoing EFFECTS trial, smRSq was sent out to 108 consecutive stroke patients 6 months after a stroke. The majority, 90% (97/108), of the patients answered the questionnaire; for the remaining 10%, it was answered by the next of kin. The patients were assessed by face-to-face mRS by 7 certified healthcare professionals at 4 Swedish stroke centres. The primary outcome was assessed by Cohen's kappa and weighted kappa. RESULTS There was good agreement between postal smRSq, answered by the patients, and the mRS face-to-face; Cohen's kappa was 0.43 (CI 95% 0.31-0.55), weighted kappa was 0.64 (CI 95% 0.55-0.73), and Spearman rank correlation was 0.82 (p < 0.0001). In 55% (59/108), there was full agreement, and of the 49 patients not showing exact agreement, 44 patients differed by 1 grade and 5 patients had a difference of 2 grades. DISCUSSION/CONCLUSION Our results show good validity of the postal smRSq, answered by the patients, compared with the mRS carried out face-to-face at 6 months after a stroke. This result could help trialists in the future simplify study design and make multicentre trials and quality registers with a large number of patients more feasible and time-saving.
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Affiliation(s)
- Eva Isaksson
- Department of Neurology, Danderyd Hospital, Stockholm, Sweden and Department of Clinical Neuroscience, Neurology, Karolinska Institutet, Stockholm, Sweden,
| | - Per Wester
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm and Department of Public Health & Clinical Medicine, Umeå University, Umeå, Sweden
| | - Ann Charlotte Laska
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Per Näsman
- Center for Safety Research, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Akademiska sjukhuset, Uppsala, Sweden
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Rudberg AS, Berge E, Laska AC, Jutterström S, Näsman P, Sunnerhagen KS, Lundström E. Stroke survivors' priorities for research related to life after stroke. Top Stroke Rehabil 2020; 28:153-158. [PMID: 32627722 DOI: 10.1080/10749357.2020.1789829] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Stroke has transitioned from an untreatable, unpreventable disease to a highly treatable and preventable disease over recent decades, and the number of stroke survivors is expected to increase. The number is also foreseen to grow larger as a result of an aging population. With an escalating number of stroke survivors, research on how to improve life after stroke is needed. AIMS The primary aim was to determine which area of research related to life after stroke that stroke patients and their informal carers prioritized as being relevant and valuable. METHODS A cross-sectional study of all patients who had completed the 12 months of follow-up in the EFFECTS trial. In the questionnaire the stroke patients and their informal carers were asked to prioritize areas of research they considered important and valuable with respect to their life after stroke. RESULTS Of the 731 patients who were still alive after the 12 months-follow-up, 589 responded. The most prioritized areas of research were Balance and walking difficulties (290 (49%) responders) and Post-stroke fatigue (173 (29%) responders). Women answered the undefined alternative "other" more often than men (43 women (11%) versus 11 men (6%), p = .04). Younger patients prioritized Post-stroke fatigue to a higher extent (88 (45%) versus (22%), p < .001), and elderly prioritized Balance and walking difficulties (214 (54%) versus 76 (40%), p = .002) and Speech difficulties (38 (10%) versus 9 (5%), p = .045). CONCLUSIONS Life after stroke is perceived differentely with aging. Future research should address strategies to face challenges such as imbalance and walking difficulties and post-stroke-fatigue.
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Affiliation(s)
- Ann-Sofie Rudberg
- Department of Clinical Neuroscience, Karolinska Institutet , Stockholm, Sweden.,Department of Neurology, Danderyd Hospital , Stockholm, Sweden
| | - Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital , Oslo, Norway.,Institute of Clinical Medicine, University of Tromsø , Tromsø, Norway
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital , Stockholm, Sweden
| | - Stina Jutterström
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital , Stockholm, Sweden
| | - Per Näsman
- Center for Safety Research, KTH Royal Institute of Technology , Stockholm, Sweden
| | - Katharina S Sunnerhagen
- Clin Neuroscience, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, Univ of Gothenburg , Göteborg, Sweden
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University , Uppsala, Sweden
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Legg LA, Tilney R, Hsieh CF, Wu S, Lundström E, Rudberg AS, Kutlubaev MA, Dennis M, Soleimani B, Barugh A, Hackett ML, Hankey GJ, Mead GE. Selective Serotonin Reuptake Inhibitors for Stroke Recovery. Stroke 2020; 51:e142-e143. [PMID: 32552532 DOI: 10.1161/strokeaha.120.029329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Lynn A Legg
- NHS Greater Glasgow and Clyde Health, Paisley, United Kingdom (L.A.L.)
| | - Russel Tilney
- Department of Medicine, Mater Dei Hospital, Msida, Malta (R.T.)
| | - Cheng-Fang Hsieh
- Division of Geriatrics and Gerontology, Departments of Internal Medicine and Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan (C.-F.H.)
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China (S.W.)
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Sweden (E.L.)
| | - Ann-Sofie Rudberg
- Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden (A.-S.R.).,Department of Neurology, Danderyd Hospital, Sweden (A.-S.R.)
| | - Mansur A Kutlubaev
- Department of Neurology, Neurosurgery and Medical Genetics, Bashkir State Medical University, Ufa, Russian Federation (M.A.K.)
| | - Martin Dennis
- Centre for Clinical Brain Sciences (M.D.), University of Edinburgh, United Kingdom
| | - Babak Soleimani
- Department of Stroke Medicine, Royal Infirmary of Edinburgh, United Kingdom (B.S.).,Department of General Medicine, Borders General Hospital, Melrose, United Kingdom (B.S.)
| | - Amanda Barugh
- Department of Geriatric Medicine (A.B), University of Edinburgh, United Kingdom
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (M.L.H.)
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia (G.J.H.)
| | - Gillian E Mead
- Centre for Clinical Brain Sciences (G.E.M.), University of Edinburgh, United Kingdom
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Dennis M, Forbes J, Graham C, Hackett M, Hankey GJ, House A, Lewis S, Lundström E, Sandercock P, Mead G. Fluoxetine to improve functional outcomes in patients after acute stroke: the FOCUS RCT. Health Technol Assess 2020; 24:1-94. [PMID: 32452356 PMCID: PMC7294394 DOI: 10.3310/hta24220] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Our Cochrane review of selective serotonin inhibitors for stroke recovery indicated that fluoxetine may improve functional recovery, but the trials were small and most were at high risk of bias. OBJECTIVES The Fluoxetine Or Control Under Supervision (FOCUS) trial tested the hypothesis that fluoxetine improves recovery after stroke. DESIGN The FOCUS trial was a pragmatic, multicentre, parallel-group, individually randomised, placebo-controlled trial. SETTING This trial took place in 103 UK hospitals. PARTICIPANTS Patients were eligible if they were aged ≥ 18 years, had a clinical stroke diagnosis, with focal neurological deficits, between 2 and 15 days after onset. INTERVENTIONS Patients were randomly allocated 20 mg of fluoxetine once per day or the matching placebo for 6 months via a web-based system using a minimisation algorithm. MAIN OUTCOME MEASURES The primary outcome was the modified Rankin Scale at 6 months. Patients, carers, health-care staff and the trial team were masked to treatment allocation. Outcome was assessed at 6 and 12 months after randomisation. Patients were analysed by their treatment allocation as specified in a published statistical analysis plan. RESULTS Between 10 September 2012 and 31 March 2017, we recruited 3127 patients, 1564 of whom were allocated fluoxetine and 1563 of whom were allocated placebo. The modified Rankin Scale score at 6 months was available for 1553 out of 1564 (99.3%) of those allocated fluoxetine and 1553 out of 1563 (99.4%) of those allocated placebo. The distribution across modified Rankin Scale categories at 6 months was similar in the two groups (common odds ratio adjusted for minimisation variables 0.951, 95% confidence interval 0.839 to 1.079; p = 0.439). Compared with placebo, patients who were allocated fluoxetine were less likely to develop a new episode of depression by 6 months [210 (13.0%) vs. 269 (16.9%), difference -3.78%, 95% confidence interval -1.26% to -6.30%; p = 0.003], but had more bone fractures [45 (2.9%) vs. 23 (1.5%), difference 1.41%, 95% confidence interval 0.38% to 2.43%; p = 0.007]. There were no statistically significant differences in any other recorded events at 6 or 12 months. Health economic analyses showed no differences between groups in health-related quality of life, hospital bed usage or health-care costs. LIMITATIONS Some non-adherence to trial medication, lack of face-to-face assessment of neurological status at follow-up and lack of formal psychiatric diagnosis during follow-up. CONCLUSIONS 20 mg of fluoxetine daily for 6 months after acute stroke did not improve patients' functional outcome but decreased the occurrence of depression and increased the risk of fractures. These data inform decisions about using fluoxetine after stroke to improve functional outcome or to prevent or treat mood disorders. The Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) (Australasia/Vietnam) and Efficacy oF Fluoxetine - a randomisEd Controlled Trial in Stroke (EFFECTS) (Sweden) trials recruited an additional 2780 patients and will report their results in 2020. These three trials have an almost identical protocol, which was collaboratively developed. Our planned individual patient data meta-analysis will provide more precise estimates of the effects of fluoxetine after stroke and indicate whether or not effects vary depending on patients' characteristics and health-care setting. TRIAL REGISTRATION Current Controlled Trials ISRCTN83290762. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 22. See the NIHR Journals Library website for further project information. The Stroke Association (reference TSA 2011101) funded the start-up phase.
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Affiliation(s)
- Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - John Forbes
- Health Research Institute, University of Limerick, Limerick, Ireland
| | - Catriona Graham
- Edinburgh Clinical Research Facility, University of Edinburgh, Edinburgh, UK
| | - Maree Hackett
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Graeme J Hankey
- Medical School, University of Western Australia, Crawley, WA, Australia
| | - Allan House
- Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stephanie Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Erik Lundström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Lundström E, Isaksson E, Näsman P, Wester P, Mårtensson B, Norrving B, Wallén H, Borg J, Dennis M, Mead G, Hankey GJ, Hackett ML, Sunnerhagen KS. Update on the EFFECTS study of fluoxetine for stroke recovery: a randomised controlled trial in Sweden. Trials 2020; 21:233. [PMID: 32111264 PMCID: PMC7048055 DOI: 10.1186/s13063-020-4124-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/30/2020] [Indexed: 12/13/2022] Open
Abstract
Studies have suggested that fluoxetine might improve neurological recovery after stroke, but the results remain inconclusive. The EFFECTS (Efficacy oF Fluoxetine - a randomisEd Controlled Trial in Stroke) reached its recruitment target of 1500 patients in June 2019. The purpose of this article is to present all amendments to the protocol and describe how we formed the EFFECTS trial collaboration in Sweden. METHODS In this investigator-led, multicentre, parallel-group, randomised, placebo-controlled trial, we enrolled non-depressed stroke patients aged 18 years or older between 2 and 15 days after stroke onset. The patients had a clinical diagnosis of stroke (ischaemic or intracerebral haemorrhage) with persisting focal neurological deficits. Patients were randomised to fluoxetine 20 mg or matching placebo capsules once daily for 6 months. RESULTS Seven amendments were made and included clarification of drug interaction between fluoxetine and metoprolol and the use of metoprolol for severe heart failure as an exclusion criterion, inclusion of data from central Swedish registries and the Swedish Stroke Register, changes in informed consent from patients, and clarification of design of some sub-studies. EFFECTS recruited 1500 patients at 35 centres in Sweden between 20 October 2014 and 28 June 2019. We plan to unblind the data in January 2020 and report the primary outcome in May 2020. CONCLUSION EFFECTS will provide data on the safety and efficacy of 6 months of treatment with fluoxetine after stroke in a Swedish health system setting. The data from EFFECTS will also contribute to an individual patient data meta-analysis. TRIAL REGISTRATION EudraCT 2011-006130-16. Registered on 8 August 2014. ISRCTN, ISRCTN13020412. Registered on 19 December 2014. ClinicalTrials.gov: NCT02683213. Retrospectively registered on 2 February 2016.
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Affiliation(s)
- Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Akademiska Sjukhuset, SE-751 85, Uppsala, Sweden.
| | - Eva Isaksson
- Department of Clinical Neuroscience, Neurology, Karolinska Institutet, Nobels väg 6, SE-171 76, Stockholm, Sweden
| | - Per Näsman
- Centre for Safety Research, KTH Royal Institute of Technology, TR10 B, SE-100 44, Stockholm, Sweden
| | - Per Wester
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, SE-182 88, Stockholm, Sweden
- Department of Public Health & Clinical Medicine, Umeå University, SE-901 87, Umeå, Sweden
| | - Björn Mårtensson
- Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Bo Norrving
- Department of Clinical Sciences, Lund, Neurology, Skåne University Hospital, Lund University, SE-221 85, Lund, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, SE-182 88, Stockholm, Sweden
| | - Jörgen Borg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, SE-182 88, Stockholm, Sweden
| | - Martin Dennis
- Royal Infirmary, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Gillian Mead
- Royal Infirmary, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, Australia
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales Sydney, Sydney, Australia
- The University of Central Lancashire, Preston, UK
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Riga Stradins University, Riga, Latvia
- Sunnaas Rehabilitation Hospital, Bjørnemy, Norway
- Rehabilitation Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Robert C, Lejeune F, Lebbé C, Lesimple T, Lundström E, Nicolas V, Gavillet B, Grégoire V, Crompton P. Combination of Triptorelin with Nivolumab in ICI Resistant Advanced Melanoma. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz451.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Legg LA, Tilney R, Hsieh C, Wu S, Lundström E, Rudberg A, Kutlubaev MA, Dennis M, Soleimani B, Barugh A, Hackett ML, Hankey GJ, Mead GE. Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery. Cochrane Database Syst Rev 2019; 2019:CD009286. [PMID: 31769878 PMCID: PMC6953348 DOI: 10.1002/14651858.cd009286.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Stroke is a major cause of adult disability. Selective serotonin reuptake inhibitors (SSRIs) have been used for many years to manage depression and other mood disorders after stroke. The 2012 Cochrane Review of SSRIs for stroke recovery demonstrated positive effects on recovery, even in people who were not depressed at randomisation. A large trial of fluoxetine for stroke recovery (fluoxetine versus placebo under supervision) has recently been published, and it is now appropriate to update the evidence. OBJECTIVES To determine if SSRIs are more effective than placebo or usual care at improving outcomes in people less than 12 months post-stroke, and to determine whether treatment with SSRIs is associated with adverse effects. SEARCH METHODS For this update, we searched the Cochrane Stroke Group Trials Register (last searched 16 July 2018), the Cochrane Controlled Trials Register (CENTRAL, Issue 7 of 12, July 2018), MEDLINE (1946 to July 2018), Embase (1974 to July 2018), CINAHL (1982 July 2018), PsycINFO (1985 to July 2018), AMED (1985 to July 2018), and PsycBITE March 2012 to July 2018). We also searched grey literature and clinical trials registers. SELECTION CRITERIA We included randomised controlled trials (RCTs) that recruited ischaemic or haemorrhagic stroke survivors at any time within the first year. The intervention was any SSRI, given at any dose, for any period, and for any indication. We excluded drugs with mixed pharmacological effects. The comparator was usual care or placebo. To be included, trials had to collect data on at least one of our primary (disability score or independence) or secondary outcomes (impairments, depression, anxiety, quality of life, fatigue, healthcare cost, death, adverse events and leaving the trial early). DATA COLLECTION AND ANALYSIS We extracted data on demographics, type of stroke, time since stroke, our primary and secondary outcomes, and sources of bias. Two review authors independently extracted data from each trial. We used standardised mean differences (SMDs) to estimate treatment effects for continuous variables, and risk ratios (RRs) for dichotomous effects, with their 95% confidence intervals (CIs). We assessed risks of bias and applied GRADE criteria. MAIN RESULTS We identified a total of 63 eligible trials recruiting 9168 participants, most of which provided data only at end of treatment and not at follow-up. There was a wide age range. About half the trials required participants to have depression to enter the trial. The duration, drug, and dose varied between trials. Only three of the included trials were at low risk of bias across the key 'Risk of bias' domains. A meta-analysis of these three trials found little or no effect of SSRI on either disability score: SMD -0.01 (95% CI -0.09 to 0.06; P = 0.75; 2 studies, 2829 participants; moderate-quality evidence) or independence: RR 1.00 (95% CI 0.91 to 1.09; P = 0.99; 3 studies, 3249 participants; moderate-quality evidence). We downgraded both these outcomes for imprecision. SSRIs reduced the average depression score (SMD 0.11 lower, 0.19 lower to 0.04 lower; 2 trials, 2861 participants; moderate-quality evidence), but there was a higher observed number of gastrointestinal side effects among participants treated with SSRIs compared to placebo (RR 2.19, 95% CI 1.00 to 4.76; P = 0.05; 2 studies, 148 participants; moderate-quality evidence), with no evidence of heterogeneity (I2 = 0%). For seizures there was no evidence of a substantial difference. When we included all trials in a sensitivity analysis, irrespective of risk of bias, SSRIs appeared to reduce disability scores but not dependence. One large trial (FOCUS) dominated the results. We identified several ongoing trials, including two large trials that together will recruit more than 3000 participants. AUTHORS' CONCLUSIONS We found no reliable evidence that SSRIs should be used routinely to promote recovery after stroke. Meta-analysis of the trials at low risk of bias indicate that SSRIs do not improve recovery from stroke. We identified potential improvements in disability only in the analyses which included trials at high risk of bias. A further meta-analysis of large ongoing trials will be required to determine the generalisability of these findings.
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Affiliation(s)
- Lynn A Legg
- NHS Greater Glasgow and Clyde Health BoardRoyal Alexandra HospitalPaisleyUKPA2 9PN
| | | | - Cheng‐Fang Hsieh
- Kaohsiung Medical UniversityDivision of Geriatrics and Gerontology, Department of Internal Medicine and Department of Neurology, Kaohsiung Medical University HospitalKaohsiungTaiwan
| | - Simiao Wu
- West China Hospital, Sichuan UniversityDepartment of NeurologyChengduChina
| | - Erik Lundström
- Uppsala UniversityDepartment of Neuroscience, NeurologyUppsalaSweden
| | - Ann‐Sofie Rudberg
- Karolinska InstitutetDepartment of Clinical NeurosciencesStockholmSweden
- Danderyd HospitalDepartment of NeurologyDanderydSweden
| | - Mansur A Kutlubaev
- Bashkir State Medical UniversityDepartment of Neurology, Neurosurgery and Medical GeneticsUfaRussian Federation
| | - Martin Dennis
- University of EdinburghCentre for Clinical Brain SciencesEdinburghUK
| | - Babak Soleimani
- Royal Infirmary of EdinburghDepartment of Stroke Medicine51 Little France CrescentEdinburghUKEH16 4SA
- Borders General HospitalDepartment of General MedicineMelroseScotlandUK
| | - Amanda Barugh
- University of EdinburghDepartment of Geriatric MedicineEdinburghUK
| | - Maree L Hackett
- The University of SydneySydney School of Public Health, Faculty of Medicine and HealthSydneyNSWAustralia2050
| | - Graeme J Hankey
- The University of Western AustraliaMedical School, Faculty of Health and Medical Sciences,6 Verdun StreetNedlandsPerthWestern AustraliaAustralia6009
| | - Gillian E Mead
- University of EdinburghCentre for Clinical Brain SciencesEdinburghUK
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Dennis M, Forbes J, Graham C, Hackett ML, Hankey GJ, House A, Lewis S, Lundström E, Sandercock P, Mead G. Fluoxetine and Fractures After Stroke. Stroke 2019; 50:3280-3282. [DOI: 10.1161/strokeaha.119.026639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background and Purpose—
The FOCUS trial (Fluoxetine or Control Under Supervision) showed that fluoxetine did not improve modified Rankin Scale scores (mRS) but increased the risk of fractures. We aimed to describe the fractures, their impact on mRS and factors associated with fracture risk.
Methods—
A United Kingdom, multicenter, parallel-group, randomized, placebo-controlled trial. Patients ≥18 years with a clinical stroke and persisting deficit assessed 2 to 15 days after onset were eligible. Consenting patients were allocated fluoxetine 20 mg or matching placebo for 6 months. The primary outcome was the mRS at 6 months and secondary outcomes included fractures.
Results—
Sixty-five of 3127 (2.1%) patients had 67 fractures within 6 months of randomization; 43 assigned fluoxetine and 22 placebo. Fifty-nine (90.8%) had fallen and 26 (40%) had fractured their neck of femur. The effect of fluoxetine on mRS (common odds ratio =0.951) was not significantly altered by excluding fracture patients (common odds ratio =0.961). Cox proportional hazards modeling showed that only age >70 year (hazard ratio =1.97; 95% CI, 1.13–3.45;
P
=0.017), female sex (hazard ratio =2.13; 95% CI, 1.29–3.51;
P
=0.003), and fluoxetine (hazard ratio =2.00; 95% CI, 1.20–3.34;
P
=0.008) were independently associated with fractures.
Conclusions—
Most fractures resulted from falls. Although many fractures were serious, and likely to impair patients’ function, the increased fracture risk did not explain the lack of observed effect of fluoxetine on mRS. Only increasing age, female sex, and fluoxetine were independent predictors of fractures.
Clinical Trial Registration—
URL:
http://www.controlled-trials.com
. Unique identifier: ISRCTN83290762.
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Affiliation(s)
- Martin Dennis
- From the CCBS (M.D., P.S., G.M.), University of Edinburgh, United Kingdom
| | - John Forbes
- Health Research Institute, University of Limerick, Ireland (J.F.)
| | | | - Maree L. Hackett
- The George Institute for Global Health, University of New South Wales, Australia (M.L.H.)
- Faculty of Health and Wellbeing, The University of Central Lancashire, Preston, United Kingdom (M.L.H.)
| | | | - Allan House
- Institute of Health Sciences, University of Leeds, United Kingdom (A.H.)
| | - Steff Lewis
- ECTU (S.L.), University of Edinburgh, United Kingdom
| | - Erik Lundström
- Department of Neuroscience, Uppsala University, Sweden (E.L.)
| | - Peter Sandercock
- From the CCBS (M.D., P.S., G.M.), University of Edinburgh, United Kingdom
| | - Gillian Mead
- From the CCBS (M.D., P.S., G.M.), University of Edinburgh, United Kingdom
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Mead GE, Legg L, Tilney R, Hsieh CF, Wu S, Lundström E, Rudberg AS, Kutlubaev M, Dennis MS, Soleimani B, Barugh A, Hackett ML, Hankey GJ. Fluoxetine for stroke recovery: Meta-analysis of randomized controlled trials. Int J Stroke 2019; 15:365-376. [PMID: 31619137 DOI: 10.1177/1747493019879655] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine whether fluoxetine, at any dose, given within the first year after stroke to patients who did not have to have mood disorders at randomization reduced disability, dependency, neurological deficits and fatigue; improved motor function, mood, and cognition at the end of treatment and follow-up, with the same number or fewer adverse effects. METHODS Searches (from 2012) in July 2018 included databases, trials registers, reference lists, and contact with experts. Co-primary outcomes were dependence and disability. Dichotomous data were synthesized using risk ratios (RR) and continuous data using standardized mean differences (SMD). Quality was appraised using Cochrane risk of bias methods. Sensitivity analyses explored influence of study quality. RESULTS The searches identified 3414 references of which 499 full texts were assessed for eligibility. Six new completed RCTs (n = 3710) were eligible, and were added to the seven trials identified in a 2012 Cochrane review (total: 13 trials, n = 4145). There was no difference in the proportion independent (3 trials, n = 3249, 36.6% fluoxetine vs. 36.7% control; RR 1.00, 95% confidence interval 0.91 to 1.09, p = 0.99, I2 = 78%) nor in disability (7 trials n = 3404, SMD 0.05, -0.02 to 0.12 p = 0.15, I2 = 81%) at end of treatment. Fluoxetine was associated with better neurological scores and less depression. Among the four (n = 3283) high-quality RCTs, the only difference between groups was lower depression scores with fluoxetine. CONCLUSION This class I evidence demonstrates that fluoxetine does not reduce disability and dependency after stroke but improves depression.
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Affiliation(s)
- Gillian E Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Lynn Legg
- Department of Medicine for the Elderly, Royal Alexandra Hospital, Paisley
| | - Russel Tilney
- Department of Neuroscience, Mater Dei Hospital, Msida, Malta
| | - Cheng Fang Hsieh
- Division of Geriatrics and Gerontology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung.,Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Erik Lundström
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Ann Sofie Rudberg
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Department of Neurology, Danderyd hospital, Sweden
| | - Mansur Kutlubaev
- Department of Neurology, G.G. Kuvatov Republican Clinical Hospital, Ufa, Russia.,Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | | | | | | | - Maree L Hackett
- Faculty of Medicine, UNSW Sydney, Sydney, Australia.,The University of Central Lancashire, Lancashire, UK.,The George Institute for Global Health, UNSW, Sydney, Australia
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, Australia
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Ahmed N, Audebert H, Turc G, Cordonnier C, Christensen H, Sacco S, Sandset EC, Ntaios G, Charidimou A, Toni D, Pristipino C, Köhrmann M, Kuramatsu JB, Thomalla G, Mikulik R, Ford GA, Martí-Fàbregas J, Fischer U, Thoren M, Lundström E, Rinkel GJ, van der Worp HB, Matusevicius M, Tsivgoulis G, Milionis H, Rubiera M, Hart R, Moreira T, Lantz M, Sjöstrand C, Andersen G, Schellinger P, Kostulas K, Sunnerhagen KS, Keselman B, Korompoki E, Purrucker J, Khatri P, Whiteley W, Berge E, Mazya M, Dippel DW, Mustanoja S, Rasmussen M, Söderqvist ÅK, Escudero-Martínez I, Steiner T. Consensus statements and recommendations from the ESO-Karolinska Stroke Update Conference, Stockholm 11-13 November 2018. Eur Stroke J 2019; 4:307-317. [PMID: 31903429 DOI: 10.1177/2396987319863606] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/22/2019] [Indexed: 11/16/2022] Open
Abstract
The purpose of the European Stroke Organisation-Karolinska Stroke Update Conference is to provide updates on recent stroke therapy research and to give an opportunity for the participants to discuss how these results may be implemented into clinical routine. The meeting started 22 years ago as Karolinska Stroke Update, but since 2014 it is a joint conference with European Stroke Organisation. Importantly, it provides a platform for discussion on the European Stroke Organisation guidelines process and on recommendations to the European Stroke Organisation guidelines committee on specific topics. By this, it adds a direct influence from stroke professionals otherwise not involved in committees and work groups on the guideline procedure. The discussions at the conference may also inspire new guidelines when motivated. The topics raised at the meeting are selected by the scientific programme committee mainly based on recent important scientific publications. This year's European Stroke Organisation-Karolinska Stroke Update Meeting was held in Stockholm on 11-13 November 2018. There were 11 scientific sessions discussed in the meeting including two short sessions. Each session except the short sessions produced a consensus statement (Full version with background, issues, conclusions and references are published as web-material and at www.eso-karolinska.org and http://eso-stroke.org) and recommendations which were prepared by a writing committee consisting of session chair(s), scientific secretary and speakers. These statements were presented to the 250 participants of the meeting. In the open meeting, general participants commented on the consensus statement and recommendations and the final document were adjusted based on the discussion from the general participants Recommendations (grade of evidence) were graded according to the 1998 Karolinska Stroke Update meeting with regard to the strength of evidence. Grade A Evidence: Strong support from randomised controlled trials and statistical reviews (at least one randomised controlled trial plus one statistical review). Grade B Evidence: Support from randomised controlled trials and statistical reviews (one randomised controlled trial or one statistical review). Grade C Evidence: No reasonable support from randomised controlled trials, recommendations based on small randomised and/or non-randomised controlled trials evidence.
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Affiliation(s)
- Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (N Ahmed, Conference Chair)
| | - Heinrich Audebert
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences & Université de Paris & INSERM U1266, Paris, France
| | - Charlotte Cordonnier
- Department of Neurology, Stroke Unit, Roger Salengro Hospital, 59037 Lille, France
| | - Hanne Christensen
- Department of Neurology Neurology, Stroke Consultant at Bispebjerg & Frederiksberg Hospitals, Copenhagen, Denmark
| | - Simona Sacco
- Department of Applied Clinical sciences and Biotechnology, Section of Neurology, University of L'Alquila, L'Alquila, Italy
| | | | - George Ntaios
- Department of Internal Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Biopolis, Larissa, Greece
| | - Andreas Charidimou
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Danilo Toni
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Pristipino
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Köhrmann
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Joji B Kuramatsu
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Götz Thomalla
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Mikulik
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Gary A Ford
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Joan Martí-Fàbregas
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Urs Fischer
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Magnus Thoren
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Erik Lundström
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Gabriel Je Rinkel
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - H Bart van der Worp
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Marius Matusevicius
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Georgios Tsivgoulis
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Haralampos Milionis
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Marta Rubiera
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Hart
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Tiago Moreira
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Lantz
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Christina Sjöstrand
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Grethe Andersen
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Schellinger
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Konstantinos Kostulas
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina Stibrant Sunnerhagen
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Boris Keselman
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Eleni Korompoki
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Purrucker
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Pooja Khatri
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - William Whiteley
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Eivind Berge
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Mazya
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Diederik Wj Dippel
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Satu Mustanoja
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Mads Rasmussen
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Åsa Kuntze Söderqvist
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Irene Escudero-Martínez
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
| | - Thorsten Steiner
- Department of Neurology, Charité -- Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany. Center for Stroke Research, Charité -- Universitätsmedizin Berlin, Berlin, Germany
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Dennis M, Mead G, Forbes J, Graham C, Hackett M, Hankey GJ, House A, Lewis S, Lundström E, Sandercock P, Innes K, Williams C, Drever J, Mcgrath A, Deary A, Fraser R, Anderson R, Walker P, Perry D, Mcgill C, Buchanan D, Chun Y, Dinsmore L, Maschauer E, Barugh A, Mikhail S, Blair G, Hoeritzauer I, Scott M, Fraser G, Lawrence K, Shaw A, Williamson J, Burgess D, Macleod M, Morales D, Sullivan F, Brady M, French R, Van Wijck F, Watkins C, Proudfoot F, Skwarski J, Mcgowan D, Murphy R, Burgess S, Rutherford W, Mccormick K, Buchan R, Macraild A, Paulton R, Fazal A, Taylor P, Parakramawansha R, Hunter N, Perry J, Bamford J, Waugh D, Veraque E, Bedford C, Kambafwile M, Idrovo L, Makawa L, Smalley P, Randall M, Thirugnana-Chandran T, Hassan A, Vowden R, Jackson J, Bhalla A, Rudd A, Tam CK, Birns J, Gibbs C, Lee Carbon L, Cattermole E, Marks K, Cape A, Hurley L, Kullane S, Smyth N, Eglinton C, Wilson J, Giallombardo E, Frith A, Reidy P, Pitt M, Sykes L, Dellafera D, Croome V, Kerwood L, Hancevic M, Narh C, Merritt C, Duffy J, Cooke D, Willson J, Ali A, Naqvi A, Kamara C, Bowler H, Bell S, Jackson T, Harkness K, Stocks K, Duty S, Doyle C, Dunn G, Endean K, Claydon F, Richards E, Howe J, Lindert R, Majid A, Dakin K, Maatouk A, Barron L, Meegada M, Rana P, Nair A, Brighouse-Johnson C, Greig J, Kyu M, Prasad S, Robinson M, Alam I, Mclean B, Greenhalgh L, Ahmed Z, Roffe C, Brammer S, Beardmore C, Finney K, Barry A, Hollinshead P, Grocott J, Maguire H, Natarajan I, Chembala J, Sanyal R, Lijko S, Abano N, Remegoso A, Ferdinand P, Stevens S, Varquez R, Causley C, Butler A, Whitmore P, Stephen C, Carpio R, Hiden J, Muddegowda G, Denic H, Sword J, Curwen R, James M, Mudd P, Hall F, Cageao J, Keenan S, Roughan C, Kingwell H, Hemsley A, Lohan C, Davenport S, Bowring A, Chapter T, Hough M, Strain D, Gupwell K, Miller K, Goff A, Cusack E, Todd S, Partridge R, Jennings G, Thorpe K, Stephenson J, Littlewood K, Barber M, Brodie F, Marshall S, Esson D, Coburn I, Mcinnes C, Ross F, Bowie E, 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Spurway J, Collins K, Bakawala R, Hughes C, Oconnell S, Hill L, Chatterjee K, Webster T, Haider S, Rushworth P, Macleod F, Nallasivan A, Perkins C, Burns E, Leason S, Carter T, Seagrave S, Sami E, Armstrong L, Naqvi SN, Hassan M, Parkinson S, Mawer S, Darnbrook G, Booth C, Hairsine B, Smith M, Williamson S, Farquhar F, Esisi B, Cassidy T, Mankin G, Mcclelland B, Bokhari M, Sproates D, Epstein E, Hurdowar S, Blackburn R, Sukhdeep N, Razak S, Osman K, Hashmi A, Upton N, Harrington F, Courtauld G, Schofield C, Lucas L, Adie K, Bond K, Mate A, Skewes J, James A, Brodie C, Johnson M, Allsop L, Driver E, Harris K, Drake M, Ellis S, Maund B, Thomas E, Moore K, Burn M, Hamilton A, Mahalingam S, Misra A, Reid F, Benford A, Hilton D, Hazell L, Ofori K, Thomas AL, Mathew M, Dayal S, Burn I, Fotherby K, Jennings-Preece K, Willberry A, Morgan D, Butler D, Sahota G, Kauldhar K, Ahmad N, Stevens A, Das S, Bruce D, Pai Y, Nyo K, Stephenson L, Nendick R, Rogers G, Dhakal M, Dima S, Brown E, Clayton S, Gamble P, Naeem M, Hayman R, Burnip R, Earnshaw P, Hargroves D, Ransom B, Rudenko H, Balogun I, Griffiths K, Mears K, Webb T, Cowie L, Hammond T, Thomson A, Ceccarelli D, Chattha N, Beranova E, Verrion A, Gillian A, Schumacher N, Bahk A, Walker S, Cvoro V, Mccormick K, Chapman N, Pound S, Cain R, Mcauley S, Couser M, Simpson M, Tachtatzis A, Ullah K, Sims D, Jones R, Smith J, Tongue R, Willmot M, Sutton C, Littleton E, Khaira J, Maiden S, Cunningham J, Green C, Chin YM, Bates M, Ahlquist K, Kane I, Breeds J, Sargent T, Latter L, Pitt Ford A, Gainsborough N, Levett T, Thompson P, Barbon E, Dunne A, Hervey S, Ragab S, Sandell T, Dickson C, Dube J, Power S, Evans N, Wadams B, Elitova S, Aubrey B, Garcia T, Mcilmoyle J, Jeffs C, Dickinson C, Ahmed A, Kumar S, Frudd J, Armer C, Potter A, Donaldson S, Howard J, Jones K, Dhar S, Collas D, Sundayi S, Denham L, Oza D, Walker E, Cunningham J, Bhandari M, Ispoglou S, Evans R, Sharobeem K, Walton E, Shanu S, Hayes A, Howard-Brown J, Billingham S, Weir N, Pressly V, Wood E, Sykes L, Howard G, Burton H, Crawford P, Egerton S, Evans S, Hakkak J, Andrews J, Lampard R, Allen C, Walters A, Said R, Marigold JR, Tsang SM, Creeden R, Cox C, Smith S, Gartrell I, Smith F, Jenkins C, Pryor J, Hedges A, Price F, Moseley L, Mercer L, Hughes C, Mcgowan D, Azim A, White J, Krasinska-Chavez M, Chaplin S, Curtis J, Singh D, Imam J, Nicolson A, Alam S, Whitworth S, Wood L, Warburton E, Kelly S, Mcgee J, Markus H, Chandrasena D, Hayden D, Sesay J, Hayhoe H, Bolton M, Macdonald J, Mitchell J, Farron C, Amis E, Day D, Culbert A, Espanol A, Hannon N, Handley D, Finlay S, Crisp S, Whitehead L, Francis J, Oconnell J, Osborne E, Beard R, Krishnamurthy R, Mokoena L, Sattar N, Myint M, Edwards M, Smith A, Corrigan P, Byrne A, Blackburn J, Mcghee C, Smart A, Macleod M, Donaldson F, Copeland C, Wilson J, Scott R, Fitzsimmons P, Lopez P, Wilkinson M, Manoj A, Cox P, Trainor L, Fletcher G, Denny L, Kavanagh K, Allsop H, Emsley H, Sultan S, Mcloughlin A, Walmsley B, Hough L, Ahmed S, Doyle D, Gregary B, Raj S, Nagaratnam K, Mannava N, Haque N, Shields N, Preston K, Mason G, Short K, Lumsdale G, Uitenbosch G, Sukys U, Valentine S, Jarrett D, Dodsworth K, Wands M, Khan N, Tandy J, Watkinson C, Golding W, Butler R, Williams M, Davies Y, Yip K, James C, Suttling A, Maney A, Gamble GE, Hague A, Charles B, Blane S, Duran B, Lambert C, Stagg K, Whiting R, Homan JE, Brown S, Hussain M, Harvey M, Graham L, Foote L, Lane C, Kemp L(J, Rowe J, Durman H, Foot J, Brotherton L, Hunt N, Pawley C, Whitcher A, Sutton P, Mcdonald S, Pak D, Wiltshire A, Jagger J, Metcalf AK, Healey GL, Balami J, Self CM, Crofts M, Chakrabarti A, Hmu C, Ravenhill G, Grimmer C, Soe T, Keshet-Price J, Langley M, Potter I, Tam PL, Macleod MJ, Cooper P, Christie M, Irvine J, Annison F, Christie D, Meneses C, Johnson A, Joyson A, Nelson S, Taylor V, Reid J, Clarke R, Furnace J, Gow H, Abousleiman Y, Beadling T, Collins S, Jones S, Purcell J, Bloom S, Goshawk S, Landicho M, Sangaralingham S, Begum Y, Mutton S, Munuswamy Vaiyapuri E, Allen J, Lowe J, Hughes M, Wiggam I, Cuddy S, Tauro S, Wells B, Mohd Nor A, Eglinton C, Persad N, Kalita M, Weatherby S, Brown C, Pace A, Lashley D, Marner M, Weinling M, Wilmshurst N, Waugh D, Mucha A, Shah A, Baker J, Westcott J, Cowan R, Vasileiadis E, Mumani S, Parry A, Mason C, Holden M, Petrides K, Nishiyama T, Mehta H, Krishnan M, Lynne D, Thomas L, Lynda C, Hughes C, Clements C, Williams R, Anjum T, Sharon S, Tucker S, Jones P, Colwill D, Thompson Jones H, Chadha D, Fairweather M, Walstow D, Fong R, Johnston S, Almadenboyle C, Ross S, Carson S, Nair P, Tenbruck E, Stirling M, Pusalkar A, Beadle H, Chan K, Dangri P, Asokanathan A, Rana A, Gohil S, Massyn M, Aruldoss P, Cook A, Crabtree K, Dabbagh S, Black T, Clarke C, Mead D, Fennelly R, Anthony A, Nardone L, Dimartino V, Tribbeck M, Broughton D, Tryambake D, Dixon L, Skotnicka A, Thompson J, Whitehouse S, Sigsworth A, Wong J, Annamalai A, Pagan J, Affley B, Sunderland C, Goldenberg L, Khan A, Wilkinson P, Nari R, Abbott L, Young E, Shakhon A, Lock S, Stewart J, Pereira R, Dsouza M, Dunn S, Mckenna AM, Cron N, Kidd M, Hull G, Bunworth K, Drummond G, Mahawish K, Hayes N, Connell L, Simpson J, Penney H, Punekar S, Nevinson J, Wareing W, Ward J, Greenwood R, Austin D, Banaras A, Hogan C, Corbett T, Oji N, Elliott E, Brezitski M, Passeron N, Howaniec L, Watchurst C, Patel K, Erande R, Shah R, Sengupta N, Metiu M, Gonzalez C, Funnell S, Margalef J, Peters G, Chadbourn I, Sivakumar R, Saksena R, Ketley-O'donel J, Needle R, Chinery E, Wright A, Cook S, Ngeh J, Proeschel H, Cook P, Ashcroft P, Sharpe S, Jones S, Jenkinson D, Kelly D, Bray H, Gunathilagan G, Griffiths K, Mears K, Gillian A, Jones S, Tilbey S, Abubakar S, Beranova E, Vassallo J, Leonard D, Orrell L, Hasan A, Khan A, Qamar S, Graham S, Hewitt E, Awolesi J, Haque M, Kent A, Bradshaw E, Cooper M, Wynter I, Rajapakse A, Janbieh J, Nasar AM, Wade L, Otter L, Haigh S, Burgoyne JR, Boulton R, Boulton A, Rayessa R, Clarkson E, Rhian H, Fleming A, Mitchelson K, Lowthorpe V, Abdul-Hamid A, Jones P, Duggan C, Hynes A, Nurse E, Raza SA, Jones S, Pallikona U, Edwards B, Morgan G, Dennett K, Tench H, Loosley R, Trugeon-Smith T, Jones R, Williams R, Robson D, Mavinamane S, Meenakshisundaram S, Ranga L, Dealing S, Hill A, Hargreaves M, Smith T, Bate J, Harrison L, Kirthivasan R, Cannon E, Topliffe J, Keskeys R, Williams S, Mcneela F, Cairns F, James T, Lyle A, Shah S, Zachariah G, Fergey L, Smolen S, Cooper L, Bohannan E, Omer S, Amlani S, Hunter N, Hawkes-Blackburn M, Gulli G, Peacocke A, Amero J, Burova M, Speirs O, Levy S, Francis L, Holland S, Brotheridge S, Lyon H, Hare C, Jackson S, Stephenson L, Al Hussayni S, Featherstone J, Bwalya A, Singh A, Goorah MN, Walford J, Bell A, Kelly C, Rusk D, Sutton D, Patel F, Duberley S, Hayes K, Hunt L, El Nour A, Cottrell P, Westmoreland J, Honour S, Box C, Wood P, Haritakis M, Dyer S, Brown L, Elliott K, Temlett E, Paterson J, Furness R, Young S, Orugun E, Brewer C, Thornthwaite S, Crowther H, Glover R, Sein M, Haque K, Gibson E, Wong S, Rotchell K, Burton K, Brookes L, Bailey L, Leonard D, Lindley C, Murray A, Waltho K, Holland M, Kumar P, Harlekar P, Booth L, Culmsee C, Drew J, Khan M, Mackenzie N, Thomas C, Ritchie J, Barker J, Haley M, Cotterill D, Lane L, Little C, Simmons D, Saunders G, Dymond H, Kidd S, Warinton R, Neves-Silva Y, Nevajda B, Villaruel M, Umasankar U, Patel S, Man A, Christmas N, Rangasamy R, Ladner R, Butt G, Alvares W, Gadi N, Power M, Wroath B, Dynan K, Wilson D, Crothers S, Leonard C, Hagan S, Douris G, Vahidassr D, Thompson A, Gallen B, Mckenna S, Edwards C, Mcgoldrick C, Bhattad M, Kawafi K, Morse D, Jacob P, Turner L, Saravanan N, Johnson L, Humphrey S, Namushi R, Patel R, Mclaughlin J, Omahony P, Osikominu E, Orefo C, Mcdonald C, Jones V, Makanju E, Khan T, Appiatse G, Stone H, Augustin M, Wardale A, Salehin M, Bailey D, Garcia-Alen L, Kalathil L, Tinsley S, Jones T, Amor K, Ritchings A, Margerum E, Horton J, Miller R, Gautam N, Meir J, Jones A, Putteril J, Lepore M, Makanju E, Gallifent R, Arundell LL, Mcredmond C, Goulding A, Nadarajan V, Laurence J, Fung Lo S, Melander S, Nicholas P, Woodford E, Mckenzie G, Le V, Crause J, Luder R, Bhargava M, Shah R, Bhome G, Johnson VV, Chesser D, Bridger H, Murali E, Scott J, Morrison S, Burns A, Graham J, Duffy M, Ali K, Sargent T, Pitcher E, Gaylard J, Newman J, Punnoose S, Besley S, Purohit K, Rees A, Davy M, Chohan O, Khan MF, Walker R, Murray V, Bent C, Oakley S, Blight A, Peixoto C, Jones S, Livingstone G, Butler F, Bradfield S, Gordon L, Schmit J, Wijewardane A, Edmunds T, Wills R, Medcalf C, Argandona L, Cuenoud L, Hassan H, Erumere E, Ocallaghan A, Gompertz P, Redjep O, Auld G, Howaniec L, Song A, Tarkas T, Kabash H, Hungwe R. Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial. Lancet 2019; 393:265-274. [PMID: 30528472 PMCID: PMC6336936 DOI: 10.1016/s0140-6736(18)32823-x] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. METHODS FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. FINDINGS Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. INTERPRETATION Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. FUNDING UK Stroke Association and NIHR Health Technology Assessment Programme.
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Rudberg AS, Berge E, Gustavsson A, Näsman P, Lundström E. Long-term health-related quality of life, survival and costs by different levels of functional outcome six months after stroke. Eur Stroke J 2018; 3:157-164. [PMID: 31008347 PMCID: PMC6460413 DOI: 10.1177/2396987317753444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/16/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Information about the impact of functional outcome after stroke is currently missing on health-related quality of life, survival and costs. This information would be valuable for health economic evaluations and for allocation of resources in stroke health care. PATIENTS AND METHODS Data on 297 Swedish patients included in the Third International Stroke Trial were analysed including functional outcome at six months (measured by Oxford Handicap Scale), health-related quality of life up to 18 months (EQ-5D-3L) and survival up to 36 months. We used record linkage to collect data on costs up to 36 months, using national patient registers. RESULTS Patients with a better functional outcome level at six months had a significantly better health-related quality of life at 18 months (p < 0.05), better long-term survival (p < 0.05) and lower costs (p < 0.001), for all time points up to 36 months. The difference in costs was mainly due to differences in days spent in hospital (p < 0.005). DISCUSSION This study showed an association between functional outcome at six months and health-related quality of life up to 18 months, and costs up to 36 months. CONCLUSION Functional outcome six months after stroke is an important determinant of health-related quality of life, survival and costs over 36 months. Effective interventions aimed at reducing short-term disability levels are therefore also expected to reduce the overall burden of stroke.
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Affiliation(s)
- Ann-Sofie Rudberg
- Department of Clinical Neuroscience,
Division of Neurology, Karolinska Institutet, Stockholm, Sweden
| | - Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University
Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Tromsø, Tromsø,
Norway
| | - Anders Gustavsson
- Quantify Research, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society,
Karolinska Institutet, Stockholm, Sweden
| | - Per Näsman
- Center for Safety Research, KTH Royal Institute of Technology,
Stockholm, Sweden
| | - Erik Lundström
- Department of Clinical Neuroscience,
Division of Neurology, Karolinska Institutet, Stockholm, Sweden
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Ervasti J, Virtanen M, Lallukka T, Friberg E, Mittendorfer-Rutz E, Lundström E, Alexanderson K. Trends in diagnosis-specific work disability before and after ischaemic heart disease: a nationwide population-based cohort study in Sweden. BMJ Open 2018; 8:e019749. [PMID: 29674367 PMCID: PMC5914777 DOI: 10.1136/bmjopen-2017-019749] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES We examined trends of diagnosis-specific work disability before and after ischaemic heart disease (IHD). DESIGN Participants were followed 4 years before and 4 years after an IHD event for diagnosis-specific work disability (sickness absence and disability pension). SETTING AND PARTICIPANTS A Swedish population-based cohort study using register data on all individuals aged 25-60 years, living in Sweden, and who suffered their first IHD event in 2006-2008 (n=23 971) was conducted. RESULTS Before the event, the most common diagnoses of work disability were musculoskeletal disorders (21 annual days for men and 44 for women) and mental disorders (19 men and 31 for women). After multivariable adjustments, we observed a fivefold increase (from 12 to 60 days) in work disability due to diseases of the circulatory system in the first postevent year compared with the last pre-event year among men. Among women, the corresponding increase was fourfold (from 14 to 62 days). By the second postevent year, the number of work disability days decreased significantly compared with the first postevent year among both sexes (to 19 days among men and 23 days among women). Among women, mean days of work disability due to diseases of the circulatory system remained at a higher level than among men during the postevent years. Work disability risk after versus before an IHD event was slightly higher among men (rate ratio (RR) 2.49; 95% CI 2.36 to 2.62) than among women (RR 2.29, 95% CI 2.12 to 2.49). When pre-event long-term work disability was excluded, diseases of the circulatory system were the most prevalent diagnosis for work disability after an IHD event among both men and women. CONCLUSIONS An IHD event was strongly associated with an increase in work disability due to diseases of the circulatory system, especially among men and particularly in the first postevent year.
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Affiliation(s)
- Jenni Ervasti
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Marianna Virtanen
- Finnish Institute of Occupational Health, Helsinki, Finland
- Department of Public Health and Caring Sciences, University of Uppsala, Uppsala, Sweden
| | - Tea Lallukka
- Finnish Institute of Occupational Health, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Emilie Friberg
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ellenor Mittendorfer-Rutz
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik Lundström
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Alexanderson
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Lundström E, Isaksson E, Wester P, Laska AC, Näsman P. Enhancing Recruitment Using Teleconference and Commitment Contract (ERUTECC): study protocol for a randomised, stepped-wedge cluster trial within the EFFECTS trial. Trials 2018; 19:14. [PMID: 29310679 PMCID: PMC5759750 DOI: 10.1186/s13063-017-2367-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/04/2017] [Indexed: 11/24/2022] Open
Abstract
Background Many randomised controlled trials (RCTs) fail to meet their recruitment goals in time. Trialists are advised to include study recruitment strategies within their trials. EFFECTS is a Swedish, academic-led RCT of fluoxetine for stroke recovery. The trial’s primary objective is to investigate whether 20 mg fluoxetine daily compared with placebo for 6 months after an acute stroke improves the patient’s functional outcome. The first patient was included on 20 October 2014 and, as of 31 August 2017, EFFECTS has included 810 of planned 1500 individuals. EFFECTS currently has 32 active centres. The primary objective of the ERUTECC (Enhancing Recruitment Using Teleconference and Commitment Contract) study is to investigate whether a structured teleconference re-visit with the study personnel at the centres, accompanied by a commitment contract, can enhance recruitment by 20% at 60 days post intervention, compared with 60 days pre-intervention, in an ongoing RCT. Methods ERUTECC is a randomised, stepped-wedge cluster trial embedded in EFFECTS. The plan is to start ERUTECC with a running-in period of September 2017. The first intervention is due in October 2017, and the study will continue for 12 months. We are planning to intervene at all active centres in EFFECTS, except the five top recruiting centres (n = 27). The rationale for not intervening at the top recruiting centres is that we believe they have reached their full potential and the intervention would be too weak for them. The hypothesis of this study is that a structured teleconference re-visit with the study personnel at the centres, accompanied by a commitment contract, can enhance recruitment by 20% 60 days post intervention, compared to 60 days pre-intervention, in an ongoing RCT. Discussion EFFECTS is a large, pragmatic RCT of stroke in Sweden. Results from the embedded ERUTECC study could probably be generalised to high-income Western countries, and is relevant to trial management and could improve trial management in the future. It might also be useful in clinical settings outside the field of stroke. Trial registrations The ERUTECC study was registered in the Northern Ireland Hub for Trials Methodology Research Studies Within a Trial repository (SWAT58) on 30 April 2017. ClinicalTrials.gov, ID: NCT02683213. Retrospectively registered on 2 February 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2367-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Erik Lundström
- Karolinska Institutet, Department of Clinical Neuroscience, Neurology, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.
| | - Eva Isaksson
- Karolinska Institutet, Department of Clinical Neuroscience, Neurology, Karolinska University Hospital, Building R3:04, Solna, 171 76, Stockholm, Sweden
| | - Per Wester
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88, Stockholm, Sweden.,Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 18288, Stockholm, Sweden
| | - Per Näsman
- Centre for Safety Research, KTH Royal Institute of Technology, 100 44, Stockholm, Sweden
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Lallukka T, Ervasti J, Lundström E, Mittendorfer-Rutz E, Friberg E, Virtanen M, Alexanderson K. Trends in Diagnosis-Specific Work Disability Before and After Stroke: A Longitudinal Population-Based Study in Sweden. J Am Heart Assoc 2018; 7:JAHA.117.006991. [PMID: 29301760 PMCID: PMC5778961 DOI: 10.1161/jaha.117.006991] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Although a stroke event often leads to work disability, diagnoses behind work disability before and after stroke are largely unknown. We examined the pre‐event and postevent trends in diagnosis‐specific work disability among patients of working age. Methods and Results We included all new nonfatal stroke events in 2006–2008 from population‐based hospital registers in Sweden among women and men aged 25 to 60 years (n=12 972). Annual days of diagnosis‐specific work disability were followed for 4 years before and after stroke. Repeated measures negative binomial regression models using the generalized estimating equations method were fitted to examine trends in diagnosis‐specific work disability before and after the event. Already during the 4 pre‐event years, work disability attributed to circulatory diseases increased among women (rate ratio, 1.99; 95% confidence interval, 1.68–2.36) and men (rate ratio, 2.20; 95% confidence interval, 1.88–2.57). Increasing trends before stroke were also found for work disability attributed to mental disorders, musculoskeletal diseases, neoplasms, diseases of the nervous, respiratory, and digestive systems, injuries, and diabetes mellitus. As expected, a sharp increase in work disability days attributed to circulatory diseases was found during the first year after the event among both sexes. Overall, during 4 years after the stroke, there was a decreasing trend for circulatory diseases and injuries, whereas the trend was increasing for nervous diseases and diabetes mellitus. Conclusions Work disability attributed to several mental and somatic diagnoses is higher already before a stroke event.
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Affiliation(s)
- Tea Lallukka
- Finnish Institute of Occupational Health, Helsinki, Finland .,Department of Public Health, University of Helsinki, Finland
| | - Jenni Ervasti
- Finnish Institute of Occupational Health, Helsinki, Finland
| | - Erik Lundström
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ellenor Mittendorfer-Rutz
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Emilie Friberg
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Marianna Virtanen
- Finnish Institute of Occupational Health, Helsinki, Finland.,Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Alexanderson
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Graham C, Lewis S, Forbes J, Mead G, Hackett ML, Hankey GJ, Gommans J, Nguyen HT, Lundström E, Isaksson E, Näsman P, Rudberg AS, Dennis M. The FOCUS, AFFINITY and EFFECTS trials studying the effect(s) of fluoxetine in patients with a recent stroke: statistical and health economic analysis plan for the trials and for the individual patient data meta-analysis. Trials 2017; 18:627. [PMID: 29282099 PMCID: PMC5745973 DOI: 10.1186/s13063-017-2385-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 12/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Small trials have suggested that fluoxetine may improve neurological recovery from stroke. FOCUS, AFFINITY and EFFECTS are a family of investigator-led, multicentre, parallel group, randomised, placebo-controlled trials which aim to determine whether the routine administration of fluoxetine (20 mg daily) for six months after an acute stroke improves patients' functional outcome. METHODS/DESIGN The core protocol for the three trials has been published (Mead et al., Trials 20:369, 2015). The trials include patients aged 18 years and older with a clinical diagnosis of stroke and persisting focal neurological deficits at randomisation 2-15 days after stroke onset. Patients are randomised centrally via each trials' web-based randomisation system using a common minimisation algorithm. Patients are allocated fluoxetine 20 mg once daily or matching placebo capsules for six months. The primary outcome measure is the modified Rankin scale (mRS) at six months. Secondary outcomes include: living circumstances; the Stroke Impact Scale; EuroQol (EQ5D-5 L); the vitality subscale of the 36-Item Short Form Health Survey (SF36); diagnosis of depression; adherence to medication; serious adverse events including death and recurrent stroke; and resource use at six and 12 months and the mRS at 12 months. DISCUSSION Minor variations have been tailored to the national setting in the UK (FOCUS), Australia, New Zealand and Vietnam (AFFINITY) and Sweden (EFFECTS). Each trial is run and funded independently and will report its own results. A prospectively planned individual patient data meta-analysis of all three trials will provide the most precise estimate of the overall effect and establish whether any effects differ between trials or subgroups. This statistical analysis plan describes the core analyses for all three trials and that for the individual patient data meta-analysis. Recruitment and follow-up in the FOCUS trial is expected to be completed by the end of 2018. AFFINITY and EFFECTS are likely to complete follow-up in 2020. TRIAL REGISTRATION FOCUS: ISRCTN , ISRCTN83290762 . Registered on 23 May 2012. EudraCT, 2011-005616-29. Registered on 3 February 2012. AFFINITY Australian New Zealand Clinical Trials Registry, ACTRN12611000774921 . Registered on 22 July 2011. EFFECTS ISRCTN , ISRCTN13020412 . Registered on 19 December 2014. Clinicaltrials.gov, NCT02683213 . Registered on 2 February 2016. EudraCT, 2011-006130-16 . Registered on 8 August 2014.
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Affiliation(s)
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - John Forbes
- Health Research Institute, University of Limerick, Limerick, Ireland
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building FU303h, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Maree L Hackett
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
| | - Graeme J Hankey
- School of Medicine, The University of Western Australia, Crawley, WA, Australia
| | - John Gommans
- Hawke's Bay District Health Board, Hastings, New Zealand
| | - Huy Thang Nguyen
- Department of Cerebro-Vascular Disease, The People's 115 Hospital, Ho Chi Minh City, Vietnam
| | - Erik Lundström
- Department of Clinical Neuroscience, Neurology, Karolinska Institutet, Stockholm, Sweden
| | - Eva Isaksson
- Department of Clinical Neuroscience, Neurology, Karolinska Institutet, Stockholm, Sweden
| | - Per Näsman
- Center for Safety Research, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Ann-Sofie Rudberg
- Department of Clinical Neuroscience, Neurology, Karolinska Institutet, Stockholm, Sweden
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building FU303h, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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Ervasti J, Virtanen M, Lallukka T, Friberg E, Mittendorfer-Rutz E, Lundström E, Alexanderson K. Permanent work disability before and after ischaemic heart disease or stroke event: a nationwide population-based cohort study in Sweden. BMJ Open 2017; 7:e017910. [PMID: 28965101 PMCID: PMC5640121 DOI: 10.1136/bmjopen-2017-017910] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We examined the risk of disability pension before and after ischaemic heart disease (IHD) or stroke event, the burden of stroke compared with IHD and which factors predicted disability pension after either event. DESIGN A population-based cohort study with follow-up 5 years before and after the event. Register data were analysed with general linear modelling with binary and Poisson distributions including interaction tests for event type (IHD/stroke). SETTING AND PARTICIPANTS All people living in Sweden, aged 25‒60 years at the first event year, who had been living in Sweden for 5 years before the event and had no indication of IHD or stroke prior to the index event in 2006‒2008 were included, except for cases in which death occurred within 30 days of the event. People with both IHD and stroke were excluded, resulting in 18 480 cases of IHD (65%) and 9750 stroke cases (35%). PRIMARY OUTCOME MEASURES Disability pension. RESULTS Of those going to suffer IHD or stroke event, 25% were already on disability pension a year before the event. The adjusted OR for disability pension at first postevent year was 2.64-fold (95% CI 2.25 to 3.11) for people with stroke compared with IHD. Economic inactivity predicted disability pension regardless of event type (OR=3.40; 95% CI 2.85 to 4.04). Comorbid mental disorder was associated with the greatest risk (OR=3.60; 95% CI 2.69 to 4.83) after an IHD event. Regarding stroke, medical procedure, a proxy for event severity, was the largest contributor (OR=2.27, 95% CI 1.43 to 3.60). CONCLUSIONS While IHD event was more common, stroke involved more permanent work disability. Demographic, socioeconomic and comorbidity-related factors were associated with disability pension both before and after the event. The results help occupational and other healthcare professionals to identify vulnerable groups at risk for permanent labour market exclusion after such an event.
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Affiliation(s)
- Jenni Ervasti
- Research and Service Centre of Occupational Health, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Marianna Virtanen
- Research and Service Centre of Occupational Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tea Lallukka
- Research and Service Centre of Occupational Health, Finnish Institute of Occupational Health, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Emilie Friberg
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ellenor Mittendorfer-Rutz
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik Lundström
- Division of Neurology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Alexanderson
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Yeo LL, Holmin S, Andersson T, Lundström E, Gopinathan A, Lim EL, Leong BS, Kuan WS, Ting E, Tan BY, Eide SE, Tay EL. Nongated Cardiac Computed Tomographic Angiograms for Detection of Embolic Sources in Acute Ischemic Stroke. Stroke 2017; 48:1256-1261. [DOI: 10.1161/strokeaha.117.016903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We assessed the feasibility of obtaining diagnostic quality images of the heart and thoracic aorta by extending the
z
axis coverage of a non–ECG-gated computed tomographic angiogram performed in the primary evaluation of acute stroke without increasing the contrast dose.
Methods—
Twenty consecutive patients with acute ischemic stroke within the 4.5 hours of symptom onset were prospectively recruited. We increased the longitudinal coverage to the domes of the diaphragm to include the heart. Contrast administration (Omnipaque 350) remained unchanged (injected at 3–4 mL/s; total 60–80 mL, triggered by bolus tracking). Images of the heart and aorta, reconstructed at 5 mm slice thickness in 3 orthogonal planes, were read by a radiologist and cardiologist, findings conveyed to the treating neurologist, and correlated with the transthoracic or transesophageal echocardiogram performed within the next 24 hours.
Results—
Of 20 patients studied, 3 (15%) had abnormal findings: a left ventricular thrombus, a Stanford type A aortic dissection, and a thrombus of the left atrial appendage. Both thrombi were confirmed by transesophageal echocardiography, and anticoagulation was started urgently the following day. None of the patients developed contrast-induced nephropathy on follow-up. The radiation dose was slightly increased from a mean of 4.26 mSV (range, 3.88–4.70 mSV) to 5.17 (range, 3.95 to 6.25 mSV).
Conclusions—
Including the heart and ascending aorta in a routine non–ECG-gated computed tomographic angiogram enhances an existing imaging modality, with no increased incidence of contrast-induced nephropathy and minimal increase in radiation dose. This may help in the detection of high-risk cardiac and aortic sources of embolism in acute stroke patients.
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Affiliation(s)
- Leonard L.L. Yeo
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Staffan Holmin
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Tommy Andersson
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Erik Lundström
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Anil Gopinathan
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Er Luen Lim
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Benjamin S.H. Leong
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Win Sen Kuan
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Eric Ting
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Benjamin Y.Q. Tan
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Sterling Ellis Eide
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Edgar L.K. Tay
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
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Virtanen M, Ervasti J, Mittendorfer-Rutz E, Lallukka T, Kjeldgård L, Friberg E, Kivimäki M, Lundström E, Alexanderson K. Work disability before and after a major cardiovascular event: a ten-year study using nationwide medical and insurance registers. Sci Rep 2017; 7:1142. [PMID: 28442715 PMCID: PMC5430721 DOI: 10.1038/s41598-017-01216-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/24/2017] [Indexed: 02/07/2023] Open
Abstract
We examined the trajectories of work disability before and after IHD and stroke events. New IHD (n = 13521) and stroke (n = 7162) cases in 2006–2008 were retrieved from nationwide Swedish hospital records and their annual work disability days five years before and after the date of diagnosis were retrieved from a nationwide disability register. There was no pre-event differences in disability days between the IHD and stroke cases and five years prior to the event, they were close to those observed in the general population. In the first post-event year, the adjusted mean days increased to 83.9 (95% CI 80.6–86.5) in IHD; to 179.5 (95% CI 172.4–186.8) in stroke, a six-fold increase in IHD and 14-fold in stroke. Work disability leveled off among the IHD cases but not among those who had stroke. The highest disability levels for the fifth post-event year after a stroke event was associated with pre-existing diabetes (146.9), mental disorder (141.2), non-employment (137.0), and immigrant status (117.9). In a working-age population, the increase in work disability after a cardiovascular event decreases close to the pre-event level in IHD but remains particularly high after stroke; among patients with comorbid depression or diabetes, immigrants, and those not in employment.
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Affiliation(s)
- Marianna Virtanen
- Finnish Institute of Occupational Health, P.O. Box 40, FI-00251, Helsinki, Finland.
| | - Jenni Ervasti
- Finnish Institute of Occupational Health, P.O. Box 40, FI-00251, Helsinki, Finland
| | - Ellenor Mittendorfer-Rutz
- Karolinska Institutet, Department of Clinical Neuroscience, Division of Insurance Medicine, SE-171 77, Stockholm, Sweden
| | - Tea Lallukka
- Finnish Institute of Occupational Health, P.O. Box 40, FI-00251, Helsinki, Finland.,Department of Public Health, University of Helsinki, Clinicum, P.O. Box 63, FI-00014, Helsinki, Finland
| | - Linnea Kjeldgård
- Karolinska Institutet, Department of Clinical Neuroscience, Division of Insurance Medicine, SE-171 77, Stockholm, Sweden
| | - Emilie Friberg
- Karolinska Institutet, Department of Clinical Neuroscience, Division of Insurance Medicine, SE-171 77, Stockholm, Sweden
| | - Mika Kivimäki
- Finnish Institute of Occupational Health, P.O. Box 40, FI-00251, Helsinki, Finland.,Department of Public Health, University of Helsinki, Clinicum, P.O. Box 63, FI-00014, Helsinki, Finland.,Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Erik Lundström
- Karolinska Institutet, Department of Clinical Neuroscience, Division of Neurology, SE-171 77, Stockholm, Sweden
| | - Kristina Alexanderson
- Karolinska Institutet, Department of Clinical Neuroscience, Division of Insurance Medicine, SE-171 77, Stockholm, Sweden
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Berge E, Cohen G, Roaldsen MB, Lundström E, Isaksson E, Rudberg AS, Slot KB, Forbes J, Smith J, Drever J, Wardlaw JM, Lindley RI, Sandercock PAG, Whiteley WN. Effects of alteplase on survival after ischaemic stroke (IST-3): 3 year follow-up of a randomised, controlled, open-label trial. Lancet Neurol 2016; 15:1028-34. [PMID: 27450474 DOI: 10.1016/s1474-4422(16)30139-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 04/18/2016] [Accepted: 06/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The effect of alteplase on patient survival after ischaemic stroke is the subject of debate. We report the effect of intravenous alteplase on long-term survival after ischaemic stroke of participants in the Third International Stroke Trial (IST-3). METHODS In IST-3, done at 156 hospitals in 12 countries (Australia, Europe, and the UK), participants (aged >18 years) were randomly assigned with a telephone voice-activated or web-based system in a 1:1 ratio to treatment with intravenous 0·9 mg/kg alteplase plus standard care or standard care alone within 6 h of ischaemic stroke. We followed up participants in the UK and Scandinavia (Sweden and Norway) for survival up to 3 years after randomisation using data from national registries and compared survival in the two groups with proportional hazards survival analysis, adjusting for key prognostic variables. IST-3 is registered with the ISRCTN registry, number ISRCTN25765518. FINDINGS Between May 5, 2000, and July 27, 2011, 3035 participants were enrolled in IST-3. Of these, 1948 (64%) of 3035 participants were scheduled for analysis of 3 year survival, and 1946 (>99%) of these were included in the analysis (967 [50%] in the alteplase plus standard care group and 979 [50%] in the standard care alone group). By 3 years after randomisation, 453 (47%) of 967 participants in the alteplase plus standard care group and 494 (50%) of 979 in the standard care alone group had died (risk difference 3·6% [95% CI -0·8 to 8·1]). Participants allocated to alteplase had a significantly higher hazard of death during the first 7 days (99 [10%] of 967 died in the alteplase plus standard care group vs 65 [7%] of 979 in the standard care alone group; hazard ratio 1·52 [95% CI 1·11-2·08]; p=0·004) and a significantly lower hazard of death between 8 days and 3 years (354 [41%] of 868 vs 429 [47%] of 914; 0·78 [0·68-0·90]; p=0·007). INTERPRETATION Alteplase treatment within 6 h after ischaemic stroke was associated with a small, non-significant reduction in risk of death at 3 years, but among individuals who survived the acute phase, treatment was associated with a significant increase in long-term survival. These results are reassuring for clinicians who have expressed concerns about the effect of alteplase on survival. FUNDING Heart and Stroke Scotland, UK Medical Research Council, Health Foundation UK, Stroke Association UK, Research Council of Norway, AFA Insurance, Swedish Heart Lung Fund, Foundation of Marianne and Marcus Wallenberg, Polish Ministry of Science and Education, Australian Heart Foundation, Australian National Health and Medical Research Council, Swiss National Research Foundation, Swiss Heart Foundation, Assessorato alla Sanita (Regione dell'Umbria), and Danube University.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway.
| | - Geoffrey Cohen
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Melinda B Roaldsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway; Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Erik Lundström
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Eva Isaksson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Ann-Sofie Rudberg
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | | | - John Forbes
- Health Research Institute, University of Limerick, Limerick, Ireland
| | - Joel Smith
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Drever
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Richard I Lindley
- George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; Discipline of Medicine, University of Sydney, Sydney, NSW, Australia
| | | | - William N Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Wallmark S, Ronne-Engström E, Lundström E. Predicting return to work after subarachnoid hemorrhage using the Montreal Cognitive Assessment (MoCA). Acta Neurochir (Wien) 2016; 158:233-9. [PMID: 26676517 DOI: 10.1007/s00701-015-2665-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Returning to work is a major issue for patients having had an aneurysmal subarachnoid hemorrhage (SAH). It is important, at an early stage, to identify the patients that are unlikely to return to work. The objective of this study was to assess the predictive value of the Montreal Cognitive Assessment (MoCA) at 6 months after ictus on return to work at 12 months. METHODS In this prospective study were 96 patients with SAH included in the acute phase. Cognitive functions were assessed at 6 months using the MoCA and return to work at 12 months. The predictive value of MoCA on return to work was analyzed using the area under the receiver operating characteristic curve as well as logistic regression. RESULTS Of those that had work before the SAH, 52 % were working at 12 months after the ictus. These patients had scored significantly better on MoCA at 6 months (p = 0.01). The area under the receiver operating characteristic curve was 0.75. By using a cut-off on MoCA of <27, 68 % of the patients could be correctly classified as returned/not returned to work. Adding data from the acute phase to the MoCA in a logistic regression model increased the percentage of patients correctly classified as returned/not returned to work by 2 %. CONCLUSIONS Returning to work is a major issue for SAH patients. It is important to identify factors that may interfere with a patient's ability to return to work, and address these issues appropriately. In our study, estimating cognitive functions at 6 months after SAH using the MoCA alone allowed us to predict return to work correctly in 68 % of the cases. We feel that this provides useful information in planning rehabilitation, but that other post-SAH symptoms have to be considered as well.
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Lundström E, Zini A, Wahlgren N, Ahmed N. How common is isolated dysphasia among patients with stroke treated with intravenous thrombolysis, and what is their outcome? Results from the SITS-ISTR. BMJ Open 2015; 5:e009109. [PMID: 26608637 PMCID: PMC4663413 DOI: 10.1136/bmjopen-2015-009109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To describe the frequency and outcome of isolated dysphasia among patients treated with intravenous thrombolysis (IVT). DESIGN Patients registered in the SITS International Stroke Thrombolysis Register (SITS-ISTR). PARTICIPANTS Patients with stroke (N=58,293) treated with IVT between December 2002 and December 2012. SETTING A multinational, prospective, observational monitoring register. MAIN OUTCOME MEASURES Isolated dysphasia and modified Rankin Scale (mRS). METHODS We identified patients presenting with isolated dysphasia by reviewing items within the baseline National Institutes of Health Stroke Scale (NIHSS). We performed descriptive statistics for baseline and demographic data, and reported patients' characteristics, radiological data and changes in their NIHSS score within 7 days and mRS score at 3 months. We also reported corresponding data from the general SITS-ISTR cohort. RESULTS We found isolated dysphasia at baseline in 1.14% (663/58,293) of all patients treated with IVT patients. Patients with isolated dysphasia had a longer onset to treatment time, lower proportion of visible infarctions on admission imaging scan and atrial fibrillation, and were less often classified as having large vessels causing strokes, in comparison with the rest of the SITS-ISTR. Symptomatic intracerebral haemorrhage occurred in 2.3% of patients per SITS-MOST definition and fatal outcome in 5.5%. At 7 days, 50% of patients with isolated dysphasia recovered completely and at 3 months, 86.3% patients were functionally independent (mRS score 0-2), 71.7% had an excellent outcome (mRS score 0-1) and 45.5% had an mRS score of 0. CONCLUSIONS A low proportion of patients with isolated dysphasia are treated with IVT. Half of these patients were fully recovered at 7 days.
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Affiliation(s)
- Erik Lundström
- Department of Neurology, Karolinska University Hospital & Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Andrea Zini
- Stroke Unit, Department of Neuroscience, Nuovo Ospedale Civile “S Agostino-Estense,” AUSL Modena, Modena, Italy
| | - Nils Wahlgren
- Department of Neurology, Karolinska University Hospital & Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital & Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Mead G, Hackett ML, Lundström E, Murray V, Hankey GJ, Dennis M. The FOCUS, AFFINITY and EFFECTS trials studying the effect(s) of fluoxetine in patients with a recent stroke: a study protocol for three multicentre randomised controlled trials. Trials 2015; 16:369. [PMID: 26289352 PMCID: PMC4545865 DOI: 10.1186/s13063-015-0864-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/14/2015] [Indexed: 12/18/2022] Open
Abstract
Background Several small trials have suggested that fluoxetine improves neurological recovery from stroke. FOCUS, AFFINITY and EFFECTS are a family of investigator-led, multicentre, parallel group, randomised, placebo-controlled trials that aim to determine whether routine administration of fluoxetine (20 mg daily) for 6 months after acute stroke improves patients’ functional outcome. Methods/Design The three trial investigator teams have collaboratively developed a core protocol. Minor variations have been tailored to the national setting in the UK (FOCUS), Australia and New Zealand (AFFINITY) and Sweden (EFFECTS). Each trial is run and funded independently and will report its own results. A prospectively planned individual patient data meta-analysis of all three trials will subsequently provide the most precise estimate of the overall effect of fluoxetine after stroke and establish whether any effects differ between trials and subgroups of patients. The trials include patients ≥18 years old with a clinical diagnosis of stroke, persisting focal neurological deficits at randomisation between 2 and 15 days after stroke onset. Patients are randomised centrally via web-based randomisation systems using a common minimisation algorithm. Patients are allocated fluoxetine 20 mg once daily or matching placebo capsules for 6 months. Our primary outcome measure is the modified Rankin scale (mRS) at 6 months. Secondary outcomes include the Stroke Impact Scale, EuroQol (EQ5D-5 L), the vitality subscale of the Short-Form 36, diagnosis of depression, adherence to medication, adverse events and resource use. Outcomes are collected at 6 and 12 months. The methods of collecting these data are tailored to the national setting. If FOCUS, AFFINITY and EFFECTS combined enrol 6000 participants as planned, they would have 90 % power (alpha 5 %) to detect a common odds ratio of 1.16, equivalent to a 3.7 % absolute difference in percentage with mRS 0–2 (44.0 % to 47.7 %). This is based on an ordinal analysis of mRS adjusted for baseline variables included in the minimisation algorithm. Discussion If fluoxetine is safe and effective in promoting functional recovery, it could be rapidly, widely and affordably implemented in routine clinical practice and reduce the burden of disability due to stroke. Trial registration FOCUS: ISRCTN83290762 (23/05/2012), AFFINITY: ACTRN12611000774921 (22/07/2011). EFFECTS: ISRCTN13020412 (19/12/2014). Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0864-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building FU303h, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
| | - Maree L Hackett
- The George Institute for Global Health, University of Sydney, Sydney, Australia.
| | - Erik Lundström
- Department of Neurology, Karolinska University Hospital, Solna, Sweden.
| | | | - Graeme J Hankey
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building FU303h, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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Wallmark S, Lundström E, Wikström J, Ronne-Engström E. Attention Deficits After Aneurysmal Subarachnoid Hemorrhage Measured Using the Test of Variables of Attention. Stroke 2015; 46:1374-6. [DOI: 10.1161/strokeaha.115.009092] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 02/26/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The aim of this pilot study was to assess attention deficits in patients with aneurysmal subarachnoid hemorrhage using the test of variables of attention (TOVA). This is a computer-based continuous performance test providing objective measures of attention. We also compared the TOVA results with the attention and concentration domains of Montgomery Åsberg Depression Rating Scale and Montreal cognitive assessment, 2 examiner-administrated neuropsychological instruments.
Methods—
Nineteen patients with moderate to good recovery (Glasgow outcome scale, 4–5) were assessed using the TOVA, Montgomery Åsberg Depression Rating Scale, and Montreal cognitive assessment. The measurements were done when the patients visited the hospital for a routine magnetic resonance imaging control of the aneurysm.
Results—
TOVA performance was pathological in 58%. The dominating pattern was a worsening of performance in the second half of the test, commonly a failing to react to correct stimuli. We found no correlation between TOVA and the performance in concentration and attention domains of Montgomery Åsberg Depression Rating Scale and Montreal cognitive assessment.
Conclusions—
Attention deficits, measured by the TOVA, were common after subarachnoid hemorrhage. This should be further studied to improve outcome.
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Affiliation(s)
- Svante Wallmark
- From the Section of Neurosurgery, Department of Neuroscience (S.W., E.R.-E.) and Section of Radiology, Department of Radiology, Oncology and Radiation Science (J.W.), Uppsala University, Uppsala, Sweden; and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden (E.L.)
| | - Erik Lundström
- From the Section of Neurosurgery, Department of Neuroscience (S.W., E.R.-E.) and Section of Radiology, Department of Radiology, Oncology and Radiation Science (J.W.), Uppsala University, Uppsala, Sweden; and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden (E.L.)
| | - Johan Wikström
- From the Section of Neurosurgery, Department of Neuroscience (S.W., E.R.-E.) and Section of Radiology, Department of Radiology, Oncology and Radiation Science (J.W.), Uppsala University, Uppsala, Sweden; and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden (E.L.)
| | - Elisabeth Ronne-Engström
- From the Section of Neurosurgery, Department of Neuroscience (S.W., E.R.-E.) and Section of Radiology, Department of Radiology, Oncology and Radiation Science (J.W.), Uppsala University, Uppsala, Sweden; and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden (E.L.)
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Blomberg H, Lundström E, Toss H, Gedeborg R, Johansson J. Agreement between ambulance nurses and physicians in assessing stroke patients. Acta Neurol Scand 2014; 129:49-55. [PMID: 23710712 DOI: 10.1111/ane.12149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES If an ambulance nurse could bypass the emergency department (ED) and bring suspected stroke patients directly to a CT scanner, time to thrombolysis could be shortened. This study evaluates the level of agreement between ambulance nurses and emergency physicians in assessing the need for a CT scan, and interventions and monitoring beforehand, in patients with suspected stroke and/or a lowered level of consciousness. METHODS From October 2008 to June 2009, we compared the ambulance nurses' and ED physicians' judgement of 200 patients with stroke symptoms. Both groups answered identical questions on patients' need for a CT scan, and interventions and monitoring beforehand. RESULTS There was poor agreement between ambulance nurses and ED physicians in judging the need for a CT scan: κ = 0.22 (95% confidence interval (CI), 0.06-0.37). The nurses' ability to select the same patients as the physician for a CT scan had a sensitivity of 84% (95% CI, 77-89) and a specificity of 37% (95% CI, 23-53). Agreement concerning the need for interventions and monitoring was also low: κ = 0.32 (95% CI, 0.18-0.47). In 18% of cases, the nurses considered interventions before a CT scan unnecessary when the physicians' deemed them necessary. CONCLUSIONS Additional tools to support ambulance nurses decisions appear to be required before suspected stroke patients can be taken directly to a CT scanner.
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Affiliation(s)
- H. Blomberg
- Department of Surgical Sciences - Anesthesiology and Intensive Care; Uppsala University Hospital; Uppsala Sweden
- Centre of Emergency Medicine; Uppsala University Hospital; Uppsala Sweden
| | - E. Lundström
- Department of Neuroscience - Neurology and Rehabilitation Medicine; Uppsala University Hospital; Uppsala Sweden
| | - H. Toss
- Department of Internal Medicine; Uppsala University Hospital; Uppsala Sweden
| | - R. Gedeborg
- Department of Surgical Sciences - Anesthesiology and Intensive Care; Uppsala University Hospital; Uppsala Sweden
| | - J. Johansson
- Department of Surgical Sciences - Anesthesiology and Intensive Care; Uppsala University Hospital; Uppsala Sweden
- Centre of Emergency Medicine; Uppsala University Hospital; Uppsala Sweden
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