Television Viewing Time and Stroke Risk: Australian Diabetes Obesity and Lifestyle Study (1999-2012).

INTRODUCTION: Having a low level of physical activity is an established risk factor for stroke, but little is known about the importance of common sedentary behavior-television viewing-to stroke risk. METHODS: We conducted a retrospective analysis of data that were collected as part of the longitudinal Australian Diabetes, Obesity, and Lifestyle study. Stroke events reported during the study (between baseline assessment in 1999-2000 and April 2011) were confirmed using adjudication based on medical records. Baseline data on minutes per week spent watching television were used as the exposure variable. Other variables were collected in assessments at wave 2 (2004-05) and wave 3 (2011-2012). Univariable and multivariable logistic regression analyses were performed. RESULTS: Among the full Australian Diabetes, Obesity, and Lifestyle study population (n = 11,247), there were 153 participants with confirmed stroke during the study period, and 9207 participants with no stroke in this period. Participants who went on to have their first stroke during the study had significantly higher levels of TV viewing time at baseline than those who did not have a stroke (P = .001). This association was not present (P = .83), however, when age and sex were included in the regression model. CONCLUSION: In the Australian Diabetes, Obesity, and Lifestyle study dataset, there was no evidence that more TV viewing is independently associated with risk of stroke, although analyses may have been underpowered.

Early Mobilization After Stroke Is Not Associated With Cognitive Outcome.

Background and Purpose- We aimed to determine whether early mobilization after stroke affects subsequent cognitive function. Methods- AVERT (A Very Early Rehabilitation Trial) was an international, 56-site, phase 3 randomized controlled trial, conducted from 2006 to 2015. Participants were included if they were aged 18+, presented within 24 hours of stroke, and satisfied physiological limits for blood pressure, heart rate, and temperature. Participants were randomized to receive either usual stroke unit care or very early and more frequent mobilization in addition to usual stroke unit care. The Montreal Cognitive Assessment, scored 0 to 30, was introduced as a 3-month outcome during 2008. Results- Of the 2104 patients included in AVERT, 317 were assessed before the Montreal Cognitive Assessment's introduction. Of the remaining 1787, 1189 (66.5%) had complete Montreal Cognitive Assessment data, 456 (25.5%) had partially or completely missing data, 136 (7.6%) had died, and 6 (0.3%) were lost to follow-up. In surviving participants with complete data, adjusting for age and stroke severity, total Montreal Cognitive Assessment score was no different in the intervention (n=595; median, 23; interquartile range, 19-26; mean, 21.9; SD, 5.9) and usual care (n=594; median, 23; interquartile range, 19-26; mean, 21.8; SD, 5.9) groups ( P=0.68). Conclusions- Exposure to earlier and more frequent mobilization in the acute stage of stroke does not influence cognitive outcome at 3 months. This stands in contrast to the primary outcome from AVERT (modified Rankin Scale), where the intervention group had less favorable outcomes than controls. Clinical Trial Registration- URL: https://www.anzctr.org.au . Unique identifier: ACTRN12606000185561.

Effects of Physical Activity on Poststroke Cognitive Function: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND AND PURPOSE: Despite the social, health, and economic burdens associated with cognitive impairment poststroke, there is considerable uncertainty about the types of interventions that might preserve or restore cognitive abilities. The objective of this systematic review and meta-analysis was to evaluate the effects of physical activity (PA) training on cognitive function poststroke and identify intervention and sample characteristics that may moderate treatment effects. METHODS: Randomized controlled trials examining the association between structured PA training and cognitive performance poststroke were identified using electronic databases EMBASE and MEDLINE. Intervention effects were represented by Hedges' g and combined into pooled effect sizes using random- and mixed-effects models. Effect sizes were subjected to moderation analyses using the between-group heterogeneity test. RESULTS: Fourteen studies met inclusion criteria, representing data from 736 participants. The primary analysis yielded a positive overall effect of PA training on cognitive performance (Hedges' g [95% confidence interval]=0.304 [0.14-0.47]). Mixed-effects analyses demonstrated that combined aerobic and strength training programs generated the largest cognitive gains and that improvements in cognitive performance were achieved even in the chronic stroke phase (mean=2.6 years poststroke). Positive moderate treatment effects were found for attention/processing speed measures (Hedges' g [confidence interval]=0.37 [0.10-0.63]), while the executive function and working memory domains did not reach significance (P>0.05). CONCLUSIONS: We found a significant positive effect of PA training on cognition poststroke with small to moderate treatment effects that are apparent even in the chronic stroke phase. Our findings support the use of PA training as a treatment strategy to promote cognitive recovery in stroke survivors.

The High Prevalence of Anxiety Disorders After Stroke.

OBJECTIVES: Previous studies indicate that post-stroke anxiety is common and persistent. We aimed to determine whether point prevalence of anxiety after stroke is higher than in the population at large, and whether the profile of anxiety symptoms is different. METHODS: This case-control study was conducted in Göteborg, Sweden, with stroke patients recruited from the Sahlgrenska University Hospital and a comparison group selected from local population health studies. We included 149 stroke survivors (assessed at 20 months post-stroke) and 745 participants from the general population matched for age and sex. A comprehensive psychiatric interview was conducted, with anxiety and depressive disorders diagnosed according to DSM-III-R criteria. RESULTS: Those in the stroke group were significantly more likely than those in the comparison group to have generalized anxiety disorder (GAD) (27% versus 8%), phobic disorder (24% versus 8%) and obsessive-compulsive disorder (9% versus 2%). Multivariate regression indicated that being in the stroke group, female sex, and having depression were all significant independent associates of having an anxiety disorder. In terms of symptom profile, stroke survivors with GAD were significantly more likely to report vegetative disturbance than those in the comparison group with GAD but less likely to have observable muscle tension or reduced sleep. CONCLUSIONS: Point prevalence of anxiety disorders is markedly higher after stroke than in the general population, and this cannot be attributed to higher rates of comorbid depression.

The health and economic benefits of reducing intimate partner violence: an Australian example.

BACKGROUND: Intimate partner violence (IPV) has important impacts on the health of women in society. Our aim was to estimate the health and economic benefits of reducing the prevalence of IPV in the 2008 Australian female adult population. METHODS: Simulation models were developed to show the effect of a 5 percentage point absolute feasible reduction target in the prevalence of IPV from current Australian levels (27%). IPV is not measured in national surveys. Levels of psychological distress were used as a proxy for exposure to IPV since psychological conditions represent three-quarters of the disease burden from IPV. Lifetime cohort health benefits for females were estimated as fewer incident cases of violence-related disease and injury; deaths; and Disability Adjusted Life Years (DALYs). Opportunity cost savings were estimated for the health sector, paid and unpaid production and leisure from reduced incidence of IPV-related disease and deaths. Workforce production gains were estimated by comparing surveyed participation and absenteeism rates of females with moderate psychological distress (lifetime IPV exposure) against high or very high distress (current IPV exposure), and valued using the friction cost approach (FCA). The impact of improved health status on unpaid household production and leisure time were modelled from time use survey data. Potential costs associated with interventions to reduce IPV were not considered. Multivariable uncertainty analyses and univariable sensitivity analyses were undertaken. RESULTS: A 5 percentage point absolute reduction in the lifetime prevalence of IPV in the 2008 Australian female population was estimated to produce 6000 fewer incident cases of disease/injury, 74 fewer deaths, 5000 fewer DALYs lost and provide gains of 926,000 working days, 371,000 days of home-based production and 428,000 leisure days. Overall, AUD371 million in opportunity cost savings could be achievable. The greatest economic savings would be home-based production (AUD147 million), followed by leisure time (AUD98 million), workforce production (AUD94 million) and reduced health sector costs (AUD38 million). CONCLUSIONS: This study contributes new knowledge about the economic impact of IPV in females. The findings provide evidence of large potential opportunity cost savings from reducing the prevalence of IPV and reinforce the need to reduce IPV in Australia, and elsewhere.

A Bahasa Malaysia version of the Montreal Cognitive Assessment: validation in stroke.

BACKGROUND: Many stroke research trials do not include assessment of cognitive function. A Very Early Rehabilitation Trial (AVERT) is an international multicenter study that includes the Montreal Cognitive Assessment (MoCA) as an outcome. At the Malaysian AVERT site, completion of the MoCA has been limited by low English proficiency in some participants. We aimed to develop a Bahasa Malaysia (BM) version of the MoCA and to validate it in a stroke population. METHODS: The original English version of the MoCA was translated into BM and then back-translated to ensure accuracy. Feasibility testing in a group of stroke patients prompted minor changes to the BM MoCA. In the validation phase, a larger group of bilingual stroke patients completed both the original English MoCA and the finalized BM MoCA, with presentation order counter-balanced. RESULTS: Forty stroke patients participated, with a mean age of 57.2 (SD = 10.3). Agreement between BM MoCA and English MoCA was strong (intra-class correlation coefficient = 0.81, 95% CI 0.68-0.90). Scores on BM MoCA were slightly higher than scores on English MoCA (median absolute difference = 2.0, IQR 0-3.5), and this difference was present regardless of which version was completed first. CONCLUSIONS: The existence of a validated BM version of the MoCA will be of major benefit to clinicians and researchers in Malaysia and the wider South-east Asian region, where the Malay language is used by over 200 million people.

The effect of physical activity on cognitive function after stroke: a systematic review.

BACKGROUND: Research in both humans and animals indicates that physical activity can enhance cognitive activity, but whether this is true in patients with stroke is largely unknown.We aimed to evaluate the relationship between increased physical activity after stroke and cognitive performance. METHODS: A systematic review was conducted of MEDLINE, EMBASE, PsycINFO and other electronic databases. All randomized controlled trials and controlled clinical studies that evaluated the effect of physical activity or exercise on cognitive function in stroke were included. Study quality was assessed using four criteria concerning sources of bias (use of randomization, allocation concealment, blinding of outcome assessment, whether all patients were accounted for in outcome data). RESULTS: The literature search (first run in 2008, updated in 2011) yielded 12 studies that satisfied inclusion criteria. Exercise interventions were heterogeneous; some studies compared different intensities of movement rehabilitation, others included a specific exercise program. Cognitive function was rarely the primary outcome measure, and cognitive assessment tools used were generally suboptimal. Nine studies had sufficient data to be included in a meta-analysis, which indicated a significant benefit of intervention over control (SMD = 0.20, 95% CI: 0.04­0.36; z = 2.43, p = 0.015). Studies that met all four quality criteria reported smaller treatment benefit than studies that did not. CONCLUSIONS: There is some evidence that increased physical activity after stroke enhances cognitive performance. The pool of studies identified, however, was small and methodological shortcomings were widespread.

The stroke exercise preference inventory is feasible to use in a community rehabilitation setting.

Exploring exercise preferences may help people to adhere to exercise programs by promoting customized programs to suit the person's choices and concerns. We investigated if the Stroke Exercise Preference Inventory, a questionnaire designed to explore stroke survivors' preferences for exercise and potential barriers, was feasible to use, and whether it assisted physiotherapists to design ongoing exercise programs in a mixed diagnostic convenience sample attending community rehabilitation. Physiotherapy staff interviewed 42 participants, and sought feedback about the questionnaire. Participant responses for exercise preferences and perceived barriers were then summarized. The questionnaire was quick to administer, readily understood, and considered relevant to consider when discussing options for exercise. Clinicians reported the questionnaire was useful for 48% (20/42) of participants, as it engaged the participant, clarified their preferences and allowed problem solving of potential barriers to exercise. Participants expressed strong preferences to be challenged, and to receive supervision and support. Preferences regarding environmental and social context of exercise varied widely. Difficulty getting started was the most common barrier reported. The Stroke Exercise Preference Inventory was feasible to use with a mixed diagnostic group during community rehabilitation, and provides structure to explore preferences and barriers to exercise. It remains to be tested whether use of the questionnaire promotes adherence to exercise programs.

The montreal cognitive assessment: short cognitive evaluation in a large stroke trial.

BACKGROUND AND PURPOSE: Cognitive function is often ignored in stroke research trials. The brief Montreal Cognitive Assessment (MoCA) may be sensitive to stroke-related cognitive deficits. METHODS: We evaluated the feasibility of administering the MoCA at 3 months in a large stroke trial (A Very Early Rehabilitation Trial [AVERT]). RESULTS: Data (blinded to intervention group) are presented for 294 patients with mean age of 70.6 years (SD, 12.8); 220 (75%) completed the MoCA, 54 (18%) had missing data, and 20 (7%) had died. Of those surviving to 3 months, the MoCA was completed by 87% with mild stroke, 79% with moderate stroke, and 67% with severe stroke on admission. Mean MoCA score was 21.1 (SD 7.5) out of 30; only 78 of 220 (35%) patients attained the "normal" cutoff (≥26). CONCLUSIONS: The MoCA is a feasible global cognitive screening tool in stroke trials. Clinical Trial Registration- URL: www.anzctr.org.au/trial_view.aspx?ID=1266. Unique identifier: ACTRN12606000185561.

Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial.

BACKGROUND AND PURPOSE: regaining functional independence is an important goal for people who have experienced stroke. We hypothesized that introducing earlier and more intensive out-of-bed activity after stroke would reduce time to unassisted walking and improve independence in activities of daily living. METHODS: a Very Early Rehabilitation Trial (AVERT) was a phase II randomized controlled trial. Patients with confirmed stroke (infarct or hemorrhage) admitted <24 hours after stroke and who met physiological safety criteria were eligible. Patients randomized to the very early and intensive mobilization group were mobilized within 24 hours of stroke and at regular intervals thereafter. Control patients received standard stroke unit care. The primary outcome for this analysis was the number of days required to return to walking 50 m unassisted. Secondary outcomes were the Barthel Index and Rivermead Motor Assessment at 3 and 12 months after stroke. RESULTS: seventy-one stroke patients with a mean age of 74.7 years were recruited from 2 hospitals. Adjusted Cox regression indicated that very early and intensive mobilization group patients returned to walking significantly faster than did standard stroke unit care controls (P=0.032; median 3.5 vs 7.0 days). Multivariable regression revealed that exposure to very early and intensive mobilization was independently associated with good functional outcome on the Barthel Index at 3 months (P=0.008) and on the Rivermead Motor Assessment at 3 (P=0.050) and 12 (P=0.024) months. CONCLUSIONS: earlier and more intensive mobilization after stroke may fast-track return to unassisted walking and improve functional recovery. Clinical Trial Registration- This trial was not registered because enrollment began before July 2005.

The economic benefits of reducing physical inactivity: an Australian example.

BACKGROUND: Physical inactivity has major impacts on health and productivity. Our aim was to estimate the health and economic benefits of reducing the prevalence of physical inactivity in the 2008 Australian adult population. The economic benefits were estimated as 'opportunity cost savings', which represent resources utilized in the treatment of preventable disease that are potentially available for re-direction to another purpose from fewer incident cases of disease occurring in communities. METHODS: Simulation models were developed to show the effect of a 10% feasible, reduction target for physical inactivity from current Australian levels (70%). Lifetime cohort health benefits were estimated as fewer incident cases of inactivity-related diseases; deaths; and Disability Adjusted Life Years (DALYs) by age and sex. Opportunity costs were estimated as health sector cost impacts, as well as paid and unpaid production gains and leisure impacts from fewer disease events associated with reduced physical inactivity. Workforce production gains were estimated by comparing surveyed participation and absenteeism rates of physically active and inactive adults, and valued using the friction cost approach. The impact of an improvement in health status on unpaid household production and leisure time were modeled from time use survey data, as applied to the exposed and non-exposed population subgroups and valued by suitable proxy. Potential costs associated with interventions to increase physical activity were not included. Multivariable uncertainty analyses and univariate sensitivity analyses were undertaken to provide information on the strength of the conclusions. RESULTS: A 10% reduction in physical inactivity would result in 6,000 fewer incident cases of disease, 2,000 fewer deaths, 25,000 fewer DALYs and provide gains in working days (114,000), days of home-based production (180,000) while conferring a AUD96 million reduction in health sector costs. Lifetime potential opportunity cost savings in workforce production (AUD12 million), home-based production (AUD71 million) and leisure-based production (AUD79 million) was estimated (total AUD162 million 95% uncertainty interval AUD136 million, AUD196 million). CONCLUSIONS: Opportunity cost savings and health benefits conservatively estimated from a reduction in population-level physical inactivity may be substantial. The largest savings will benefit individuals in the form of unpaid production and leisure gains, followed by the health sector, business and government.

The societal benefits of reducing six behavioural risk factors: an economic modelling study from Australia.

BACKGROUND: A large proportion of disease burden is attributed to behavioural risk factors. However, funding for public health programs in Australia remains limited. Government and non-government organisations are interested in the productivity effects on society from reducing chronic diseases. We aimed to estimate the potential health status and economic benefits to society following a feasible reduction in the prevalence of six behavioural risk factors: tobacco smoking; inadequate fruit and vegetable consumption; high risk alcohol consumption; high body mass index; physical inactivity; and intimate partner violence. METHODS: Simulation models were developed for the 2008 Australian population. A realistic reduction in current risk factor prevalence using best available evidence with expert consensus was determined. Avoidable disease, deaths, Disability Adjusted Life Years (DALYs) and health sector costs were estimated. Productivity gains included workforce (friction cost method), household production and leisure time. Multivariable uncertainty analyses and correction for the joint effects of risk factors on health status were undertaken. Consistent methods and data sources were used. RESULTS: Over the lifetime of the 2008 Australian adult population, total opportunity cost savings of AUD2,334 million (95% Uncertainty Interval AUD1,395 to AUD3,347; 64% in the health sector) were found if feasible reductions in the risk factors were achieved. There would be 95,000 fewer DALYs (a reduction of about 3.6% in total DALYs for Australia); 161,000 less new cases of disease; 6,000 fewer deaths; a reduction of 5 million days in workforce absenteeism; and 529,000 increased days of leisure time. CONCLUSIONS: Reductions in common behavioural risk factors may provide substantial benefits to society. For example, the total potential annual cost savings in the health sector represent approximately 2% of total annual health expenditure in Australia. Our findings contribute important new knowledge about productivity effects, including the potential for increased household and leisure activities, associated with chronic disease prevention. The selection of targets for risk factor prevalence reduction is an important policy decision and a useful approach for future analyses. Similar approaches could be applied in other countries if the data are available.

The NIH stroke scale can establish cognitive function after stroke.

BACKGROUND: Cognitive impairment is an important but underrecognised consequence of stroke. We investigated whether a subset of items from the NIH Stroke Scale (NIHSS) could yield valid information on cognitive status in a group of stroke patients. METHODS: 149 stroke patients from the Göteborg 70+ Stroke Study were investigated after 18 months. We extracted 4 items corresponding to the NIHSS items on orientation, executive function, language and inattention. Scores on this subset of 4 NIHSS items (Cog-4) and the Mini-Mental State Examination (MMSE) were evaluated against a reference diagnosis of severe cognitive impairment. RESULTS: The area under the receiver-operator curve (AUC) plotted for the Cog-4 scale against the diagnosis of severe cognitive impairment was 0.78; the MMSE had a slightly better diagnostic precision, with an AUC of 0.84. Making the executive task more difficult increased the precision of the Cog-4, raising the AUC to 0.81. CONCLUSIONS: A composite score based on 4 NIHSS items is almost as good as the MMSE in detecting severe cognitive impairment. Ideally, dedicated measures of cognition should be employed as a matter of course after stroke, but in their absence, the Cog-4 subscale provides an indication of cognitive functioning.

Quality of life: an important outcome measure in a trial of very early mobilisation after stroke.

Purpose. Commencing an early and active mobilisation programme in the acute stages of stroke may have important physical and psychological benefits that might improve long-term quality of life. We hypothesised that patients who received very early mobilisation (VEM) would experience better quality of life than those receiving standard care (SC). Methods. The study was a Phase II single-blind randomised controlled trial: VEM patients received earlier (within 24 h of stroke onset) and more intensive physical therapy than SC patients for the first 14 days (or until discharge). Quality of life was measured using the Assessment of Quality of Life (AQoL) questionnaire, administered face-to-face by a blinded assessor at 12 months post-stroke. Results. Seventy-one individuals with stroke (VEM 38, SC 33) were recruited. At follow-up, the median overall AQoL score was higher in VEM patients (0.32) than SC patients (0.24). This group difference was not significant (p = 0.17), but it was significant at the 75th percentile (p = 0.003) in favour of VEM. VEM patients also reported higher quality of life than SC patients in the physical function related 'Independent Living' domain of the AQoL (p = 0.03 adjusted for age; p = 0.04 adjusted for stroke severity). Conclusions. VEM may help improve long-term quality of life after stroke, particularly in relation to functional independence, but this requires further examination.

The AVERT MoCA Data: Scoring Reliability in a Large Multicenter Trial.

The Montreal Cognitive Assessment (MoCA) is a widely used cognitive screening tool in stroke. As scoring the visuospatial/executive MoCA items involves subjective judgement, reliability is important. Analyzing data on these items from A Very Early Rehabilitation Trial (AVERT), we compared the original scoring of assessors (n = 102) to blind scoring by a single, independent rater. In a sample of scoresheets from 1,119 participants, we found variable interrater reliability. The match between original assessors and the independent rater was the following: trail-making 97% (κ = 0.94), cube copy 90% (κ = 0.80), clock contour 92% (κ = 0.49), clock numbers 89% (κ = 0.67), and clock hands 72% (κ = 0.46). For all items except clock contour, the independent rater was "stricter" than the original assessors. Discrepancies were typically errors in original scoring, rather than borderline differences in subjective judgement. In trials that include the MoCA, researchers should emphasize scoring rules to assessors and implement independent data checking, especially for clock hands, to maximize accuracy.

Hemispatial neglect and rehabilitation in acute stroke.

OBJECTIVES: To compare 2 methods for determining neglect in patients within 2 days of stroke, and to investigate whether early neglect was related to rehabilitation practice, and whether this relationship was affected by an early, intensive mobilization intervention. DESIGN: Data were collected from patients participating in a phase II randomized controlled trial of early rehabilitation after stroke. SETTING: Acute hospital stroke unit. PARTICIPANTS: Stroke patients (N=71). INTERVENTION: The 2 arms of the trial were very early mobilization (VEM) and standard care (SC). MAIN OUTCOME MEASURES: Neglect was assessed using the Star Cancellation Test and the National Institutes of Health Stroke Scale (NIHSS) inattention item within 48 hours of stroke onset, and therapy details were recorded during the hospital stay. RESULTS: Assessing neglect so acutely after stroke was difficult: 29 of the 71 patients were unable to complete the Star Cancellation Test, and agreement between this test and the NIHSS measure was only .42. Presence of neglect did not preclude early mobilization. SC group patients with neglect had longer hospital stays (median, 11d) than those without neglect (median, 4d); there was no difference in length of stay between patients with and without neglect in the VEM group (median, 6d in both). CONCLUSION: Early mobilization of patients with neglect was feasible and may contribute to a shorter acute hospital stay.

Early mobilization and quality of life after stroke: Findings from AVERT.

OBJECTIVE: To determine whether early and more frequent mobilization after stroke affects health-related quality of life. METHODS: A Very Early Rehabilitation Trial (AVERT) was an international, multicenter (56 sites), phase 3 randomized controlled trial, spanning 2006-2015. People were included if they were aged ≥18 years, presented within 24 hours of a first or recurrent stroke (ischemic or hemorrhagic), and satisfied preordained physiologic criteria. Participants were randomized to usual care alone or very early and more frequent mobilization in addition to usual care. Quality of life at 12 months was a prespecified secondary outcome, evaluated using the Assessment of Quality of Life 4D (AQoL-4D). This utility-weighted scale has scores ranging from -0.04 (worse than death) to 1 (perfect health). Participants who died were assigned an AQoL-4D score of 0. RESULTS: No significant difference in quality of life at 12 months between intervention (median 0.47, interquartile range [IQR] 0.07-0.81) and usual care (median 0.49, IQR 0.08-0.81) groups was identified (p = 0.86), nor were there any group differences across the 4 AQoL-4D domains. The same lack of group difference in quality of life was observed at 3 months. When cohort data were analyzed (both groups together), quality of life was strongly associated with acute length of stay, independence in activities of daily living, cognitive function, depressive symptoms, and anxiety symptoms (all p < 0.001). Quality of life in AVERT participants was substantially lower than population norms, and the gap increased with age. CONCLUSIONS: Earlier and more frequent mobilization after stroke did not influence quality of life. CLINICAL TRIAL REGISTRATION: anzctr.org.au; ACTRN12606000185561 CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for people with stroke, earlier and more frequent mobilization did not influence quality of life over the subsequent year.

Investigating post-stroke fatigue: An individual participant data meta-analysis.

OBJECTIVE: The prevalence of post-stroke fatigue differs widely across studies, and reasons for such divergence are unclear. We aimed to collate individual data on post-stroke fatigue from multiple studies to facilitate high-powered meta-analysis, thus increasing our understanding of this complex phenomenon. METHODS: We conducted an Individual Participant Data (IPD) meta-analysis on post-stroke fatigue and its associated factors. The starting point was our 2016 systematic review and meta-analysis of post-stroke fatigue prevalence, which included 24 studies that used the Fatigue Severity Scale (FSS). Study authors were asked to provide anonymised raw data on the following pre-identified variables: (i) FSS score, (ii) age, (iii) sex, (iv) time post-stroke, (v) depressive symptoms, (vi) stroke severity, (vii) disability, and (viii) stroke type. Linear regression analyses with FSS total score as the dependent variable, clustered by study, were conducted. RESULTS: We obtained data from 14 of the 24 studies, and 12 datasets were suitable for IPD meta-analysis (total n = 2102). Higher levels of fatigue were independently associated with female sex (coeff. = 2.13, 95% CI 0.44-3.82, p = 0.023), depressive symptoms (coeff. = 7.90, 95% CI 1.76-14.04, p = 0.021), longer time since stroke (coeff. = 10.38, 95% CI 4.35-16.41, p = 0.007) and greater disability (coeff. = 4.16, 95% CI 1.52-6.81, p = 0.010). While there was no linear association between fatigue and age, a cubic relationship was identified (p < 0.001), with fatigue peaks in mid-life and the oldest old. CONCLUSION: Use of IPD meta-analysis gave us the power to identify novel factors associated with fatigue, such as longer time since stroke, as well as a non-linear relationship with age.

Diversity of risk factors for stroke: the putative roles and mechanisms of depression and air pollution.

Several conventional risk factors for stroke and cerebrovascular disease, such as hypertension, smoking, and atrial fibrillation, are widely recognized. Correct management of these modifiable factors significantly reduces stroke risk. We review the research evidence that depressive symptoms and increased atmospheric pollution are associated with an increased risk of stroke, and outline putative mechanisms that may account for these associations. The data on depression and stroke risk strongly indicate the need for treatment intervention studies. The design and implementation of intervention studies related to air pollution requires better understanding of the pathophysiologic mechanisms linking exposures to the onset of stroke.