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Pedersen SG, Anke A, Friborg O, Ørbo MC, Løkholm MT, Kirkevold M, Heiberg G, Halvorsen MB. Metacognitive beliefs, mood symptoms, and fatigue four years after stroke: An explorative study. PLoS One 2024; 19:e0305896. [PMID: 38917133 PMCID: PMC11198774 DOI: 10.1371/journal.pone.0305896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVE This cross-sectional study investigated the relationship between metacognition and mood symptoms four years post-stroke and examined fatigue as a potential moderator for this relationship. METHODS A number of 143 participants completed a survey that included the Hospital Anxiety and Depression Scale (HADS), the Metacognition Questionnaire-30 (MCQ-30), the Fatigue Severity Scale (FSS), and the modified Rankin Scale (mRS) (functional status) four years after stroke. Multiple regression analyses adjusting for demographic and stroke-specific covariates were performed with anxiety and depression as dependent variables and fatigue as a moderator. RESULTS The proportions of participants satisfying the caseness criteria for anxiety and depression were 20% and 19%, respectively, and 35% reported severe fatigue. Analysed separately, all MCQ-30 subscales contributed significantly to anxiety, whereas only three MCQ-30 subscales contributed significantly to depression. In the adjusted analyses, the MCQ-30 subscales 'positive beliefs' (p < 0.05) and 'uncontrollability and danger' (p < 0.001), as well as fatigue (p < 0.001) and functional status at four years (p < 0.05) were significantly associated with anxiety symptoms. Similarly, the MCQ-30 subscales 'cognitive confidence' (p < 0.05) and 'self-consciousness' (p < 0.05), as well as fatigue (p < 0.001), stroke severity at baseline (p < 0.01), and functional status at four years (p < 0.01) were significantly associated with depression symptoms. Fatigue did not significantly moderate the relationship between any MCQ-30 subscale and HADS scores. CONCLUSION Maladaptive metacognitions were associated with the mood symptoms of anxiety and depression, independent of fatigue, even after controlling for demographic and stroke-specific factors. Future studies should implement longitudinal designs to determine whether metacognitions precede anxiety or depression after a stroke, and more strongly indicate the potential of metacognitive therapy for improving the mental health of individuals after a stroke.
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Affiliation(s)
- Synne G. Pedersen
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway
| | - Audny Anke
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Model and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT–The Arctic University of Norway, Tromsø, Norway
| | - Oddgeir Friborg
- Department of Psychology, Faculty of Health Sciences, UiT–The Arctic University of Norway, Tromsø, Norway
| | - Marte C. Ørbo
- Department of Psychology, Faculty of Health Sciences, UiT–The Arctic University of Norway, Tromsø, Norway
| | - Mari T. Løkholm
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway
| | - Marit Kirkevold
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Model and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
- Faculty of Health Promotion, Oslo Metropolitan University, Oslo, Norway
| | - Guri Heiberg
- Department of Rehabilitation, University Hospital of North Norway, Tromsø, Norway
| | - Marianne B. Halvorsen
- Department of Pediatric Rehabilitation, University Hospital of North Norway, Tromsø, Norway
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Fors S, Bråndal A, Pessah-Rasmussen H, Lindgren I. Experiences of chain of care and rehabilitation after stroke: a qualitative study of persons discharged to skilled nursing facilities before returning home. J Rehabil Med 2024; 56:jrm35240. [PMID: 38899476 PMCID: PMC11218674 DOI: 10.2340/jrm.v56.35240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE To explore how people with stroke, discharged to skilled nursing facilities before returning home, experience the chain of care and rehabilitation. DESIGN Qualitative, semi-structured interview design. METHODS Thirteen stroke survivors discharged from a stroke unit to a skilled nursing facility before returning to independent living participated. Semi-structured telephone interviews were conducted 2-5 months after stroke and analysed with content analysis. RESULTS The analysis resulted in three categories, Organizational processes, critical and complex, Rehabilitation, the right support at the right time and Adaptation to the changed situation, with a total of 9 subcategories. The informants perceived low participation in planning and goalsetting and limited information. Support from the healthcare services was important to proceed with improvements although the amount of supported training varied. Factors hindering and facilitating managing everyday life were described, as well as lingering uncertainty of what the future would be like. CONCLUSION Support and rehabilitation as well as individuals' needs varied, throughout the chain of care. To enable participation in the rehabilitation, assistance in setting goals and repeated information is warranted. Tailored care and rehabilitation throughout the chain of care should be provided, followed up at home, and coordinated for smooth transitions between organizations.
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Affiliation(s)
- Sofie Fors
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Sweden; Department of Health Sciences, Lund University, Sweden.
| | - Anna Bråndal
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Sweden
| | - Hélène Pessah-Rasmussen
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Sweden; Department of Clinical Sciences, Lund, Lund University, Sweden
| | - Ingrid Lindgren
- Department of Neurology, Rehabilitation Medicine, Memory Disorders and Geriatrics, Skåne University Hospital, Sweden; Department of Health Sciences, Lund University, Sweden
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Zhu X, Lan L, Liu Y, He N, Wu J, Guo Y, Li H, Li D. Thrombo-inflammatory prognostic score can predict the outcome of stroke: a retrospective cohort study. Front Aging Neurosci 2024; 16:1391559. [PMID: 38872624 PMCID: PMC11169932 DOI: 10.3389/fnagi.2024.1391559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/16/2024] [Indexed: 06/15/2024] Open
Abstract
Introduction Inflammatory and thrombotic biomarkers are simple prognostic indicators of adverse clinical outcomes in patients with ischemic stroke (IS). However, isolated assessment of inflammatory or thrombus biomarkers in patients with IS is limited in clinical practice. Methods This study aimed to evaluate the predictive value of a novel, simplified thrombo-inflammatory prognostic score (TIPS) that combines both inflammatory and thrombus biomarkers in the early phase of IS and to identify high-risk patients at the time of admission. The study population comprised 915 patients with a primary diagnosis of IS in the emergency departments of five grade A tertiary hospitals in China. Results Patients were divided into two groups based on the modified Rankin Scale (mRS): <3 and ≥3. TIPS with a value of "2" indicates biomarkers for high inflammation and thrombosis, "1" represents a biomarker, and "0" signals the absence of a biomarker. Multivariate logistic regression analysis was employed to identify the association between TIPS and clinical outcomes. TIPS was an independent predictor of unfavorable functional outcomes and mortality. It had a superior predictive value for clinical outcomes compared to the National Institutes of Health Stroke Scale (NIHSS) (effect ratio, 37.5%), D-dimer (effect ratio, 12.5%), and neutrophil-to-lymphocyte ratio (effect ratio, 25%). Conclusion The survival probability of TIPS with a score of 0 is twice as high as that of TIPS with a score of 2. The survival rate for TIPS with a score of 1 is one time higher than that for TIPS with a score of 2. The predictive value of TIPS for unfavorable functional outcomes is represented by an AUC of 0.653. TIPS is associated with an increased risk of death and unfavorable functional outcomes in patients with IS and may be a useful tool for identifying high-risk patients at the time of admission.
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Affiliation(s)
- Xingyu Zhu
- Department of Cardiovascular Surgery, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
- Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Lan
- Department of Emergency Medicine, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Yi Liu
- Department of Emergency Medicine, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Na He
- Department of Emergency Medicine, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Jie Wu
- Department of Emergency Medicine, West China Tianfu Hospital, West China Hospital, Sichuan University, Chengdu, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
- Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Li
- Department of Emergency Medicine, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, China
| | - Dongze Li
- Department of Emergency Medicine, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
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Abbasi MH, Yuan K, Kasner SE, McPartland E, Owens KC, Sloane KL. Text Message-Based Assessment of 90-Day Modified Rankin Scale After Stroke. J Am Heart Assoc 2024; 13:e033301. [PMID: 38686866 PMCID: PMC11179808 DOI: 10.1161/jaha.123.033301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND The modified Rankin Scale (mRS) is commonly used to measure disability after stroke, traditionally assessed through telephone or in-person evaluation. Here, we investigated the validity of mRS assessment through an automated text messaging system based on the simplified mRS questionnaire as an alternative method to traditional methods of assessment. METHODS AND RESULTS A total of 250 patients admitted to 3 hospitals within the University of Pennsylvania Health System with ischemic or hemorrhagic stroke were enrolled. Participants received automated text messages sent 48 hours before their outpatient appointment at about 90 days after stroke. The mRS scores were assigned on the basis of participant responses to 2 to 4 text questions eliciting yes/no responses. The mRS was then evaluated in person or by telephone interview for comparison. Responses were compared with κ. A total of 142 patients (57%) completed the study. The spontaneous response rate to text messages was 46.5% and up to 72% with an additional direct in-person or phone call reminder. Agreement was substantial (quadratic-weighted κ=0.87 [95% CI, 0.83-0.89]) between responses derived from the automated text messaging and traditional interviews. Agreement for distinguishing functional independence (mRS 0-1) from dependence (mRS 2-5) was substantial (unweighted κ=0.79 [95% CI, 0.69-0.90]). CONCLUSIONS An automated text messaging system is a feasible method for remotely obtaining the mRS after stroke and a potential alternative to traditional in-person or telephone assessment. Further studies are needed to evaluate the generalizability of text message-based approaches to stroke outcome measurement.
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Affiliation(s)
| | - Kristy Yuan
- Department of NeurologyUniversity of Pennsylvania, Perelman School of MedicinePhiladelphiaPAUSA
| | - Scott E. Kasner
- Department of NeurologyUniversity of Pennsylvania, Perelman School of MedicinePhiladelphiaPAUSA
| | - Ellen McPartland
- Department of NeurologyUniversity of Pennsylvania, Perelman School of MedicinePhiladelphiaPAUSA
| | - Karrima C. Owens
- Department of NeurologyUniversity of Pennsylvania, Perelman School of MedicinePhiladelphiaPAUSA
| | - Kelly L. Sloane
- Department of NeurologyUniversity of Pennsylvania, Perelman School of MedicinePhiladelphiaPAUSA
- Department of Physical Medicine and RehabilitationUniversity of Pennsylvania, Perelman School of MedicinePhiladelphiaPAUSA
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C de Andrade JB, Quinn TJ, Carbonera LA, Montanaro VVA, Robles AC, Pádua Gomes R, Ribeiro S, Sampaio Silva G. An automated flowchart for the Modified Rankin Scale assessment: A multicenter inter-rater agreement analysis. Int J Stroke 2024:17474930241246157. [PMID: 38546172 DOI: 10.1177/17474930241246157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND OBJECTIVE The Modified Rankin Scale (mRS) is a widely adopted scale for assessing stroke recovery. Despite limitations, the mRS has been adopted as primary outcome in most recent clinical acute stroke trials. Designed to be used by multidisciplinary clinical staff, the congruency of this scale is not consistent, which may lead to mistakes in clinical or research application. We aimed to develop and validate an interactive and automated digital tool for assessing the mRS-the iRankin. METHODS A panel of five board-certified and mRS-trained vascular neurologists developed an automated flowchart based on current mRS literature. Two international experts were consulted on content and provided feedback on the prototype platform. The platform contained five vignettes and five real video cases, representing mRS grades 0-5. For validation, we invited neurological staff from six comprehensive stroke centers to complete an online assessment. Participants were randomized into two equal groups usual practice versus iRankin. The participants were randomly allocated in pairs for the congruency analysis. Weighted kappa (kw) and proportions were used to describe agreement. RESULTS A total of 59 professionals completed the assessment. The kw was dramatically improved among nurses, 0.76 (95% confidence interval (CI) = 0.55-0.97) × 0.30 (0.07-0.67), and among vascular neurologists, 0.87 (0.72-1) × 0.82 (0.66-0.98). In the accuracy analysis, after the standard mRS values for the vignettes and videos were determined by a panel of experts, and considering each correct answer as equivalent to 1 point on a scale of 0-15, it revealed a higher mean of 10.6 (±2.2) in the iRankin group and 8.2 (±2.3) points in the control group (p = 0.02). In an adjusted analysis, the iRankin adoption was independently associated with the score of congruencies between reported and standard scores (beta coefficient = 2.22, 95% CI = 0.64-3.81, p = 0.007). CONCLUSION The iRankin adoption led to a substantial or near-perfect agreement in all analyzed professional categories. More trials are needed to generalize our findings. Our user-friendly and free platform is available at https://www.irankinscale.com/.
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Affiliation(s)
- Joao Brainer C de Andrade
- Departments of Health Informatics and Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Bioengineering Laboratory, Aeronautics Institute of Technology (ITA), São Jose dos Campos, Brazil
- Centro Universitário São Camilo, São Paulo, Brazil
| | | | | | | | | | | | | | - Gisele Sampaio Silva
- Departments of Health Informatics and Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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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] [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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Yi K, Nakajima M, Ikeda T, Yoshigai M, Ueda M. Modified Rankin scale assessment by telephone using a simple questionnaire. J Stroke Cerebrovasc Dis 2022; 31:106695. [PMID: 36054972 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/23/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The modified Rankin Scale (mRS) is widely used as a measure of post-stroke physical disability in clinical stroke trials; however, it is affected by inter-rater discrepancies. A Japanese version of the simplified mRS questionnaire (J-RASQ) has the potential to overcome the inter-rater discrepancies and might be feasible for clinical surveys. We aimed to determine the reliability of J-RASQ in a telephone survey administered by non-medical staff. METHODS We recruited 103 patients (age = 73 ± 11 years; 57% males) with a history of ischemic stroke who visited the outpatient clinic of the department of neurology at our hospital between March and May, 2021. After obtaining informed consent for participation in the study, a stroke neurologist assessed the mRS score during the visit using the Japanese version of mRS. On the same day, a clerk telephoned the patient or his/her family members to administer the J-RASQ. The percentage of agreement between mRS and J-RASQ scores was evaluated using the kappa coefficient and weighted kappa coefficient. RESULTS The median time for the telephone survey was 85 s (interquartile range = 70-135 s). The mRS and J-RASQ scores had an agreement of 63.1%, with a kappa statistic of 0.51 (95% confidence interval [CI] = 0.39-0.63). The weighted kappa statistic, which takes into account the extent of disagreement, was 0.81 (95% CI = 0.75-0.88). CONCLUSION J-RASQ is easy to administer and reliable for assessment in telephone-based surveys performed by non-medical staff.
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Affiliation(s)
- Kenichiro Yi
- Department of Neurology, Minamata City Hospital and Medical Center, Minamata, Japan.
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
| | - Tomoaki Ikeda
- Department of Neurology, Minamata City Hospital and Medical Center, Minamata, Japan
| | - Mineko Yoshigai
- Department of Neurology, Minamata City Hospital and Medical Center, Minamata, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
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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] [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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