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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; 19:798-808. [PMID: 38497332 PMCID: PMC11298115 DOI: 10.1177/17474930241242628] [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: 01/03/2024] [Accepted: 02/16/2024] [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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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] [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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Kalbouneh HM, Toubasi AA, Albustanji FH, Obaid YY, Al‐Harasis LM. Safety and Efficacy of SSRIs in Improving Poststroke Recovery: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e025868. [PMID: 35730636 PMCID: PMC9333390 DOI: 10.1161/jaha.122.025868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/09/2022] [Indexed: 12/04/2022]
Abstract
Background Several studies investigated the role of selective serotonin reuptake inhibitors (SSRIs) in improving poststroke recovery; thus, we have decided to conduct this systematic review and meta-analysis to investigate the efficacy and safety of SSRIs in poststroke recovery. Methods and Results In this meta-analysis we searched the following databases: PubMed, Cochrane, Scopus, and Google Scholar. The studies were included if they were placebo-controlled trials in design and reported SSRIs' effects on poststroke depression, anxiety, disability, dependence, motor abilities, and cognitive functions. The quality of the included studies was assessed using the revised Cochrane risk-of-bias tool for randomized trials. The search yielded 44 articles that included 16 164 patients, and about half of the participants were treated with SSRIs. Our results showed that SSRIs had a significant effect on preventing depression (weighted mean difference [WMD], -7.05 [95% CI, -11.78 to -2.31]), treating depression according to the Hamilton Rating Scale for Depression score (WMD, -1.45 [95% CI, -2.77 to -0.14]), anxiety (relative risk, 0.23 [95% CI, 0.09-0.61]), dependence (WMD, 8.86 [95% CI, 1.23-16.48]), motor abilities according to National Institutes of Health Stroke Scale score (WMD, -0.79 [95% CI, -1.42 to -0.15]), and cognitive functions (WMD, 1.00 [95% CI, 0.12-1.89]). On the other hand, no significant effect of SSRIs on disability was observed. Additionally, we found that treating with SSRIs increased the risk of seizures (relative risk, 1.44 [95% CI, 1.13-1.83]), whereas there was no difference in the incidence of gastrointestinal symptoms or bleeding between SSRIs and a placebo. Conclusions Our study showed that SSRIs are effective in preventing and treating depression, and improving anxiety, motor function, cognitive function, and dependence in patients after stroke. These benefits were only reproducible with the citalopram subanalysis but not fluoxetine. Further well-conducted placebo-controlled trials are needed to investigate the safety and efficacy of citalopram among patients after stroke. Registration URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021285766.
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Affiliation(s)
- Heba M. Kalbouneh
- Department of AnatomyFaculty of MedicineUniversity of JordanAmmanJordan
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Fang C, Zhang Z, Xu H, Liu Y, Wang X, Yuan L, Xu Y, Zhu Z, Zhang A, Shao A, Lou M. Natural Products for the Treatment of Post-stroke Depression. Front Pharmacol 2022; 13:918531. [PMID: 35712727 PMCID: PMC9196125 DOI: 10.3389/fphar.2022.918531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/10/2022] [Indexed: 11/21/2022] Open
Abstract
Post-stroke depression (PSD) is the most frequent and important neuropsychiatric consequence of stroke. It is strongly associated with exacerbated deterioration of functional recovery, physical and cognitive recoveries, and quality of life. However, its mechanism is remarkably complicated, including the neurotransmitters hypothesis (which consists of a monoaminergic hypothesis and glutamate-mediated excitotoxicity hypothesis), inflammation hypothesis, dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, and neurotrophic hypothesis and neuroplasticity. So far, the underlying pathogenesis of PSD has not been clearly defined yet. At present, selective serotonin reuptake inhibitors (SSRIs) have been used as the first-line drugs to treat patients with PSD. Additionally, more than SSRIs, a majority of the current antidepressants complied with multiple side effects, which limits their clinical application. Currently, a wide variety of studies revealed the therapeutic potential of natural products in the management of several diseases, especially PSD, with minor side effects. Accordingly, in our present review, we aim to summarize the therapeutic targets of these compounds and their potential role in-clinic therapy for patients with PSD.
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Affiliation(s)
- Chaoyou Fang
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zeyu Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Houshi Xu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yibo Liu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Xiaoyu Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Ling Yuan
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanzhi Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhengyang Zhu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Anke Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
- *Correspondence: Anke Zhang, ; Anwen Shao, ; Meiqing Lou,
| | - Anwen Shao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
- *Correspondence: Anke Zhang, ; Anwen Shao, ; Meiqing Lou,
| | - Meiqing Lou
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Anke Zhang, ; Anwen Shao, ; Meiqing Lou,
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Almeida OP, Hankey GJ, Ford AH, Etherton-Beer C, Flicker L, Hackett ML. Measures Associated With Early, Late, and Persistent Clinically Significant Symptoms of Depression 1 Year After Stroke in the AFFINITY Trial. Neurology 2022; 98:e1021-e1030. [PMID: 35042738 DOI: 10.1212/wnl.0000000000200058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the sociodemographic and clinical factors associated with early, late and persistent clinically significant symptoms of depression during the first year after a stroke. METHODS Cohort study of 1221 men and women recruited within two weeks of stroke onset in Australia, New Zealand and Vietnam. The NIH Stroke Scale (NIHSS) was used to assess the severity of the stroke. Other study measures included age, sex, marital status, living arrangements, function before the stroke, depression before the stroke, modified Rankin Scale (mRS), and treatment with fluoxetine or placebo for 26 weeks. Clinically significant symptoms of depression during the 52 weeks after baseline was the outcome of interest, and its presence was defined by a total PHQ-9 score of 9 or higher at weeks 4, 12, 26 or 52, a clinician diagnosis of depression between assessments, or by pharmacological or psychological treatment of depression during follow up. Participants were classified as not depressed, or as early (initial 12 weeks), late (12 to 52 weeks) or persistent depression (before and after 12 weeks). We used multinomial logistic regression to assess depression risk, with all listed measures entered simultaneously into the model. RESULTS The mean age of participants was 63.8 (SD=12.3) years and 775 (63.5%) were male. At baseline, 48 (3.9%) participants had previous treated depression, and 228 (18.7%) had clinically significant symptoms of depression (PHQ-9 ≥ 9). 734 (63.3%) participants showed no evidence of depression in the year following the stroke, 208 (17.9%) had early, 86 (7.4%) late, and 131 (11.3%) persistent depression. Increased stroke severity, as measured by doubling of NIHSS scores, was associated with an increased risk of early (Risk Ratio [RR]=2.08, 95%CI=1.65-2.62), late (RR=1.53, 95%CI=1.14-2.06) and persistent clinically significant symptoms of depression (RR=2.50, 95%CI=1.89-3.32). Similar findings were apparent for the mRS, a measure of functional disability. Past depression was associated with increased risk of persistent clinically significant symptoms of depression (RR=6.28, 95%CI=2.88-13.71), as was being married or partnered (RR=3.94, 95%CI=2.42-6.41). The risk of clinically significant symptoms of depression was higher in Australia and New Zealand than in Vietnam. CONCLUSION The severity of neurological and functional deficits increases the risk of post-stroke clinically significant symptoms of depression early and persistently. Depression before stroke, personal relationships and cultural context contribute to mediate depression risk. Interventions that minimise the severity of neurological and functional deficits should decrease the risk of post-stroke clinically significant symptoms of depression.
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Affiliation(s)
| | | | | | | | - Leon Flicker
- Medical School, University of Western Australia, Australia
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, the University of New South Wales, Australia
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Mortensen JK, Andersen G. Safety considerations for prescribing SSRI antidepressants to patients at increased cardiovascular risk. Expert Opin Drug Saf 2021; 21:467-475. [PMID: 34569395 DOI: 10.1080/14740338.2022.1986001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION With the development of selective serotonin reuptake inhibitors (SSRI), a relatively uncomplicated treatment of depression and a safer alternative to tricyclic antidepressants was introduced. Any medical treatment has potential safety risks, however, and these risks should also be considered when prescribing SSRIs. AREAS COVERED The present review focuses on safety considerations when prescribing SSRIs to patients with previous stroke and myocardial infarction, as depression, and the need for antidepressant treatment, is common in these patients. At the same time, patients with stroke and myocardial infarction may be at increased risk of developing adverse events due to higher age, comorbidity, and co-medication. Specifically, the evidence of the risk of QT prolongation and bleeding versus thrombotic events will be discussed in the present review. EXPERT OPINION No medical treatment comes without risk and SSRIs are no exception. Depression, a common complication after vascular events, is a potentially life-threatening condition in itself and relevant and sufficient treatment is imperative. SSRIs are often the first medical treatment choice in the ambulatory setting, also in patients at increased cardiovascular risk. Relevant comorbidity and co-medication, however, should always be taken into account when initiating treatment and when choosing a specific SSRI.
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Affiliation(s)
- Janne Kaergaard Mortensen
- Dept of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Dept. Of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Grethe Andersen
- Dept of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Dept. Of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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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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Almeida OP, Hankey GJ, Ford A, Etherton-Beer C, Flicker L, Hackett M. Depression Outcomes Among Patients Treated With Fluoxetine for Stroke Recovery: The AFFINITY Randomized Clinical Trial. JAMA Neurol 2021; 78:1072-1079. [PMID: 34338714 DOI: 10.1001/jamaneurol.2021.2418] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance One in 3 adults experiences clinically significant symptoms of depression during the first year after a stroke, but evidence to support the use of antidepressants in this population remains scant. Objective To investigate whether daily treatment with 20 mg of fluoxetine hydrochloride reduces the proportion of people affected by clinically significant symptoms of depression after stroke. Design, Setting, and Participants In this secondary analysis of the Assessment of Fluoxetine in Stroke Recovery parallel-group, randomized (1:1 assignment), double-blind, placebo-controlled clinical trial, 1221 participants in Australia, New Zealand, and Vietnam were recruited between January 11, 2013, and June 30, 2019, and were followed up for 6 months. Adults aged 18 years or older were recruited 2 to 15 days after experiencing a stroke associated with modified Rankin Scale score of 1 or higher. Interventions Fluoxetine hydrochloride, 20 mg, or matched placebo daily for 26 weeks. Main Outcomes and Measures A 9-item Patient Health Questionnaire (PHQ-9) score of 9 or lower was a prespecified secondary outcome of the trial. Assessments were completed at baseline and at 4, 12, and 26 weeks. Other outcomes of interest included participant-reported clinician diagnosis of depression, prescription of a nontrial antidepressant, or nonpharmacologic treatment of depression. Analysis was on an intention-to-treat basis. Results A total of 607 participants (378 men [62.3%]; mean [SD] age, 64.3 [12.2] years) were randomly assigned treatment with placebo, and 614 participants (397 men [64.7%]; mean [SD] age, 63.4 [12.4] years) were randomly assigned treatment with 20 mg of fluoxetine hydrochloride daily. The groups were balanced for demographic and clinical measures. At baseline, 112 patients (18.5%) in the placebo group and 116 patients (18.9%) in the fluoxetine group had PHQ-9 scores of 9 or higher. During follow-up, 126 of 596 participants (21.1%) treated with placebo and 121 of 598 participants (20.2%) treated with fluoxetine had PHQ-9 scores of 9 or higher (P = .70). A similar proportion of participants with PHQ-9 scores less than 9 at baseline who were treated with fluoxetine hydrochloride and placebo developed PHQ-9 scores of 9 or higher during the trial (placebo, 72 of 488 [14.8%]; and fluoxetine, 63 of 485 [13.0%]; P = .43). A slightly higher number of participants in the placebo group than in the fluoxetine group had a participant-reported clinician diagnosis of depression (42 of 602 [7.0%] vs 26 of 601 [4.3%]; P = .05). By week 26, 14 participants (2.3%) in the placebo group and 12 participants (1.9%) in the fluoxetine group had died (P = .67). Conclusions and Relevance Routine daily treatment with 20 mg of fluoxetine did not decrease the proportion of people affected by clinically significant symptoms of depression after a stroke, nor did it affect the proportion of people prescribed an antidepressant or receiving nonpharmacologic treatments compared with placebo. Trial Registration http://anzctr.org.au Identifier: ACTRN12611000774921.
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Affiliation(s)
- Osvaldo P Almeida
- Division of Psychiatry, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Graeme J Hankey
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Ford
- Division of Psychiatry, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Christopher Etherton-Beer
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Leon Flicker
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Maree Hackett
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Camperdown, New South Wales, Australia
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9
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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] [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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10
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Does the Initiation of Fluoxetine Postacute Stroke Result in Improved Functional Recovery?: A Critically Appraised Topic. Neurologist 2021; 26:112-115. [PMID: 33942795 DOI: 10.1097/nrl.0000000000000314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stroke is a leading cause of disability worldwide. Selective serotonin reuptake inhibitors are often prescribed following stroke due to high rates of depression. Interest in selective serotonin reuptake inhibitor use for poststroke motor and functional recovery was generated after the publication of the Fluoxetine for motor recovery after acute ischemic stroke (FLAME) trial in 2011, which showed improved motor recovery in ischemic stroke patients with moderate to severe motor deficits. The objective of this study was to critically assess current evidence regarding the use of fluoxetine compared with placebo for poststroke functional recovery. METHODS The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario and question, literature search, critical appraisal, results, evidence summary, commentary, and clinical bottom line conclusions. Participants included consultant and resident neurologists, medical librarian, clinical epidemiologists, and content experts in the field of cerebrovascular neurology and physical medicine and rehabilitation. RESULTS A randomized, placebo-controlled clinical trial was selected for critical appraisal. This trial compared the functional outcomes of subjects poststroke receiving fluoxetine versus placebo. There was no significant difference in functional outcome measured by the Modified Rankin Scale between the 2 groups. Prespecified secondary analysis showed significantly decreased rates of depression in the fluoxetine group, but significantly increased rates of bone fracture. CONCLUSION Among patients with stroke, early initiation of fluoxetine did not result in improved functional recovery. Lower rates of depression were observed in the fluoxetine-treated group; however these patients experienced higher rates of bone fracture.
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11
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Levels of physical activity before and after stroke in relation to early cognitive function. Sci Rep 2021; 11:9078. [PMID: 33907260 PMCID: PMC8079693 DOI: 10.1038/s41598-021-88606-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/13/2021] [Indexed: 11/08/2022] Open
Abstract
Regular physical activity is widely recommended in the primary and secondary prevention of stroke. Physical activity may enhance cognitive performance after stroke, but cognitive impairments could also hinder a person to take part in physical activity. However, a majority of previous studies have not found any association between post-stroke cognitive impairments and a person’s subsequent level of activity. In this explorative, longitudinal study, we describe the intraindividual change in physical activity from before to 6 months after stroke, in relation to early screening of post-stroke cognitive impairments. Participants were recruited at 2 to 15 days after stroke, and screened for cognitive impairments using the Montreal Cognitive Assessment tool. Information on pre-stroke physical activity was retrospectively collected at hospital admittance by physiotherapists. Post-stroke physical activity was evaluated after 6 months. Of 49 participants included, 44 were followed up. The level of physical activity changed in more than half of all participants after stroke. Participants who were physically active 6 months after stroke presented with significantly less cognitive impairments. These results highlight that many stroke survivors experience a change in their physical activity level following stroke, and that unimpaired cognition may be important for a stroke survivors’ ability to be physically active.
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12
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Mortensen JK, Andersen G. Pharmacological management of post-stroke depression: an update of the evidence and clinical guidance. Expert Opin Pharmacother 2021; 22:1157-1166. [PMID: 33530765 DOI: 10.1080/14656566.2021.1880566] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Post-stroke depression (PSD) is common, serious and of considerable high risk of being chronic. Pharmacological treatment is highly recommended (class I recommendation) based on level B evidence. Still, treatment is often insufficient and the diagnosis can be challenging.Areas covered: The present paper is an update on pharmacological treatment of PSD and a review of recent clinical guidelines. To put this into perspective, the authors highlight the risk factors that might help clinicians identify patients with PSD, and discuss pharmacological prevention, functional outcome, and safety of antidepressant treatment in stroke patients.Expert opinion: Although there are still gaps in our knowledge of PSD, the seriousness should not be neglected, and pharmacological treatment should be recommended when relevant. A selective serotonin reuptake inhibitor (SSRI) is first choice, but is not always tolerated or effective. Close follow-up and dose adjustments as well as add-on possibilities are therefore important aspects of treatment as well. Antidepressant treatment prevents PSD but the effect on enhancement of stroke recovery is less clear.
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Affiliation(s)
- Janne Kaergaard Mortensen
- Dept of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Dept. Of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Grethe Andersen
- Dept of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Dept. Of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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13
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He JQ, Sussman ES, Steinberg GK. Revisiting Stem Cell-Based Clinical Trials for Ischemic Stroke. Front Aging Neurosci 2020; 12:575990. [PMID: 33381020 PMCID: PMC7767918 DOI: 10.3389/fnagi.2020.575990] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
Stroke is the leading cause of serious long-term disability, significantly reducing mobility in almost half of the affected patients aged 65 years and older. There are currently no proven neurorestorative treatments for chronic stroke. To address the complex problem of restoring function in ischemic brain tissue, stem cell transplantation-based therapies have emerged as potential restorative therapies. Aligning with the major cell types found within the ischemic brain, stem-cell-based clinical trials for ischemic stroke have fallen under three broad cell lineages: hematopoietic, mesenchymal, and neural. In this review article, we will discuss the scientific rationale for transplanting cells from each of these lineages and provide an overview of published and ongoing trials using this framework.
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Affiliation(s)
- Joy Q He
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Eric S Sussman
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States.,Stanford Stroke Center, Stanford Health Care, Stanford, CA, United States
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14
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“Hyperacute” Stroke Rehabilitation Care: Common Issues and Considerations. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Update to the FOCUS, AFFINITY and EFFECTS trials studying the effect(s) of fluoxetine in patients with a recent stroke: statistical analysis plan for the trials and for the individual patient data meta-analysis. Trials 2020; 21:971. [PMID: 33239053 PMCID: PMC7687683 DOI: 10.1186/s13063-020-04875-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022] Open
Abstract
Background Three large trials of fluoxetine for stroke recovery (FOCUS (fluoxetine or control under supervision), AFFINITY (the Assessment oF FluoxetINe In sTroke recovery) and EFFECTS (Efficacy oF Fluoxetine—a randomisEd Controlled Trial in Stroke)) have been collaboratively designed with the same basic protocol to facilitate an individual patient data analysis (IPDM). The statistical analysis plan for the three individual trials has already been reported in Trials, including a brief description of the IPDM. In this protocol, we describe in detail how we will perform the IPDM. Methods/design Data from EFFECTS and AFFINITY will be transferred securely to the FOCUS statistician, who will perform a one-stage IPDM and a two-stage IPDM. For the one-stage IPDM, data will be combined into a single data set and the same analyses performed as described for the individual trials. For the two-stage IPDM, the results for the three individual trials will be combined using fixed effects meta-analyses. The primary and secondary outcome domains for the IPDM are the same as for individual trials. We will also perform analyses according to several subgroups including country of recruitment, ethnicity and trial. We will also explore the effects of fluoxetine on our primary and secondary outcomes in subgroups defined by combinations of characteristics. We also describe additional research questions that will be addressed using the combined data set, and published subsequently, including predictors of important post-stroke problems such as seizures, low mood and bone fractures. Discussion An IPDM of our three large trials of fluoxetine for stroke recovery will allow us to provide the most precise estimates of any risks and benefits of fluoxetine vs placebo, to detect reliably a smaller overall effect size than those detectable by the individual trials, to better determine the effects of fluoxetine vs placebo in subgroups of patients and outcomes and to broaden the generalisability of the results. Also, we may identify differences in treatment effects between studies. 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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16
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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] [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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Safety and efficacy of fluoxetine on functional recovery after acute stroke (EFFECTS): a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2020; 19:661-669. [PMID: 32702335 DOI: 10.1016/s1474-4422(20)30219-2] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Studies have suggested that fluoxetine could improve neurological recovery after stroke. The Efficacy oF Fluoxetine-a randomisEd Controlled Trial in Stroke (EFFECTS) trial aimed to assess whether administration of oral fluoxetine for 6 months after acute stroke improves functional outcome. METHODS EFFECTS was an investigator-led, multicentre, randomised, placebo-controlled, double-blind, parallel group trial that enrolled patients aged 18 years or older between 2 and 15 days after stroke onset in 35 stroke and rehabilitation centres in Sweden. Eligible patients had a clinical diagnosis of ischaemic or intracerebral haemorrhage, brain imaging that was consistent with intracerebral haemorrhage or ischaemic stroke, and had at least one persisting focal neurological deficit. A web-based randomisation system that incorporated a minimisation algorithm was used to randomly assign (1:1) participants to receive oral fluoxetine 20 mg once daily or matching placebo capsules for 6 months. Patients, care providers, investigators, and outcomes assessors were masked to the allocation. The primary outcome was functional status, measured with the modified Rankin Scale (mRS) at 6 months, analysed in all patients with available mRS data at the 6-month follow-up; we did an ordinal analysis adjusted for the minimisation variables used in the randomisation. This trial is registered with EudraCT, 2011-006130-16; ISRCTN, 13020412; and ClinicalTrials.gov, NCT02683213. FINDINGS Between Oct 20, 2014, and June 28, 2019, 1500 patients were enrolled, of whom 750 were randomly assigned to fluoxetine and 750 were randomly assigned to placebo. At 6 months, mRS data were available for 737 (98%) patients in the fluoxetine group and 742 (99%) patients in the placebo group. There was no effect of fluoxetine on the primary outcome-distribution across mRS score categories-compared with placebo (adjusted common odds ratio 0·94 [95% CI 0·78 to 1·13]; p=0·42). The proportion of patients with a new diagnosis of depression was lower with fluoxetine than with placebo (54 [7%] patients vs 81 [11%] patients; difference -3·60% [-6·49 to -0·71]; p=0·015), but fluoxetine was associated with more bone fractures (28 [4%] vs 11 [2%]; difference 2·27% [0·66 to 3·87]; p=0·0058) and hyponatraemia (11 [1%] vs one [<1%]; difference 1·33% [0·43 to 2·23]; p=0·0038) at 6 months. INTERPRETATION Functional outcome after acute stroke did not improve with oral fluoxetine 20 mg once daily for 6 months. Fluoxetine reduced the occurrence of depression but increased the risk of bone fractures and hyponatraemia. Our results do not support the use of fluoxetine after acute stroke. FUNDING The Swedish Research Council, the Swedish Heart-Lung Foundation, the Swedish Brain Foundation, the Swedish Society of Medicine, King Gustav V and Queen Victoria's Foundation of Freemasons, and the Swedish Stroke Association (STROKE-Riksförbundet).
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Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2020; 19:651-660. [PMID: 32702334 DOI: 10.1016/s1474-4422(20)30207-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Trials of fluoxetine for recovery after stroke report conflicting results. The Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) trial aimed to show if daily oral fluoxetine for 6 months after stroke improves functional outcome in an ethnically diverse population. METHODS AFFINITY was a randomised, parallel-group, double-blind, placebo-controlled trial done in 43 hospital stroke units in Australia (n=29), New Zealand (four), and Vietnam (ten). Eligible patients were adults (aged ≥18 years) with a clinical diagnosis of acute stroke in the previous 2-15 days, brain imaging consistent with ischaemic or haemorrhagic stroke, and a persisting neurological deficit that produced a modified Rankin Scale (mRS) score of 1 or more. Patients were randomly assigned 1:1 via a web-based system using a minimisation algorithm to once daily, oral fluoxetine 20 mg capsules or matching placebo for 6 months. Patients, carers, investigators, and outcome assessors were masked to the treatment allocation. The primary outcome was functional status, measured by the mRS, at 6 months. The primary analysis was an ordinal logistic regression of the mRS at 6 months, adjusted for minimisation variables. Primary and safety analyses were done according to the patient's treatment allocation. The trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12611000774921. FINDINGS Between Jan 11, 2013, and June 30, 2019, 1280 patients were recruited in Australia (n=532), New Zealand (n=42), and Vietnam (n=706), of whom 642 were randomly assigned to fluoxetine and 638 were randomly assigned to placebo. Mean duration of trial treatment was 167 days (SD 48·1). At 6 months, mRS data were available in 624 (97%) patients in the fluoxetine group and 632 (99%) in the placebo group. The distribution of mRS categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio 0·94, 95% CI 0·76-1·15; p=0·53). Compared with patients in the placebo group, patients in the fluoxetine group had more falls (20 [3%] vs seven [1%]; p=0·018), bone fractures (19 [3%] vs six [1%]; p=0·014), and epileptic seizures (ten [2%] vs two [<1%]; p=0·038) at 6 months. INTERPRETATION 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 epileptic seizures. These results do not support the use of fluoxetine to improve functional outcome after stroke. FUNDING National Health and Medical Research Council of Australia.
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19
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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: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [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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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] [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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Use of Selective Serotonin Reuptake Inhibitors and Outcomes in Stroke Rehabilitation: A Prospective Observational Pilot Cohort Study. Drugs R D 2020; 19:367-379. [PMID: 31741176 PMCID: PMC6890586 DOI: 10.1007/s40268-019-00287-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose The aim of this study was to examine the association between selective serotonin reuptake inhibitor (SSRI) therapy and rehabilitation outcomes, specifically disability and quality of life (QOL), in a real-world setting of multi-ethnic Asian patients with first-ever stroke. Methods In this prospective observational pilot cohort study, we included patients with first-ever stroke admitted to two inpatient rehabilitation centres in Singapore between January and July 2018. Outcomes were measured using Functional Independence Measure (FIM)-motor scale, modified Barthel Index (MBI) and the Stroke and Aphasia Quality of Life Scale-39 generic (SAQOL-39g) questionnaire. Linear regression was used to assess the association between SSRI therapy and outcomes. Regression coefficients and 95% confidence intervals (CIs) were reported. Results Among 57 patients included for analyses, 38.6% received SSRIs. Although SSRI therapy was significantly associated with gains in MBI (coefficient 11.35; 95% CI 0.21–22.50) and SAQOL-39g overall score (coefficient 0.45; 95% CI 0.05–0.85) based on simple linear regression, no significant association between SSRI therapy and any of the investigated outcomes was found after adjustment for confounders. However, an increase in the mean number of physiotherapy and occupational therapy (PT/OT) sessions per day significantly improved FIM-motor (coefficient 16.86; 95% CI 2.64–31.07) and MBI (coefficient 22.79; 95% CI 2.35–43.23) scores. Conclusion SSRI therapy did not improve disability and QOL in multi-ethnic Asian patients with first-ever stroke undergoing rehabilitation. Electronic supplementary material The online version of this article (10.1007/s40268-019-00287-y) contains supplementary material, which is available to authorized users.
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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] [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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Zhou S, Liu S, Liu X, Zhuang W. Selective serotonin reuptake inhibitors for functional independence and depression prevention in early stage of post-stroke: A meta-analysis. Medicine (Baltimore) 2020; 99:e19062. [PMID: 32028426 PMCID: PMC7015581 DOI: 10.1097/md.0000000000019062] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/17/2019] [Accepted: 01/07/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The efficacy and safety of selective serotonin reuptake inhibitors (SSRIs) for functional independence and depression prevention in early stage of post-stroke (within 1 month after stroke onset) are still unclear. METHODS Relevant randomized controlled trials (RCTs) comparing early SSRIs therapy with placebo were sought from PubMed, Cochrane Library, Medline, and Embase. Primary outcomes were functional independence and depression occurrence. Secondary outcomes contained the improvement of Fugl-Meyer motor scale (FMMS) score and adverse events. We used fixed or random effects model to pooled effect estimates. And we chose risk ratio (RR) or mean differences (MDs) with the 95% confidence intervals (CIs) for data analysis. RESULTS We included 10 RCTs with total 5370 patients. The outcome of functional independence showed no significant difference between SSRIs and placebo group (RR, 1.28; 95% CI, 0.96-1.72; P = .10; I = 92%). However, depression occurrence differed significantly between these 2 groups, which favored SSRIs group (RR, 0.78; 95% CI, 0.67-0.90; P = .001; I = 23%). In addition, we observed that the side effects of SSRIs were seizure and nausea. Except psychiatric disorders/insanity rate was less in SSRIs group than placebo group (RR, 0.66; 95% CI, 0.48-0.90; P = .009) (I = 0%), other adverse events were revealed non-significant in our meta-analysis. CONCLUSIONS Our meta-analysis revealed that early SSRIs therapy were effective to prevent post-stroke depression. However, SSRIs did not improve patient's post-stroke functional independence. In addition to increase the occurrence of seizure and nausea, SSRIs were relatively safe.
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Affiliation(s)
- Shaojiong Zhou
- Shantou University Medical College
- Neurology Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Shuo Liu
- Neurology Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaoqiang Liu
- Neurology Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Weiduan Zhuang
- Neurology Department, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
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Vogel AC, Okeng'o K, Chiwanga F, Ismail SS, Buma D, Pothier L, Mateen FJ. MAMBO: Measuring ambulation, motor, and behavioral outcomes with post-stroke fluoxetine in Tanzania: Protocol of a phase II clinical trial. J Neurol Sci 2020; 408:116563. [PMID: 31731111 DOI: 10.1016/j.jns.2019.116563] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND SSA has a high stroke incidence and post-stroke morbidity. An inexpensive pharmacological treatment for stroke recovery would be beneficial to patients in the region. Fluoxetine, currently on the World Health Organization Essential Medicines List, holds promise as a treatment for motor recovery after ischemic stroke, but its effectiveness is controversial and untested in this context in SSA. AIM To determine if fluoxetine 20 mg by mouth daily, given within 14 days of acute ischemic stroke, and taken for 90 days, is well-tolerated and safe with adequate adherence to justify a future randomized, controlled trial of fluoxetine in the United Republic of Tanzania. METHODS Open-label, phase II clinical trial enrolling up to 120 patients. Participants will be recruited from the Muhimbili National Hospital in Dar es Salaam, Tanzania, and followed for 90 days. The primary outcomes are: 1) safety, including serum sodium and hepatic enzyme levels; and 2) tolerability, as measured through study case report forms. The secondary outcomes are: 1) change in motor strength, as measured through the Fugl-Meyer Motor Scale; 2) adherence, as measured with electronic pill bottles; and 3) participant depressive symptom burden measured via standard questionnaires. CONCLUSIONS Expanding the evidence base for fluoxetine for Sub-Saharan African stroke survivors requires testing of its safety, tolerability, and adherence. Compared to prior studies in France and the United Kingdom, the patient characteristics, health infrastructure, and usual care for stroke recovery differ substantially in Tanzania. If fluoxetine reveals favorable endpoints, scale up of its use post-stroke is possible.
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Affiliation(s)
- Andre C Vogel
- Massachusetts General Hospital, Department of Neurology, 165 Cambridge St. #627, Boston, MA 02114, USA.
| | - Kigocha Okeng'o
- Muhimbili National Hospital, Neurology Unit, Dar es Salaam, Tanzania
| | - Faraja Chiwanga
- Muhimbili National Hospital, Department of Pharmacy, Dar es Salaam, Tanzania.
| | | | - Deus Buma
- Muhimbili National Hospital, Department of Pharmacy, Dar es Salaam, Tanzania.
| | - Lindsay Pothier
- Massachusetts General Hospital, Department of Neurology, 165 Cambridge St. #627, Boston, MA 02114, USA.
| | - Farrah J Mateen
- Massachusetts General Hospital, Department of Neurology, 165 Cambridge St. #627, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
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Castilla-Guerra L, Fernandez Moreno MDC, Esparrago-Llorca G, Colmenero-Camacho MA. Pharmacological management of post-stroke depression. Expert Rev Neurother 2019; 20:157-166. [PMID: 31860359 DOI: 10.1080/14737175.2020.1707666] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Post-stroke depression (PSD) is a common clinical problem affecting approximately one-third of stroke survivors. PSD is associated with poor functional outcome and higher morbidity and mortality rates. Currently, uncertainty remains regarding optimal pharmacological strategies for its prevention and treatment.Areas covered: This article reviews the state of the current literature on pharmacologic intervention strategies for PSD, providing a summary of the most recent evidence to support pharmacological treatment in PSD.Expert opinion: Experimental and clinical research have increased our knowledge on PSD, although unanswered questions still remain regarding the best time to begin treatment, the effect of the antidepressants in areas other than emotion, or their capability to reduce mortality in stroke patients, among others.Currently, though numerous trials and meta-analyses suggest that antidepressants are effective in treating PSD and guidelines recommend their use for PSD, in the daily clinical practice, only a minority of patients are properly assessed and treated. Therefore, though further evidence is needed to clarify the real role of antidepressants in patients with stroke, physicians and other healthcare professionals must be familiar with the pharmacological treatment of PSD, in order to improve the outcome and increase the quality of life of this vulnerable group of patients.
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Affiliation(s)
- Luis Castilla-Guerra
- Department of Internal Medicine, Hospital Universitario Virgen Macarena, Seville, Spain.,Department of Medicine, University of Seville, Seville, Spain
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Identifying important barriers to recruitment of patients in randomised clinical studies using a questionnaire for study personnel. Trials 2019; 20:618. [PMID: 31666093 PMCID: PMC6822437 DOI: 10.1186/s13063-019-3737-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background Many randomised controlled trials (RCT) fail to meet their recruitment goals. Study personnel play a key role in recruitment. The aim of this study was to identify successful strategies that study personnel consider to be important in patient recruitment to RCT. Methods We constructed a questionnaire based on the literature, discussions with colleagues and our own experience as trialists. The survey was named “What is Important for Making a Study Successful questionnaire” (WIMSS-q). Our target group was the study personnel in the ongoing EFFECTS study. The questionnaire was sent out electronically to all physicians and nurses (n = 148). Success factors and barriers were divided according to patient, centre and study level, respectively. Results Responses were received from 94% of the study personnel (139/148). The five most important factors at centre level for enhancing recruitment were that the research question was important (97%), a simple procedure for providing information and gaining consent (92%), a highly engaged local principal investigator and research nurse (both 87%), and that study-related follow-ups are practically feasible and possible to coordinate with the clinical follow-up (87%). The most significant barrier at the local centre was lack of time and resources devoted to research (72%). Important patient-related barriers were fear of side effects (35%) and language problems (30%). Conclusions For recruitment in an RCT to be successful, the research question must be relevant, and the protocol must be simple and easy to implement in the daily routine. Trial registration The protocol for this study was registered at the Northern Ireland Hub for trials methodology research (SWAT ID 64). The EFFECTS study has EudraCT number 2011–006130-16 and was registered 17 February 2016 at ClinicalTrials.gov number NCT02683213.
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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] [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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Glymour MM, Gibbons LE, Gilsanz P, Gross AL, Mez J, Brewster PW, Marden J, Zahodne LB, Nho K, Hamilton J, Li G, Larson EB, Crane PK. Initiation of antidepressant medication and risk of incident stroke: using the Adult Changes in Thought cohort to address time-varying confounding. Ann Epidemiol 2019; 35:42-47.e1. [PMID: 31200987 PMCID: PMC8074509 DOI: 10.1016/j.annepidem.2019.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/08/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Depression strongly predicts stroke incidence, suggesting that treating depression may reduce stroke risk. Antidepressant medications, however, may increase stroke risk via direct pathways. Previous evidence on antidepressant medication and stroke incidence is mixed. We evaluated associations between antidepressant use and incident stroke. METHODS For 2302 Adult Changes in Thought cohort participants with no stroke at study entry, we characterized antidepressant use from pharmacy records, biennial depressive symptoms with a 10-item Centers for Epidemiologic Study-Depression scale, and incident strokes from ICD codes. We used discrete-time survival models with inverse probability weighting to compare stroke risk associated with filling antidepressant prescriptions and by medication category: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors, or other. RESULTS Over an average 8.4-year follow-up, 441 incident strokes occurred. Filling antidepressant medications 3+ times versus 0-2 times predicted 35% increased odds of stroke (OR = 1.35; 95% CI: 0.98, 1.66). Use of TCAs was associated with stroke onset (OR per 10 fills = 1.28; CI: 1.04, 1.57), but use of selective serotonin reuptake inhibitors (OR = 0.98; CI: 0.80, 1.20) or other antidepressants (OR = 0.99; CI: 0.67, 1.45) was not. CONCLUSIONS Although patients who received antidepressant medication were at higher risk of stroke, this association appeared specific to TCA prescriptions.
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Affiliation(s)
- M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA.
| | - Laura E Gibbons
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Alden L Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins University Center on Aging and Health, Baltimore, MD
| | - Jesse Mez
- Alzheimer's Disease and Chronic Traumatic Encephalopathy Center, Boston University School of Medicine, Boston, MA
| | - Paul W Brewster
- Institute on Aging & Lifelong Health and Department of Psychology, University of Victoria, Victoria BC
| | | | - Laura B Zahodne
- Department of Psychology, University of Michigan, Ann Arbor, MI
| | - Kwangsik Nho
- Center for Neuroimaging, Center for Computational Biology and Bioinformatics, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN
| | - Jamie Hamilton
- The Michael J. Fox Foundation for Parkinson's Research, New York, NY
| | - Gail Li
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - Eric B Larson
- Department of Medicine, University of Washington, Seattle, WA; Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Paul K Crane
- Department of Medicine, University of Washington, Seattle, WA
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Quinn TJ. Fluoxetine in stroke (FOCUS) trial-reasons to be cheerful about antidepressants in stroke? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S131. [PMID: 31576338 DOI: 10.21037/atm.2019.05.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
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Marklund N, Bellander BM, Godbolt AK, Levin H, McCrory P, Thelin EP. Treatments and rehabilitation in the acute and chronic state of traumatic brain injury. J Intern Med 2019; 285:608-623. [PMID: 30883980 PMCID: PMC6527474 DOI: 10.1111/joim.12900] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of acquired disability globally, and effective treatment methods are scarce. Lately, there has been increasing recognition of the devastating impact of TBI resulting from sports and other recreational activities, ranging from primarily sport-related concussions (SRC) but also more severe brain injuries requiring hospitalization. There are currently no established treatments for the underlying pathophysiology in TBI and while neuro-rehabilitation efforts are promising, there are currently is a lack of consensus regarding rehabilitation following TBI of any severity. In this narrative review, we highlight short- and long-term consequences of SRCs, and how the sideline management of these patients should be performed. We also cover the basic concepts of neuro-critical care management for more severely brain-injured patients with a focus on brain oedema and the necessity of improving intracranial conditions in terms of substrate delivery in order to facilitate recovery and improve outcome. Further, following the acute phase, promising new approaches to rehabilitation are covered for both patients with severe TBI and athletes suffering from SRC. These highlight the need for co-ordinated interdisciplinary rehabilitation, with a special focus on cognition, in order to promote recovery after TBI.
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Affiliation(s)
- N Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden
| | - B-M Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - A K Godbolt
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
- University Department of Rehabilitation Medicine Stockholm, Danderyd Hospital, Danderyd, Sweden
| | - H Levin
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA
- Michael E. De Bakey Veterans Affairs Medical Center, Houston, TX, USA
| | - P McCrory
- TBI Laboratory, Florey Institute of Neurosciences & Mental Health, Parkville, Vic, Australia
| | - E P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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32
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The misleading use of the term pragmatic in pre-licensing medicine trials. Eur J Clin Pharmacol 2019; 75:1033-1035. [DOI: 10.1007/s00228-019-02672-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/20/2019] [Indexed: 11/26/2022]
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, 3584 CX Utrecht, Netherlands.
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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: 185] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [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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Jones M, Corcoran A, Jorge RE. The psychopharmacology of brain vascular disease/poststroke depression. PSYCHOPHARMACOLOGY OF NEUROLOGIC DISEASE 2019; 165:229-241. [DOI: 10.1016/b978-0-444-64012-3.00013-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Mortensen JK, Andersen G. Potential Role of Selective Serotonin Reuptake Inhibitors in Improving Functional Outcome after Stroke. CNS Drugs 2018; 32:895-903. [PMID: 30225777 DOI: 10.1007/s40263-018-0573-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The great advances in acute stroke treatment during the last decades have changed life after stroke considerably. However, the use of intravenous thrombolysis and endovascular thrombectomy is limited by a relatively narrow time window or contraindications for treatment. Further, patients receiving acute reperfusion therapies may still have cognitive and emotional complications due to underlying brain infarcts even though physical problems may almost disappear. Consequently, stroke is still a frequent cause of adult disability and death worldwide, and an effort to identify additional treatments to enhance recovery, preferably also feasible in the time after the acute phase, is warranted. Albeit several drugs and treatment modalities have been studied for their potential to enhance recovery after stroke, no treatment has unambiguously proven to potentiate the rehabilitation process. A promising candidate for pharmacological treatment is selective serotonin reuptake inhibitors (SSRIs), a group of commonly used antidepressants that may also possess neuro-regenerative properties. The current paper reviews the evidence for SSRIs as potential enhancers of stroke recovery and discusses the potential mechanisms behind the effects reported and the implications for the management of patients post-stoke, including potential adverse events and drug-drug interactions.
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Affiliation(s)
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus C, Denmark
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Magaard G, Wester P, Levi R, Lindvall P, Gustafsson E, Nazemroaya Sedeh A, Lönnqvist M, Berggren S, Nyman K, Hu X. Identifying Unmet Rehabilitation Needs in Patients After Stroke With a Graphic Rehab-Compass TM. J Stroke Cerebrovasc Dis 2018; 27:3224-3235. [PMID: 30097401 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/28/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Unmet rehabilitation needs are common among stroke survivors. We aimed to evaluate whether a comprehensive graphic "Rehab-Compass," a novel combination of structured patient-reported outcome measures, was feasible and useful in facilitating a capture of patients' rehabilitation needs in clinical practice. METHODS A new graphic overview of broad unmet rehabilitation needs covers deficits in functioning, daily activity, participation, and quality of life. It was constructed by using 5 patient-oriented, well-validated, and reliable existing instruments with converted data into a 0 (worst outcome) to 100 (best outcome) scale but unchanged in terms of variable properties. Satisfaction of the Rehab-CompassTM was studied by a qualitative interview of 9 patients with stroke and 3 clinicians. Practical feasibility and capacity of the instrument were evaluated in a cross-sectionalstudy with 48 patients at 5-month follow-ups after subarachnoid hemorrhage. RESULTS The Rehab-CompassTM identified and graphically visualized a panoramic view of the multidimensional needs over time which was completed before clinical consultation. The Rehab-CompassTM appeared to be feasible and time-efficientin clinical use. The interviews of both patients and clinicians showed high satisfaction when using the Rehab-CompassTM graph. In the studied stroke patients, the Rehab-CompassTM identified memory and processing information, fatigue, mood, and pain after subarachnoid hemorrhage as the most common problems. CONCLUSIONS The graphic Rehab-CompassTM seems to be a feasible, useful, and time-saving tool for identification of unmet rehabilitation needs among stroke survivors in clinical practice. Further research is needed to make the Rehab-CompassTM more concise and evaluate the instrument among different stroke subgroups.
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Affiliation(s)
- Gustaf Magaard
- Community Medicine and Rehabilitation, Umeå University, Sweden
| | - Per Wester
- Public Health and Clinical Medicine, Umeå University, Sweden; Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stochholm, Sweden
| | - Richard Levi
- Rehabilitation Medicine, Linköping University, Linköping, Sweden
| | - Peter Lindvall
- Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Emma Gustafsson
- Community Medicine and Rehabilitation, Umeå University, Sweden
| | | | - Malin Lönnqvist
- Community Medicine and Rehabilitation, Umeå University, Sweden
| | - Stina Berggren
- Community Medicine and Rehabilitation, Umeå University, Sweden
| | - Kristin Nyman
- Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Xiaolei Hu
- Community Medicine and Rehabilitation, Umeå University, Sweden.
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Bhattacharjee S, Al Yami M, Kurdi S, Axon DR. Prevalence, patterns and predictors of depression treatment among community-dwelling older adults with stroke in the United States: a cross sectional study. BMC Psychiatry 2018; 18:130. [PMID: 29769065 PMCID: PMC5956759 DOI: 10.1186/s12888-018-1723-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 05/04/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Depression is one of the most common psychiatric conditions among stroke survivors and is associated with several negative health outcomes. However, little is known about the depression treatment patterns among stroke survivors. The objective of this study was to examine national-level prevalence, patterns and predictors of depression treatment among community-dwelling stroke survivors. METHODS This study adopted a retrospective, cross-sectional study design using multiple years of Medical Expenditure Panel Survey (MEPS) (2002-2012) data. The study population consisted of older adults (age ≥ 50 years) who (i) were stroke survivors (ICD-9-CM codes of 430-438), (ii) did not die during the calendar year, and (iii) had co-occurring depression (ICD-9-CM code of 296.xx, or 311.xx). Depression treatment, identified by antidepressant medication and/or psychotherapy use, was the dependent variable of this study. Multinomial logistic regression analysis was conducted to examine the association of individual level factors with depression treatment among stroke survivors with co-occurring depression. RESULTS The final study sample consisted 370 (unweighted) community-dwelling older adults with self-reported stroke and depression. The prevalence of co-occurring depression among stroke survivors was 22.03% [95% Confidence Interval (CI) 19.7-24.4%]. An overwhelming majority (87.6%) of stroke survivors with co-occurring depression reported some form of depression treatment. Antidepressants only and combination therapy was reported by 74.8% (95% CI, 71.6-78.0%] and 12.8% (95% CI, 10.5-15.1%) by stroke survivors with co-occurring depression respectively. Approximately, 61% of stroke survivors with co-occurring depression reported using SSRIs, followed by SNRIs (15.2%), miscellaneous antidepressants (12.1%), TCAs (9.8%), phenylpiperazine antidepressants (5.2%), and tetracyclic antidepressants (4%). Sertraline (15.8, 95% CI, 12.7-19.0%) had the highest reported use among individual antidepressants. CONCLUSIONS Vast majority (nearly 90%) of the study sample received some form of depression treatment and several individual level factors (such as age, education) were associated with the report of depression treatment use. Future longitudinal studies are warranted to assess the comparative treatment benefits of antidepressants, psychotherapy and their combination. Healthcare providers should carefully assess the risks and benefits of antidepressant (such as SSRIs or TCAs) use in this vulnerable population prior to their use.
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Affiliation(s)
- Sandipan Bhattacharjee
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, 1295 North Martin Avenue, Tucson, AZ, 85721, USA.
| | - Majed Al Yami
- 0000 0001 2168 186Xgrid.134563.6Health Outcomes & PharmacoEconomic Research (HOPE) Center, College of Pharmacy, The University of Arizona, Tucson, AZ USA
| | - Sawsan Kurdi
- 0000 0001 2168 186Xgrid.134563.6Health Outcomes & PharmacoEconomic Research (HOPE) Center, College of Pharmacy, The University of Arizona, Tucson, AZ USA
| | - David Rhys Axon
- 0000 0001 2168 186Xgrid.134563.6Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, 1295 North Martin Avenue, Tucson, AZ 85721 USA
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Yeo SH, Lim ZJI, Mao J, Yau WP. Effects of Central Nervous System Drugs on Recovery After Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Drug Investig 2018; 37:901-928. [PMID: 28756557 DOI: 10.1007/s40261-017-0558-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Pilot trials have suggested that pharmacotherapy may aid stroke recovery. The aim of this study was to systematically review the effects of antidepressants, anti-Alzheimer drugs, anti-Parkinson drugs, central nervous system (CNS) stimulants and piracetam on gross motor function, cognition, disability, dependency and quality of life (QOL) after stroke. METHODS PubMed, EMBASE and the Cochrane Central Register of Controlled Trials databases were searched, and 44 randomized controlled trials that compared outcomes of interest between drug treatment and placebo or no treatment were included. For each study, standardized mean difference (SMD) or mean difference (MD) with 95% confidence interval (CI) were calculated. Meta-analyses were conducted to pool results using either the fixed-effects or random-effects model. RESULTS Selective serotonin reuptake inhibitors (SSRIs) improved gross motor function (SMD 0.54, 95% CI 0.22-0.85; three studies), disability (SMD 0.49, 95% CI 0.32-0.66; 14 studies) and QOL (MD 6.46, 95% CI 4.71-8.22; two studies), but there was insufficient evidence for their use in enhancing global cognition (SMD 0.23, 95% CI -0.01 to 0.46; five studies) and dependency (risk ratio 0.81, 95% CI 0.68-0.97; one fluoxetine study). In particular, gross motor function was improved by fluoxetine (SMD 0.64, 95% CI 0.31-0.98; two studies), while disability was improved by paroxetine (SMD 1.05, 95% CI 0.63-1.46; two studies), citalopram (SMD 0.51, 95% CI 0.08-0.93; two studies) and fluoxetine (SMD 0.41, 95% CI 0.22-0.60; nine studies). There is insufficient evidence for the use of anti-Alzheimer drugs, anti-Parkinson drugs, CNS stimulants and piracetam to promote stroke recovery. CONCLUSIONS Administration of SSRIs may improve gross motor function, reduce disability and enhance QOL for patients recovering from stroke.
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Affiliation(s)
- See-Hwee Yeo
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Zheng-Jie Ian Lim
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Jia Mao
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Wai-Ping Yau
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore.
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Wechsler LR, Bates D, Stroemer P, Andrews-Zwilling YS, Aizman I. Cell Therapy for Chronic Stroke. Stroke 2018; 49:1066-1074. [DOI: 10.1161/strokeaha.117.018290] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/26/2017] [Accepted: 11/01/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Lawrence R. Wechsler
- From the Department of Neurology, University of Pittsburgh School of Medicine and UPMC, PA (L.R.W.)
| | - Damien Bates
- SanBio, Inc, Mountain View, CA (D.B., Y.S.A.-Z., I.A.)
| | - Paul Stroemer
- Advanced Therapies Consultancy, Cardiff, Wales, UK (P.S.)
| | | | - Irina Aizman
- SanBio, Inc, Mountain View, CA (D.B., Y.S.A.-Z., I.A.)
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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] [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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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] [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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Gu SC, Wang CD. Early Selective Serotonin Reuptake Inhibitors for Recovery after Stroke: A Meta-Analysis and Trial Sequential Analysis. J Stroke Cerebrovasc Dis 2017; 27:1178-1189. [PMID: 29276014 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/16/2017] [Accepted: 11/23/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Potential benefits and risks of early (≤30 days from stroke onset) selective serotonin reuptake inhibitors (SSRIs) treatment for neurologic functional recovery after stroke are not fully understood. METHODS We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials that assessed SSRI medications during the initial ictus after stroke versus placebo. Primary outcome was decrease in National Institutes of Health Stroke Scale (NIHSS) score. Secondary outcomes included the improvement of Barthel index, functional independence (modified Rankin Scale score 0-2 at the end of follow-up), the incidence of depression, and adverse events including diarrhea, insomnia, hepatic enzyme disorders, seizure, and intracranial hemorrhage. We used fixed effects models or random effects models to estimate weighted mean differences (WMDs) and relative risks (RRs) with 95% confidence intervals (CIs) according to heterogeneity. RESULTS Eight trials were included, with 1549 patients. Compared with placebo, decrease in NIHSS was greater in SSRI-treated patients (WMD, 0.82; 95% CI, 0.31-1.33; P = .002). Trial sequential analysis showed that the cumulative z curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. Early SSRI treatment also promoted Barthel index (WMD, 5.32; 95% CI, 1.65-8.99; P = .005) and functional independence (RR, 2.54; 95% CI, 1.82-3.55; P < .0001). There was no difference in the incidence of depression and adverse events between groups. No evidence of publication bias was detected. CONCLUSIONS The early SSRIs treatment reduces the defective neurologic function in patients undergoing rehabilitation after stroke.
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Affiliation(s)
- Si-Chun Gu
- Department of Neurology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chang-De Wang
- Department of Neurology, TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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Le Friec A, Salabert AS, Davoust C, Demain B, Vieu C, Vaysse L, Payoux P, Loubinoux I. Enhancing Plasticity of the Central Nervous System: Drugs, Stem Cell Therapy, and Neuro-Implants. Neural Plast 2017; 2017:2545736. [PMID: 29391951 PMCID: PMC5748136 DOI: 10.1155/2017/2545736] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/19/2017] [Accepted: 10/23/2017] [Indexed: 01/01/2023] Open
Abstract
Stroke represents the first cause of adult acquired disability. Spontaneous recovery, dependent on endogenous neurogenesis, allows for limited recovery in 50% of patients who remain functionally dependent despite physiotherapy. Here, we propose a review of novel drug therapies with strong potential in the clinic. We will also discuss new avenues of stem cell therapy in patients with a cerebral lesion. A promising future for the development of efficient drugs to enhance functional recovery after stroke seems evident. These drugs will have to prove their efficacy also in severely affected patients. The efficacy of stem cell engraftment has been demonstrated but will have to prove its potential in restoring tissue function for the massive brain lesions that are most debilitating. New answers may lay in biomaterials, a steadily growing field. Biomaterials should ideally resemble lesioned brain structures in architecture and must be proven to increase functional reconnections within host tissue before clinical testing.
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Affiliation(s)
- Alice Le Friec
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Anne-Sophie Salabert
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
- Radiopharmacy Department, CHU Toulouse, Toulouse, France
| | - Carole Davoust
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Boris Demain
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Christophe Vieu
- LAAS-CNRS, Université de Toulouse, CNRS, INSA, UPS, Toulouse, France
| | - Laurence Vaysse
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Pierre Payoux
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
- Nuclear Medicine Department, CHU Toulouse, Toulouse, France
| | - Isabelle Loubinoux
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
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Clarke CL, Witham MD. The Effects of Medication on Activity and Rehabilitation of Older People – Opportunities and Risks. Rehabil Process Outcome 2017. [DOI: 10.1177/1179572717711433] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Multiple medication use, or polypharmacy, is common in people undergoing rehabilitation. Polypharmacy is also common in older people, where it has the potential to impact on habitual physical activity. Despite this, the interactions between medication, disease, activity, and rehabilitation outcomes are insufficiently researched. In this review, we consider common classes of medications that can affect physical activity levels and outcomes of rehabilitation. We consider medications that improve disease processes and improve limiting symptoms (eg, breathlessness in heart failure and lung disease, pain in arthritis), unwanted side effects of medications (eg, central slowing caused by opioids and hypnotics), and also medication classes that might have the ability to improve activity and rehabilitation outcomes via beneficial effects on neuromuscular function (eg, angiotensin-converting enzyme inhibitors). We conclude by giving practical advice on how to review and optimise medication use to support habitual physical activity and ensure the best results from rehabilitation.
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Affiliation(s)
- Clare L Clarke
- Section of Ageing and Health, University of Dundee, Dundee, UK
| | - Miles D Witham
- Section of Ageing and Health, University of Dundee, Dundee, UK
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Berge E, Salman RAS, van der Worp HB, Stapf C, Sandercock P, Sprigg N, Macleod MR, Kelly PJ, Nederkoorn PJ, Ford GA, Arnold M, Berge E, Diez-Tejedor E, Jatuzis D, Kelly PJ, Krieger DW, Nederkoorn PJ, Sandercock P, Stapf C, Weimar C, Ford GA, Salman RAS. Increasing value and reducing waste in stroke research. Lancet Neurol 2017; 16:399-408. [DOI: 10.1016/s1474-4422(17)30078-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/21/2022]
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Doubal FN, Ali M, Batty GD, Charidimou A, Eriksdotter M, Hofmann-Apitius M, Kim YH, Levine DA, Mead G, Mucke HAM, Ritchie CW, Roberts CJ, Russ TC, Stewart R, Whiteley W, Quinn TJ. Big data and data repurposing - using existing data to answer new questions in vascular dementia research. BMC Neurol 2017; 17:72. [PMID: 28412946 PMCID: PMC5392951 DOI: 10.1186/s12883-017-0841-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/14/2017] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Traditional approaches to clinical research have, as yet, failed to provide effective treatments for vascular dementia (VaD). Novel approaches to collation and synthesis of data may allow for time and cost efficient hypothesis generating and testing. These approaches may have particular utility in helping us understand and treat a complex condition such as VaD. METHODS We present an overview of new uses for existing data to progress VaD research. The overview is the result of consultation with various stakeholders, focused literature review and learning from the group's experience of successful approaches to data repurposing. In particular, we benefitted from the expert discussion and input of delegates at the 9th International Congress on Vascular Dementia (Ljubljana, 16-18th October 2015). RESULTS We agreed on key areas that could be of relevance to VaD research: systematic review of existing studies; individual patient level analyses of existing trials and cohorts and linking electronic health record data to other datasets. We illustrated each theme with a case-study of an existing project that has utilised this approach. CONCLUSIONS There are many opportunities for the VaD research community to make better use of existing data. The volume of potentially available data is increasing and the opportunities for using these resources to progress the VaD research agenda are exciting. Of course, these approaches come with inherent limitations and biases, as bigger datasets are not necessarily better datasets and maintaining rigour and critical analysis will be key to optimising data use.
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Affiliation(s)
- Fergus N. Doubal
- Stroke Association Garfield Weston Foundation Clinical Senior Lecturer, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Myzoon Ali
- VISTA and VICCTA Coordinator, Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - G. David Batty
- Reader in Epidemiology, Department of Epidemiology & Public Health, University College London, London, UK
| | - Andreas Charidimou
- J Philip Kistler Stroke Research Centre, Department of neurology, Massachusetts General Hospital Stroke Research Centre, Harvard medical School, Boston, MA USA
| | - Maria Eriksdotter
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and department of Geriatric Medicine, Karolinska university hospital, Stockholm, Sweden
| | - Martin Hofmann-Apitius
- Chair and Head of Department, Fraunhofer Institute for Algorithms and Scientific Computing, Schloss Birlinghoven, Sankt Augustin, Germany
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Centre for Prevention and Rehabilitation, Heart Vascular and Stroke Institute, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Deborah A. Levine
- Department of Internal Medicine, University of Michigan and the VA Ann Arbor Healthcare System, Ann Arbor, MI USA
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Craig W. Ritchie
- Centre for Dementia Prevention, University of Edinburgh, Edinburgh, UK
| | - Charlotte J. Roberts
- ICHOM International Consortium for Health Outcomes Measurement, Hamilton House, Mabledon Place, London, WC1H 9BB UK
| | - Tom C. Russ
- Marjorie MacBeath Intermediate Clinical Fellow, Alzheimer Scotland Dementia Research Centre, & Centre for Dementia Prevention, University of Edinburgh, Edinburgh, UK
| | - Robert Stewart
- King’s College London (Institute of Psychiatry, Psychology and Neuroscience), South London and Maudsley NHS Foundation Trust, London, UK
| | - William Whiteley
- MRC Clinician Scientist and Honorary Consultant Neurologist, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Terence J. Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Mijajlović MD, Pavlović A, Brainin M, Heiss WD, Quinn TJ, Ihle-Hansen HB, Hermann DM, Assayag EB, Richard E, Thiel A, Kliper E, Shin YI, Kim YH, Choi S, Jung S, Lee YB, Sinanović O, Levine DA, Schlesinger I, Mead G, Milošević V, Leys D, Hagberg G, Ursin MH, Teuschl Y, Prokopenko S, Mozheyko E, Bezdenezhnykh A, Matz K, Aleksić V, Muresanu D, Korczyn AD, Bornstein NM. Post-stroke dementia - a comprehensive review. BMC Med 2017; 15:11. [PMID: 28095900 PMCID: PMC5241961 DOI: 10.1186/s12916-017-0779-7] [Citation(s) in RCA: 389] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/03/2017] [Indexed: 12/11/2022] Open
Abstract
Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients ('at risk brains') from those with better prognosis or to discriminate Alzheimer's disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.
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Affiliation(s)
- Milija D Mijajlović
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Dr Subotica 6, 11000, Belgrade, Serbia.
| | - Aleksandra Pavlović
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Dr Subotica 6, 11000, Belgrade, Serbia
| | - Michael Brainin
- Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | | | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Hege B Ihle-Hansen
- Department of internal medicine, Oslo University Hospital, Ullevål and Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Dirk M Hermann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Einor Ben Assayag
- Stroke Unit, Department of Neurology, Tel-Aviv Sorasky Medical Center, Tel-Aviv, Israel
- Shaare Zedek Medical Center, Jerusalem, Israel
| | - Edo Richard
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Alexander Thiel
- Department of Neurology and Neurosurgery, McGill University at SMBD Jewish General Hospital and Lady Davis Institute for Medical Research, Montreal, Québec, Canada
| | - Efrat Kliper
- Stroke Unit, Department of Neurology, Tel-Aviv Sorasky Medical Center, Tel-Aviv, Israel
- Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yong-Il Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Sungkyunkwan University School of Medicine, Center for Prevention and Rehabilitation, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - SeongHye Choi
- Department of Neurology, Inha University School of Medicine, Incheon, South Korea
| | - San Jung
- Hallym University Medical Center, Kang Nam Sacred Heart Hospital, Seoul, South Korea
| | - Yeong-Bae Lee
- Department of Neurology, Gachon University Gil Medical Center, Incheon, South Korea
| | - Osman Sinanović
- Department of Neurology, University Clinical Center Tuzla, School of Medicine University of Tuzla, 75000, Tuzla, Bosnia and Herzegovina
| | - Deborah A Levine
- Department of Internal Medicine, University of Michigan and the VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ilana Schlesinger
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Technion Faculty of Medicine, Haifa, Israel
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Vuk Milošević
- Clinic of Neurology, Clinical Center Nis, Nis, Serbia
| | - Didier Leys
- U1171-Department of Neurology, University of Lille, Inserm, Faculty of Medicine, Lille University Hospital, Lille, France
| | - Guri Hagberg
- Department of internal medicine, Oslo University Hospital, Ullevål and Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Marie Helene Ursin
- Department of internal medicine, Oslo University Hospital, Ullevål and Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Yvonne Teuschl
- Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Semyon Prokopenko
- Department of Neurology and Medical Rehabilitation, Krasnoyarsk State Medical University named after Professor V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - Elena Mozheyko
- Department of Neurology and Medical Rehabilitation, Krasnoyarsk State Medical University named after Professor V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - Anna Bezdenezhnykh
- Department of Neurology and Medical Rehabilitation, Krasnoyarsk State Medical University named after Professor V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - Karl Matz
- Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Vuk Aleksić
- Department of Neurosurgery, Clinical Hospital CenterZemun, Belgrade, Serbia
| | - DafinFior Muresanu
- Department of Clinical Neurosciences, "Iuliu Hatieganu" University of Medicine, Clij-Napoca, Romania
| | - Amos D Korczyn
- Department of Neurology, Tel Aviv University, Ramat Aviv, 69978, Israel
| | - Natan M Bornstein
- Stroke Unit, Department of Neurology, Tel-Aviv Sorasky Medical Center, Tel-Aviv, Israel
- Shaare Zedek Medical Center, Jerusalem, Israel
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49
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Kim JS, Lee EJ, Chang DI, Park JH, Ahn SH, Cha JK, Heo JH, Sohn SI, Lee BC, Kim DE, Kim HY, Kim S, Kwon DY, Kim J, Seo WK, Lee J, Park SW, Koh SH, Kim JY, Choi-Kwon S. Efficacy of early administration of escitalopram on depressive and emotional symptoms and neurological dysfunction after stroke: a multicentre, double-blind, randomised, placebo-controlled study. Lancet Psychiatry 2017; 4:33-41. [PMID: 28012485 DOI: 10.1016/s2215-0366(16)30417-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Mood and emotional disturbances are common in patients with stroke, and adversely affect the clinical outcome. We aimed to evaluate the efficacy of early administration of escitalopram to reduce moderate or severe depressive symptoms and improve emotional and neurological dysfunction in patients with stroke. METHODS This was a placebo controlled, double-blind trial done at 17 centres in South Korea. Patients who had had an acute stroke within the past 21 days were randomly assigned in a 1:1 ratio to receive oral escitalopram (10 mg/day) or placebo for 3 months. Randomisation was done with permuted blocks stratified by centre, via a web-based system. The primary endpoint was the frequency of moderate or severe depressive symptoms (Montgomery-Åsberg Depression Rating Scale [MADRS] ≥16). Endpoints were assessed at 3 months after randomisation in the full analysis set (patients who took study medication and underwent assessment of primary endpoint after randomisation), in all patients who were enrolled and randomly assigned (intention to treat), and in all patients who completed the trial (per-protocol analysis). This trial is registered with ClinicalTrials.gov, number NCT01278498. FINDINGS Between Jan 27, 2011, and June 30, 2014, 478 patients were assigned to placebo (n=237) or escitalopram (n=241); 405 were included in the full analysis set (195 in the placebo group, 210 in the escitalopram group). The primary outcome did not differ by study group in the full analysis set (25 [13%] patients in the placebo group vs 27 [13%] in the escitalopram group; odds ratio [OR] 1·00, 95% CI 0·56-1·80; p>0·99) or in the intention-to-treat analysis (34 [14%] vs 35 [15%]; OR 1·01, 95% CI 0·61-1·69, p=0·96). The study medication was generally well tolerated; the most common adverse events were constipation (14 [6%] patients who received placebo vs 14 [6%] who received escitalopram), muscle pain (16 [7%] vs ten [4%]), and insomnia (12 [5%] vs 12 [5%]). Diarrhoea was more common in the escitalopram group (nine [4%] patients) than in the placebo group (two [1%] patients). INTERPRETATION Escitalopram did not significantly reduce moderate or severe depressive symptoms in patients with acute stroke. FUNDING Dong-A Pharmaceutical and Ministry for Health, Welfare, and Family Affairs, South Korea.
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Affiliation(s)
- Jong S Kim
- Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, South Korea.
| | - Eun-Jae Lee
- Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, South Korea
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University Medical Center, Seoul, South Korea
| | - Jong-Ho Park
- Department of Neurology, Seonam University, Myongji Hospital, Goyang, South Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University Hospital, Gwangju, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University, Severance Hospital, Seoul, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University, Dongsan Medical Center, Daegu, South Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University, Sacred Heart Hospital, Pyungchon, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University, Ilsan Hospital, Goyang, South Korea
| | - Hahn Young Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, South Korea
| | - Seongheon Kim
- Department of Neurology, Kangwon National University College of Medicine, Chuncheon, South Korea
| | - Do-Young Kwon
- Department of Neurology, Korea University, Ansan Hospital, Ansan, South Korea
| | - Jei Kim
- Department of Neurology, Chungnam University Hospital, Daejeon, South Korea
| | - Woo-Keun Seo
- Department of Neurology, Sungkyunkwan University, Samsung Medical Center, Seoul South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, South Korea
| | - Sang-Won Park
- Department of Neurology, Daegu Fatima Hospital, Daegu, South Korea
| | - Seong-Ho Koh
- Department of Neurology, Hanyang University, Guri Hospital, Guri, South Korea
| | - Jin Young Kim
- Department of Psychiatry, Hyundai Hospital, Eumseong, South Korea
| | - Smi Choi-Kwon
- College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
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50
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Schambra H, Im B, O'Dell MW. Should This Patient With Ischemic Stroke Receive Fluoxetine? PM R 2016; 7:1294-1299. [PMID: 26709246 DOI: 10.1016/j.pmrj.2015.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Heidi Schambra
- Department of Rehabilitation & Regenerative Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Brian Im
- Rusk Rehabilitation, NYU Langone Medical Center, New York, NY
| | - Michael W O'Dell
- Department of Rehabilitation Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E. 68th St. F-1602, New York, NY 10021
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