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Bray EP, Georgiou RF, Hives L, Iqbal N, Benedetto V, Spencer J, Harris C, Clegg A, Williams N, Rutter P, Watkins C. Non-pharmacological interventions for the reduction and maintenance of blood pressure in people with prehypertension: a systematic review protocol. BMJ Open 2024; 14:e078189. [PMID: 38253457 PMCID: PMC10806604 DOI: 10.1136/bmjopen-2023-078189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION Prehypertension is defined as blood pressure that is above the normal range but not high enough to be classed as hypertension. Prehypertension is a warning of development of hypertension as well as a risk for cardiovascular disease, heart attack and stroke. In the UK, non-pharmacological interventions are recommended for prehypertension management but no reviews have focused on the effectiveness of these types of interventions solely in people with prehypertension. Therefore, the proposed systematic review will assess the clinical effectiveness and cost-effectiveness of non-pharmacological interventions in reducing or maintaining blood pressure in prehypertensive people. METHODS AND ANALYSIS This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases/trial registries that will be searched to identify relevant randomised controlled trials (RCTs) and economic evaluations include Medline, EMBASE, CINAHL, PsycINFO, CENTRAL, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Cochrane Library, Scopus and the International HTA Database. Search terms have been identified by the team including an information specialist. Three reviewers will be involved in the study selection process. Risk of bias will be evaluated using the Cochrane risk-of-bias tool for RCTs and the Consensus Health Economic Criteria list for economic evaluations. Findings from the included studies will be tabulated and synthesised narratively. Heterogeneity will be assessed through visual inspection of forest plots and the calculation of the χ2 and I2 statistics and causes of heterogeneity will be assessed where sufficient data are available. If possible, we plan to investigate differential effects on specific subgroups and from different types of interventions using meta-regression. Where relevant, the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) will be used to assess the certainty of the evidence found. ETHICS AND DISSEMINATION Ethical approval is not needed. Results will be published in a peer-reviewed journal, disseminated via the wider study website and shared with the study sites and participants. REGISTRATION DETAILS The review is registered with PROSPERO (CRD420232433047).
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Affiliation(s)
- Emma P Bray
- Stroke Research Team, University of Central Lancashire, Preston, UK
| | | | - Lucy Hives
- School of Community Health and Midwifery, University of Central Lancashire, Preston, UK
| | - Nafisa Iqbal
- Stroke Research Team, University of Central Lancashire, Preston, UK
| | - Valerio Benedetto
- Synthesis, Economic Evaluation and Decision Science Group, University of Central Lancashire, Preston, UK
| | - Joseph Spencer
- Research Facilitation and Delivery Unit, University of Central Lancashire, Preston, UK
| | - Cath Harris
- Synthesis, Economic Evaluation and Decision Science Group, University of Central Lancashire, Preston, UK
| | - Andrew Clegg
- Synthesis, Economic Evaluation and Decision Science Group, University of Central Lancashire, Preston, UK
| | - Nefyn Williams
- Primary Care, Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Paul Rutter
- Pharmacy Practice, School of Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Caroline Watkins
- Stroke Research Team, University of Central Lancashire, Preston, UK
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Hives L, Georgiou RF, Spencer J, Benedetto V, Clegg A, Rutter P, Watkins C, Williams N, Bray EP. Risk reduction intervention for raised blood pressure (REVERSE): protocol for a mixed-methods feasibility study. BMJ Open 2023; 13:e072225. [PMID: 37258072 DOI: 10.1136/bmjopen-2023-072225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Around 40% of adults have pre-hypertension (blood pressure between 120-139/80-89), meaning they are at increased risk of developing hypertension and other cardiovascular disease-related conditions. There are limited studies on the management of pre-hypertension; however, guidance recommends that it should be focused on lifestyle modification rather than on medication. Self-monitoring of blood pressure could allow people to monitor and manage their risk status and may allow individuals to modify lifestyle factors. The purpose of this study is to determine the feasibility and acceptability, to both healthcare professionals and people with pre-hypertension, of blood pressure self-monitoring. METHODS AND ANALYSIS A prospective, non-randomised feasibility study, with a mixed-methods approach will be employed. Eligible participants (n=114) will be recruited from general practices, pharmacies and community providers across Lancashire and South Cumbria. Participants will self-monitor their blood pressure at home for 6 months and will complete questionnaires at three timepoints (baseline, 6 and 12 months). Healthcare professionals and participants involved in the study will be invited to take part in follow-up interviews and a focus group. The primary outcomes include the willingness to engage with the concept of pre-hypertension, the acceptability of self-monitoring, and the study processes. Secondary outcomes will inform the design of a potential future trial. A cost-analysis and cost-benefit analysis will be conducted. ETHICS AND DISSEMINATION Ethics approval has been obtained from London-Fulham NHS Research Ethics Committee, the University of Central Lancashire Health Ethics Review Panel and the HRA. The results of the study will be disseminated via peer-reviewed publications, feedback to service users and healthcare professionals, and to professional bodies in primary care and pharmacy. TRIAL REGISTRATION NUMBER ISRCTN13649483.
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Affiliation(s)
- Lucy Hives
- Research Facilitation and Delivery Unit, Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Rachel F Georgiou
- Stroke Research Team, School of Nursing, University of Central Lancashire, Preston, UK
| | - Joseph Spencer
- Research Facilitation and Delivery Unit, Applied Health Research Hub, University of Central Lancashire, Preston, UK
| | - Valerio Benedetto
- Health Technology Assessment Unit, Applied Health Research Hub, University of Central Lancashire, Preston, UK
- Methodological Innovation, Development, Adaptation and Support (MIDAS) Theme, NIHR Applied Research Collaboration North West Coast, Liverpool, UK
| | - Andrew Clegg
- Health Technology Assessment Unit, Applied Health Research Hub, University of Central Lancashire, Preston, UK
- Methodological Innovation, Development, Adaptation and Support (MIDAS) Theme, NIHR Applied Research Collaboration North West Coast, Liverpool, UK
| | - Paul Rutter
- Faculty of Science and Health, School of Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Caroline Watkins
- Stroke Research Team, School of Nursing, Facility of Health and Care, University of Central Lancashire, Preston, UK
| | - Nefyn Williams
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Emma P Bray
- Stroke Research Team, School of Nursing, Facility of Health and Care, University of Central Lancashire, Preston, UK
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McMahon NE, Bangee M, Benedetto V, Bray EP, Georgiou RF, Gibson JME, Lane DA, Al-Khalidi AH, Chatterjee K, Chauhan U, Clegg AJ, Lightbody CE, Lip GYH, Sekhar A, Watkins CL. Etiologic Workup in Cases of Cryptogenic Stroke: A Systematic Review of International Clinical Practice Guidelines. Stroke 2020; 51:1419-1427. [PMID: 32279620 PMCID: PMC7185056 DOI: 10.1161/strokeaha.119.027123] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke.
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Affiliation(s)
- Naoimh E McMahon
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Munirah Bangee
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Valerio Benedetto
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Emma P Bray
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Rachel F Georgiou
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Josephine M E Gibson
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, United Kingdom (D.A.L., G.Y.H.L.).,Department of Clinical Medicine, Aalborg University, Denmark (D.A.L., G.Y.H.L.)
| | | | | | - Umesh Chauhan
- Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, United Kingdom (U.C.)
| | - Andrew J Clegg
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - C Elizabeth Lightbody
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
| | - Gregory Y H Lip
- Department of Clinical Medicine, Aalborg University, Denmark (D.A.L., G.Y.H.L.).,Medtronic Limited, Watford, United Kingdom (A.H.A.-K.)
| | - Alakendu Sekhar
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom (A.S.)
| | - Caroline L Watkins
- From the Faculty of Health and Wellbeing, University of Central Lancashire, Preston, United Kingdom (N.E.M., M.B., V.B., E.P.B., R.F.G., J.M.E.G., A.J.C., C.E.L., C.L.W.)
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4
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Bray EP, McMahon NE, Bangee M, Al-Khalidi AH, Benedetto V, Chauhan U, Clegg AJ, Georgiou RF, Gibson J, Lane DA, Lip GYH, Lightbody E, Sekhar A, Chatterjee K, Watkins CL. Etiologic workup in cases of cryptogenic stroke: protocol for a systematic review and comparison of international clinical practice guidelines. Syst Rev 2019; 8:331. [PMID: 31847884 PMCID: PMC6918649 DOI: 10.1186/s13643-019-1247-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Stroke is a leading cause of death and disability worldwide. Identifying the aetiology of ischaemic stroke is essential in order to initiate appropriate and timely secondary prevention measures to reduce the risk of recurrence. For the majority of ischaemic strokes, the aetiology can be readily identified, but in at least 30% of cases, the exact aetiology cannot be determined using existing investigative protocols. Such strokes are classed as 'cryptogenic' or as a stroke of unknown origin. However, there exists substantial variation in clinical practice when investigating cases of seemingly cryptogenic stroke, often reflecting local service availability and the preferences of treating clinicians. This variation in practice is compounded by the lack of international consensus as to the optimum level and timing of investigations required following a stroke. To address this gap, we aim to systematically review and compare recommendations in evidence-based clinical practice guidelines (CPGs) that relate to the assessment and investigation of the aetiology of ischaemic stroke, and any subsequent diagnosis of cryptogenic stroke. METHOD We will search for CPGs using electronic databases (MEDLINE, Health Management Information Consortium (HMIC), EMBASE, and CINAHL), relevant websites and search engines (e.g. guideline specific websites, governmental, charitable, and professional practice organisations) and hand-searching of bibliographies and reference lists. Two reviewers will independently screen titles, abstracts and CPGs using a pre-defined relevance criteria form. From each included CPG, we will extract definitions and terms for cryptogenic stroke; recommendations related to assessment and investigation of the aetiology of stroke, including the grade of recommendations and underpinning evidence. The quality of the included CPGs will be assessed using the AGREE II (Appraisal of Guidelines for Research and Evaluation) tool. Recommendations across the CPGs will be summarised descriptively highlighting areas of convergence and divergence between CPGs. DISCUSSION To our knowledge, this will be the first review to systematically compare recommendations of international CPGs on investigating the aetiology of ischaemic stroke. The findings will allow for a better understanding of international perspectives on the optimum level of investigations required following a stroke and thus contribute to achieving greater international consensus on best practice in this important and complex area. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019127822.
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Affiliation(s)
- Emma P. Bray
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Naoimh E. McMahon
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Munirah Bangee
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - A. Hakam Al-Khalidi
- Medtronic Limited, Building 9, Croxley Park, Hatters Lane, Watford, WD18 8WW UK
| | - Valerio Benedetto
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Umesh Chauhan
- Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE UK
| | - Andrew J. Clegg
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Rachel F. Georgiou
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Josephine Gibson
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Elizabeth Lightbody
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Alakendu Sekhar
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ UK
| | | | - Caroline L. Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
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Drake C, Boutin H, Jones MS, Denes A, McColl BW, Selvarajah JR, Hulme S, Georgiou RF, Hinz R, Gerhard A, Vail A, Prenant C, Julyan P, Maroy R, Brown G, Smigova A, Herholz K, Kassiou M, Crossman D, Francis S, Proctor SD, Russell JC, Hopkins SJ, Tyrrell PJ, Rothwell NJ, Allan SM. Brain inflammation is induced by co-morbidities and risk factors for stroke. Brain Behav Immun 2011; 25:1113-22. [PMID: 21356305 PMCID: PMC3145158 DOI: 10.1016/j.bbi.2011.02.008] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 02/11/2011] [Accepted: 02/12/2011] [Indexed: 01/22/2023] Open
Abstract
Chronic systemic inflammatory conditions, such as atherosclerosis, diabetes and obesity are associated with increased risk of stroke, which suggests that systemic inflammation may contribute to the development of stroke in humans. The hypothesis that systemic inflammation may induce brain pathology can be tested in animals, and this was the key objective of the present study. First, we assessed inflammatory changes in the brain in rodent models of chronic, systemic inflammation. PET imaging revealed increased microglia activation in the brain of JCR-LA (corpulent) rats, which develop atherosclerosis and obesity, compared to the control lean strain. Immunostaining against Iba1 confirmed reactive microgliosis in these animals. An atherogenic diet in apolipoprotein E knock-out (ApoE(-/-)) mice induced microglial activation in the brain parenchyma within 8 weeks and increased expression of vascular adhesion molecules. Focal lipid deposition and neuroinflammation in periventricular and cortical areas and profound recruitment of activated myeloid phagocytes, T cells and granulocytes into the choroid plexus were also observed. In a small, preliminary study, patients at risk of stroke (multiple risk factors for stroke, with chronically elevated C-reactive protein, but negative MRI for brain pathology) exhibited increased inflammation in the brain, as indicated by PET imaging. These findings show that brain inflammation occurs in animals, and tentatively in humans, harbouring risk factors for stroke associated with elevated systemic inflammation. Thus a "primed" inflammatory environment in the brain may exist in individuals at risk of stroke and this can be adequately recapitulated in appropriate co-morbid animal models.
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Affiliation(s)
- Caroline Drake
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Hervé Boutin
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Matthew S. Jones
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Adam Denes
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Barry W. McColl
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Johann R. Selvarajah
- Clinical Neurosciences Group and Stroke Medicine, Salford Royal Foundation Trust, UK
| | - Sharon Hulme
- Clinical Neurosciences Group and Stroke Medicine, Salford Royal Foundation Trust, UK
| | - Rachel F. Georgiou
- Clinical Neurosciences Group and Stroke Medicine, Salford Royal Foundation Trust, UK
| | - Rainer Hinz
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Alexander Gerhard
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Andy Vail
- Health Methodology Research Group, University of Manchester, UK
| | - Christian Prenant
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Peter Julyan
- North Western Medical Physics, Christie Hospital, Manchester, UK
| | | | - Gavin Brown
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Alison Smigova
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Karl Herholz
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Michael Kassiou
- Brain and Mind Research Institute, University of Sydney, NSW 2050, Australia,Discipline of Medical Radiation Sciences, University of Sydney, NSW 1825, Australia,School of Chemistry, University of Sydney, NSW 2006, Australia
| | - David Crossman
- NIHR Biomedical Research Unit, University of Sheffield, Sheffield, UK
| | - Sheila Francis
- Department of Cardiovascular Science, University of Sheffield, UK
| | - Spencer D. Proctor
- Metabolic and Cardiovascular Diseases Laboratory, Alberta Institute for Human Nutrition, University of Alberta, Edmonton, Alberta, Canada
| | - James C. Russell
- Metabolic and Cardiovascular Diseases Laboratory, Alberta Institute for Human Nutrition, University of Alberta, Edmonton, Alberta, Canada
| | - Stephen J. Hopkins
- Clinical Neurosciences Group and Stroke Medicine, Salford Royal Foundation Trust, UK
| | - Pippa J. Tyrrell
- Clinical Neurosciences Group and Stroke Medicine, Salford Royal Foundation Trust, UK
| | | | - Stuart M. Allan
- Faculty of Life Sciences, University of Manchester, Manchester, UK,Corresponding author. Address: Faculty of Life Sciences, University of Manchester, AV Hill Building, Oxford Road, Manchester M13 9PT, UK. Fax: +44 (0) 161 275 3938.
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6
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Selvarajah JR, Smith CJ, Hulme S, Georgiou RF, Vail A, Tyrrell PJ. Prognosis in patients with transient ischaemic attack (TIA) and minor stroke attending TIA services in the North West of England: the NORTHSTAR Study. J Neurol Neurosurg Psychiatry 2008; 79:38-43. [PMID: 18033799 DOI: 10.1136/jnnp.2007.129163] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The ABCD2 score predicts stroke risk within a few days of transient ischaemic attack (TIA). It is not clear whether the predictive value of the ABCD2 score can be generalised to UK TIA services, where delayed presentation of TIA and minor stroke are common. We investigated prognosis, and the use of the ABCD2 score, in patients attending TIA services in the North West of England with a diagnosis of TIA or minor stroke. METHODS 711 patients with TIA or minor stroke were prospectively recruited from five centres (median duration from index event to recruitment 15 days). The primary outcome was the composite of incident TIA, stroke, acute coronary syndrome or cardiovascular death at the 3 month follow-up. Prognostic factors were analysed using Cox proportional hazards regression. RESULTS The primary outcome occurred in 126 (18%) patients. Overall, there were 30 incident strokes. At least one incident TIA occurred in 100 patients (14%), but only four had a subsequent stroke. In multifactorial analyses, the ABCD2 score was unrelated to the risk of the primary outcome, but predicted the risk of incident stroke: score 4-5: hazard ratio (HR) 3.4 (95% CI 1.0 to 12); score 6-7: HR 4.8 (1.3 to 18). Of the components of the ABCD2 score, unilateral motor weakness predicted both the primary outcome (HR 1.8 (1.2 to 2.8)) and stroke risk (HR 4.2 (1.3 to 14)). CONCLUSIONS In patients attending typical NHS TIA services, the risk of incident stroke was relatively low, probably reflecting delays to assessment. Current provision of TIA services, where delayed presentation to "rapid access" TIA clinics is common, does not appear to provide an appropriate setting for urgent evaluation, risk stratification or timely secondary prevention for those who may be at highest risk.
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Affiliation(s)
- J R Selvarajah
- Department of Neurology, Leeds General Infirmary, Leeds, UK
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Emsley HCA, Smith CJ, Gavin CM, Georgiou RF, Vail A, Barberan EM, Illingworth K, Scarth S, Wickramasinghe V, Hoadley ME, Rothwell NJ, Tyrrell PJ, Hopkins SJ. Clinical outcome following acute ischaemic stroke relates to both activation and autoregulatory inhibition of cytokine production. BMC Neurol 2007; 7:5. [PMID: 17328808 PMCID: PMC1810309 DOI: 10.1186/1471-2377-7-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2006] [Accepted: 02/28/2007] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND As critical mediators of local and systemic inflammatory responses, cytokines are produced in the brain following ischaemic stroke. Some have been detected in the circulation of stroke patients, but their role and source is unclear. Focusing primarily on interleukin(IL)-1-related mechanisms, we serially measured plasma inflammatory markers, and the production of cytokines by whole blood, from 36 patients recruited within 12 h and followed up to 1 year after acute ischaemic stroke (AIS). RESULTS Admission plasma IL-1 receptor antagonist (IL-1ra) concentration was elevated, relative to age-, sex-, and atherosclerosis-matched controls. IL-1beta, soluble IL-1 receptor type II, tumour necrosis factor (TNF)-alpha, TNF-RII, IL-10 and leptin concentrations did not significantly differ from controls, but peak soluble TNF receptor type I (sTNF-RI) in the first week correlated strongly with computed tomography infarct volume at 5-7 days, mRS and BI at 3 and 12 months. Neopterin was raised in patients at 5-7 d, relative to controls, and in subjects with significant atherosclerosis. Spontaneous IL-1beta, TNF-alpha and IL-6 gene and protein expression by blood cells was minimal, and induction of these cytokines by lipopolysaccharide (LPS) was significantly lower in patients than in controls during the first week. Minimum LPS-induced cytokine production correlated strongly with mRS and BI, and also with plasma cortisol. CONCLUSION Absence of spontaneous whole blood gene activation or cytokine production suggests that peripheral blood cells are not the source of cytokines measured in plasma after AIS. Increased plasma IL-1ra within 12 h of AIS onset, the relationship between sTNF-RI and stroke severity, and suppressed cytokine induction suggests early activation of endogenous immunosuppressive mechanisms after AIS.
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Affiliation(s)
- Hedley CA Emsley
- Division of Neuroscience, The University of Liverpool, The Walton Centre for Neurology & Neurosurgery, Lower Lane, Liverpool L9 7LJ, UK
| | - Craig J Smith
- Division of Medicine and Neuroscience, The University of Manchester, Hope Hospital, Salford, UK
| | - Carole M Gavin
- Department of Emergency Medicine, Hope Hospital, Salford, UK
| | - Rachel F Georgiou
- Division of Medicine and Neuroscience, The University of Manchester, Hope Hospital, Salford, UK
| | - Andy Vail
- Biostatistics Group, The University of Manchester, Hope Hospital, Salford, UK
| | | | | | | | | | | | | | - Pippa J Tyrrell
- Division of Medicine and Neuroscience, The University of Manchester, Hope Hospital, Salford, UK
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8
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Smith CJ, Emsley HCA, Vail A, Georgiou RF, Rothwell NJ, Tyrrell PJ, Hopkins SJ. Variability of the systemic acute phase response after ischemic stroke. J Neurol Sci 2006; 251:77-81. [PMID: 17087970 DOI: 10.1016/j.jns.2006.09.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Revised: 04/10/2006] [Accepted: 09/06/2006] [Indexed: 10/23/2022]
Abstract
Despite apparent relationships between ischemic stroke and the acute phase response (APR), considerable variation in the APR exists between individuals. We therefore performed post-hoc analysis of individual APR profiles in 31 patients with ischemic stroke in relation to volume of brain infarction. Patients with ischemic stroke had serial blood samples taken within 12 h, and up to 12 months of symptom onset, for analysis of plasma C-reactive protein (CRP) and interleukin-6 (IL-6). Computed tomography (CT) brain infarct volume was measured at 5 to 7 days (median 23.9 cm(3)). An increase in plasma CRP after the admission sample was evident in 94% of patients by day 5 to 7 (median increase 558% of admission value). CRP response, assessed as area under the curve between admission and day 5 to 7, correlated strongly (r=0.62, p<0.001) with CT infarct volume. Those with greater infarct volumes had more evidence of infection, either prior to or during the first week after stroke. The pattern of response was similar for IL-6, although only 77% showed an increase in plasma IL-6 after the admission sample (median increase 148% of admission value). These data suggest that, although infection and other factors may contribute to systemic inflammation, the extent of acute brain injury after ischemic stroke is a major factor influencing the magnitude and variability of the APR.
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Affiliation(s)
- Craig J Smith
- Division of Medicine and Neurosciences, University of Manchester, Clinical Sciences Building, Hope Hospital, Salford, UK.
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Emsley HCA, Smith CJ, Georgiou RF, Vail A, Hopkins SJ, Rothwell NJ, Tyrrell PJ. A randomised phase II study of interleukin-1 receptor antagonist in acute stroke patients. J Neurol Neurosurg Psychiatry 2005; 76:1366-72. [PMID: 16170078 PMCID: PMC1739363 DOI: 10.1136/jnnp.2004.054882] [Citation(s) in RCA: 325] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The cytokine interleukin (IL)-1 mediates ischaemic brain damage in rodents. The endogenous, highly selective, IL-1 receptor antagonist (IL-1ra) protects against ischaemic cerebral injury in a range of experimental settings, and IL-1ra causes a marked reduction of cell death when administered peripherally or at a delay in transient cerebral ischaemia. We report here the first randomised, double blind, placebo controlled trial of recombinant human IL-1ra (rhIL-1ra) in patients with acute stroke. METHODS Patients within 6 hours of the onset of symptoms of acute stroke were randomised to rhIL-1ra or matching placebo. Test treatment was administered intravenously by a 100 mg loading dose over 60 seconds, followed by a 2 mg/kg/h infusion over 72 h. Adverse events and serious adverse events were recorded for up to 3 months, serial blood samples were collected for biological markers up to 3 months, and 5-7 day brain infarct volume was measured by computed tomography. RESULTS No adverse events were attributed to study treatment among 34 patients randomised. Markers of biological activity, including neutrophil and total white cell counts, C reactive protein, and IL-6 concentrations, were lower in rhIL-1ra treated patients. Among patients with cortical infarcts, clinical outcomes at 3 months in the rhIL-1ra treated group were better than in placebo treated. CONCLUSIONS These data suggest that rhIL-1ra is safe and well tolerated in acute stroke. In addition, rhIL-1ra exhibited biological activity that is relevant to the pathophysiology and clinical outcome of ischaemic stroke. Our findings identify rhIL-1ra as a potential new therapeutic agent for acute stroke.
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Affiliation(s)
- H C A Emsley
- Division of Neuroscience, The University of Liverpool, The Walton Centre for Neurology & Neurosurgery, Liverpool, UK
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Emsley HCA, Smith CJ, Georgiou RF, Vail A, Tyrrell PJ, Barberan EM, Rothwell NJ, Hopkins SJ. Correlation of Systemic Inflammatory Response With Infarct Volume in Acute Ischemic Stroke Patients. Stroke 2005; 36:228-9; author reply 228-9. [PMID: 15625287 DOI: 10.1161/01.str.0000155197.88944.ac] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Smith CJ, Emsley HCA, Gavin CM, Georgiou RF, Vail A, Barberan EM, del Zoppo GJ, Hallenbeck JM, Rothwell NJ, Hopkins SJ, Tyrrell PJ. Erratum to: Peak plasma interleukin-6 and other peripheral markers of inflammation in the first week of ischaemic stroke correlate with brain infarct volume, stroke severity and long-term outcome. BMC Neurol 2004. [PMCID: PMC385235 DOI: 10.1186/1471-2377-4-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Smith CJ, Emsley HCA, Gavin CM, Georgiou RF, Vail A, Barberan EM, del Zoppo GJ, Hallenbeck JM, Rothwell NJ, Hopkins SJ, Tyrrell PJ. Peak plasma interleukin-6 and other peripheral markers of inflammation in the first week of ischaemic stroke correlate with brain infarct volume, stroke severity and long-term outcome. BMC Neurol 2004; 4:2. [PMID: 14725719 PMCID: PMC331413 DOI: 10.1186/1471-2377-4-2] [Citation(s) in RCA: 312] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Accepted: 01/15/2004] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Cerebral ischaemia initiates an inflammatory response in the brain and periphery. We assessed the relationship between peak values of plasma interleukin-6 (IL-6) in the first week after ischaemic stroke, with measures of stroke severity and outcome. METHODS Thirty-seven patients with ischaemic stroke were prospectively recruited. Plasma IL-6, and other markers of peripheral inflammation, were measured at pre-determined timepoints in the first week after stroke onset. Primary analyses were the association between peak plasma IL-6 concentration with both modified Rankin score (mRS) at 3 months and computed tomography (CT) brain infarct volume. RESULTS Peak plasma IL-6 concentration correlated significantly (p < 0.001) with CT brain infarct volume (r = 0.75) and mRS at 3 months (r = 0.72). It correlated similarly with clinical outcome at 12 months or stroke severity. Strong associations were also noted between either peak plasma C-reactive protein (CRP) concentration or white blood cell (WBC) count, and all outcome measures. CONCLUSIONS These data provide evidence that the magnitude of the peripheral inflammatory response is related to the severity of acute ischaemic stroke, and clinical outcome.
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Affiliation(s)
- Craig J Smith
- University of Manchester, Manchester M13 9PT, UK
- Stroke Services, Clinical Sciences Building, Hope Hospital, Salford, M6 8HD, UK
| | - Hedley CA Emsley
- University of Manchester, Manchester M13 9PT, UK
- Stroke Services, Clinical Sciences Building, Hope Hospital, Salford, M6 8HD, UK
| | - Carole M Gavin
- Accident and Emergency Medicine, Hope Hospital, Salford M6 8HD, UK
| | - Rachel F Georgiou
- Stroke Services, Clinical Sciences Building, Hope Hospital, Salford, M6 8HD, UK
| | - Andy Vail
- Biostatistics Group, University of Manchester, Hope Hospital, Salford M6 8HD, UK
| | - Elisa M Barberan
- Stroke Services, Clinical Sciences Building, Hope Hospital, Salford, M6 8HD, UK
| | - Gregory J del Zoppo
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - John M Hallenbeck
- Stroke Branch, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | - Nancy J Rothwell
- School of Biological Sciences, University of Manchester, Manchester M13 9PT, UK
| | - Stephen J Hopkins
- North Western Injury Research Collaboration (NWIRC), Clinical Sciences Building, Hope Hospital, Salford M6 8HD, UK
| | - Pippa J Tyrrell
- University of Manchester, Manchester M13 9PT, UK
- Stroke Services, Clinical Sciences Building, Hope Hospital, Salford, M6 8HD, UK
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Emsley HCA, Smith CJ, Gavin CM, Georgiou RF, Vail A, Barberan EM, Hallenbeck JM, del Zoppo GJ, Rothwell NJ, Tyrrell PJ, Hopkins SJ. An early and sustained peripheral inflammatory response in acute ischaemic stroke: relationships with infection and atherosclerosis. J Neuroimmunol 2003; 139:93-101. [PMID: 12799026 DOI: 10.1016/s0165-5728(03)00134-6] [Citation(s) in RCA: 220] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Central nervous system and peripheral inflammation is important in the responses to ischaemic stroke, and may also predispose to its development. We aimed to identify (1) the extent to which a peripheral inflammatory response is activated in patients following acute stroke, and (2) whether there was evidence for preexisting peripheral inflammation. Thirty-six patients with ischaemic stroke within 12 h of onset of symptoms had serial blood samples taken up to 12 months for analysis of markers of inflammation. Thirty-six control subjects, individually matched for age, sex and degree of atherosclerosis, were also studied. Median C-reactive protein (CRP) was elevated, relative to controls (2.08 mg/l), from admission (4.31 mg/l) (p</=0.001) until 3 months (2.90 mg/l) (p</=0.01), the greatest elevation occurring at 5-7 days (17.67 mg/l) (p</=0.001). Elevations were also seen in erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count until 3 months. Median plasma IL-6 was also elevated, relative to controls (9 pg/ml), by 24 h after onset of symptoms (22 pg/ml) (p</=0.01), and remained elevated at 5-7 days (23 pg/ml) (p</=0.01), but not at 3 months. Less marked elevations in these markers were seen in patients without evidence of infection except for IL-6, which was not increased in the absence of infection. These data provide evidence of an early and sustained peripheral inflammatory response to acute ischaemic stroke in patients with or without evidence of infection. The very early increase in concentrations of inflammatory markers after stroke may either be induced by stroke itself, or may indicate a preexisting inflammatory condition in stroke patients which may contribute to the development of stroke.
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