Benefit of urban greenness on patients after an ischaemic stroke: mortality or recurrence? A registry-based cohort study

Raphaël Anxionnat; Nadine Bernard; Anne-Sophie Mariet; Sophie Pujol; Anne-Laure Parmentier; Kadiatou Diallo; Hélène Houot; Théophile Pierre; Yannick Béjot; Frédéric Mauny

doi:10.1371/journal.pone.0339241

Peer Review History

Original SubmissionJanuary 18, 2025
18 Jan 2025 Author Response Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. https://doi.org/10.1371/journal.pone.0339241.r001
6 Aug 2025 Decision Letter - Redoy Ranjan, Editor PONE-D-24-52535-->-->Benefit of urban greenness on patients after an ischaemic stroke: mortality or recurrence? A registry-based cohort study-->-->PLOS ONE?> Dear Dr. Mauny, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 20 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Dr Redoy Ranjan, MBBS, MRCSEd, Ch.M., MS (CV&TS), FACS Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1.Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. 3. Please note that funding information should not appear in any section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript. 4. We note that you have indicated that there are restrictions to data sharing for this study. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. 5. In the online submission form, you indicated that “Data cannot be shared publicly because of Europrean LEgacy restriction. Data are available from the CHU of Besancon (contact via the coresponding author) for researchers who meet the criteria for access to confidential data.” All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information . 7. Please remove all personal information, ensure that the data shared are in accordance with participant consent, and re-upload a fully anonymized data set. Note: spreadsheet columns with personal information must be removed and not hidden as all hidden columns will appear in the published file. Additional guidance on preparing raw data for publication can be found in our Data Policy (https://journals.plos.org/plosone/s/data-availability#loc-human-research-participant-data-and-other-sensitive-data) and in the following article: http://www.bmj.com/content/340/bmj.c181.long . 8. Thank you for stating the following financial disclosure: “NO2 pollution exposure assessment was supported by the Agence de l'Environnement et de la Maîtrise de l'Énergie (ADEME) [1217C0065] as part of the National Environmental Research and Occupational Health Program 2012 from the French Agency for Food, Environmental and Occupational Health and Safety (ANSES). PM10 pollution exposure assessment was supported by the Fondation de France (Engagement 00089823). The Dijon Stroke Registry was funded by Santé Publique France (French Institute for Public Health Surveillance), Institut national de la santé et de la recherche médicale (INSERM), and CHU Dijon Bourgogne.” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 9. Thank you for stating the following in the Competing Interests section: “NO2 pollution exposure assessment was supported by the Agence de l'Environnement et de la Maîtrise de l'Énergie (ADEME) [1217C0065] as part of the National Environmental Research and Occupational Health Program 2012 from the French Agency for Food, Environmental and Occupational Health and Safety (ANSES). PM10 pollution exposure assessment was supported by the Fondation de France (Engagement 00089823). The Dijon Stroke Registry was funded by Santé Publique France (French Institute for Public Health Surveillance), Institut national de la santé et de la recherche médicale (INSERM), and CHU Dijon Bourgogne.” We note that you received funding from a commercial source: BMS, Pfizer, Medtronic, Amgen, Servier, NovoNordisk, Novartis Please provide an amended Competing Interests Statement that explicitly states this commercial funder, along with any other relevant declarations relating to employment, consultancy, patents, products in development, marketed products, etc. Within this Competing Interests Statement, please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your amended Competing Interests Statement within your cover letter. We will change the online submission form on your behalf. 10. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments: The authors are thanked for this submission to PLOS ONE. After a critical external peer review by three experts and considering the overall reviewers' comments, I recommend improving your paper's clarity and presentation based on recent literature and acknowledging reviewers' concerns. PLOS ONE's publication criteria consider methodological rigour and ethical standards, regardless of the paper's novelty. [Note: HTML markup is below. Please do not edit.] Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Reviewer comments for PLOS ONE (PONE-D-24-52535): The authors demonstrated the beneficial effects of greenness on post-ischemic stroke recurrence patients in an urban area using a registry based cohort study. However, owing to the limited no. of a large amount of information such as theoretical, logically consistent (rational and research studies), statistical analysis, and survey database information does not get into my head (especially in the introduction, results, and discussion section). Based on the above limitation, I do have some major and minor concerns that should be addressed by the authors. Major points- 1). Please add appropriate keywords related to this study and check keywords with abstract section content. 2). Introduction section is too short and needs to be elaborated. 3) Clearly state the research gap or knowledge deficit in the introduction section that the current study aims to address. Emphasize why investigating relationship between urban greeness and ischemic stroke patients is important and how it contributes to filling this gap in the literature. 4). Authors should maintain consistency, if once used abbreviation in the manuscript. 5). While conclusion section covers various aspects related to the beneficial effects of greenness on post-ischemic stroke recurrence patients in an urban area using a registry based cohort study, however authors should add as a suggestion, future research directions and clinical implications based on the findings of the current study. 6). Discussion section is too large. It is highly encouraged that the author should includes only relevant things with justify to results and also articles in discussion that can directly be correlated with the current study. Try to concise the discussion section. Reviewer #2: As the age of strokes is getting older and stroke severity is becoming milder, research on recurrence after stroke is valuable. The authors' study showed the beneficial influence of greenness on post-stroke outcomes in an urban area, suggesting the importance of the living environment after stroke. To complete this paper, I would like to offer some suggestions. Regarding the last line on page 7, "The area and percentage of green spaces within radii of 100 and 400 metres around the 7places of residence were calculated for each patient," why was "The area and percentage of green spaces" decided to be "within radii of 100 and 400 metres"? It would be better to describe the reason why to deside "within radii of 100 and 400 metres". Regarding the line 3-5 on page 10, "After one year of follow-up, there were 30 composite events (13 deaths and 17 recurrences). Regarding separate death and recurrence events, there were 15 and 17 deaths and recurrences," , were 2 of the 17 recurrences deaths? Regarding lines 7-8 of the Results on page 10 “Patients who presented a subsequent event (death or recurrence) were older and had higher post-stroke mRS scores.”, I am unable to find data on higher post-stroke mRS scores. While this may be an oversight on my part, if the data is not listed, the authors should include it in the Results section. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: Yes: HITESH S CHAOUHAN Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0339241.r002
Revision 1
12 Nov 2025 Author Response 5. Review Comments to the Author Reviewer #1: Reviewer comments for PLOS ONE (PONE-D-24-52535): The authors demonstrated the beneficial effects of greenness on post-ischemic stroke recurrence patients in an urban area using a registry based cohort study. However, owing to the limited no. of a large amount of information such as theoretical, logically consistent (rational and research studies), statistical analysis, and survey database information does not get into my head (especially in the introduction, results, and discussion section). Based on the above limitation, I do have some major and minor concerns that should be addressed by the authors. Major points- 1). Please add appropriate keywords related to this study and check keywords with abstract section content. We removed the less relevant keywords and added one, all of which are present in the study abstract. Please see page 4. The list of the keywords includes : stroke, environmental health, cohort studies, greenness, population-based study. We deleted “neurology “ and “epidemiology”. 2). Introduction section is too short and needs to be elaborated. In response to both point 2 and point 3, and as also requested by the second reviewer, we totally modified and expanded the Introduction part to address the importance of studying the outcomes of stroke survivors, the relevance of investigating the impact of greenness on stroke recurrence risk, and the pathophysiological mechanisms underlying the presumed effects. Please see page 4 to page 6. 3) Clearly state the research gap or knowledge deficit in the introduction section that the current study aims to address. Emphasize why investigating relationship between urban greenness and ischemic stroke patients is important and how it contributes to filling this gap in the literature. We clarified these elements in the introduction section, as indicated in point 2 above. 4). Authors should maintain consistency, if once used abbreviation in the manuscript. We revised the manuscript to ensure consistent use of abbreviations, for example “mRS” (modified Rankin Scale or post-stroke Rankin Scale), and removed unnecessary abbreviations to improve clarity. 5). While conclusion section covers various aspects related to the beneficial effects of greenness on post-ischemic stroke recurrence patients in an urban area using a registry based cohort study, however authors should add as a suggestion, future research directions and clinical implications based on the findings of the current study. In response, we revised the conclusion section to add suggestions for future research directions and to highlight the potential clinical implications of our findings, including the encouragement of nearby green space use as part of secondary prevention strategies. The manuscript was modified as follows: page 14, Perspective part, lines 2-3 “They will enable exploration of the potential mechanisms involved, such as physical activity, stress reduction, or immune function.” and page 14-15, last two lines of the Perspective part “For a clinical perspective, encouraging the use of nearby green spaces may represent a simple, non-pharmacological complement to secondary prevention strategies.” 6). Discussion section is too large. It is highly encouraged that the author should include only relevant things with justify to results and also articles in discussion that can directly be correlated with the current study. Try to concise the discussion section. The authors thanks for this comment. Indeed, the discussion part was not focused on the main topic of the results. We reduced the length of the discussion (from 82 lines to 61 lines). In response, and also to address points 2 and 3, we moved the discussion on the pathophysiological mechanisms to the Introduction, and reduced the sections on methodological biases, comparisons with studies reporting similar results, and explanations related to the study period. Please see page 12 to page 14. Reviewer #2: As the age of strokes is getting older and stroke severity is becoming milder, research on recurrence after stroke is valuable. The authors' study showed the beneficial influence of greenness on post-stroke outcomes in an urban area, suggesting the importance of the living environment after stroke. To complete this paper, I would like to offer some suggestions. Regarding the last line on page 7, "The area and percentage of green spaces within radii of 100 and 400 metres around the places of residence were calculated for each patient," why was "The area and percentage of green spaces" decided to be "within radii of 100 and 400 metres"? It would be better to describe the reason why to deside "within radii of 100 and 400 metres". In response, we revised the Methods section to clarify the rationale for defining greenness within 100- and 400-m radii. We provided more information and references considering the way the areas were defined, and explicated the living and the walking neighborhoods. We also inserted bibliographic references supporting this approach. The method part was modified as follows, page 8: ”This index was computed for the area of the walking and living neighborhood (ref Smith et al 2010; Choix et an 2009). For each patient, we defined these areas using a circular buffer around the residence. According to Forsyth et al (2008) and our previous studies (ref Tenailleau et al,2014 et 2015), the area and percentage of green spaces were defined calculated within radii of 100 and 400 metres. Regarding the line 3-5 on page 10, "After one year of follow-up, there were 30 composite events (13 deaths and 17 recurrences). Regarding separate death and recurrence events, there were 15 and 17 deaths and recurrences," , were 2 of the 17 recurrences deaths? We clarified this point at the beginning of the results section. Please see page 10, third line of the result part: ” After one year of follow-up, 30 subjects experienced a composite event (13 deaths and 17 recurrences). Among these subjects, two experienced a recurrence and died before the end of the one-year follow up”. Regarding lines 7-8 of the Results on page 10 “Patients who presented a subsequent event (death or recurrence) were older and had higher post-stroke mRS scores.”, I am unable to find data on higher post-stroke mRS scores. While this may be an oversight on my part, if the data is not listed, the authors should include it in the Results section. The information was not sufficiently clear; we have specified the values in the results section and renamed the variable as “Median post-stroke mRS score” in Table 1 (study population characteristics). Please see page 11, lines 2 to 5: “Patients who presented a subsequent event (death or recurrence) were older (median age 81 years [IQR 74–87] vs. 74 years [IQR 63–82], p = 0.002) and had higher post-stroke mRS scores (median 2 [IQR 1–3] vs. 1 [IQR 0–2], p < 0.001).” Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0339241.r003
3 Dec 2025 Decision Letter - Redoy Ranjan, Editor <p>Benefit of urban greenness on patients after an ischaemic stroke: mortality or recurrence? A registry-based cohort study PONE-D-24-52535R1 Dear Dr. Mauny, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Redoy Ranjan, MS (CV&TS), Ch.M. (Edin), PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #2: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #2: Yes ****** Reviewer #2: The authors have considered the comments I made in my review and have revised the manuscript appropriately. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0339241.r004
Formally Accepted
Acceptance Letter - Redoy Ranjan, Editor PONE-D-24-52535R1 PLOS One Dear Dr. Mauny, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Redoy Ranjan Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0339241.r005

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .