Clinical course and risk factors for sleep disturbance in patients with ischemic stroke

Hui-Ju Tsai; Yi-Sin Wong; Cheung-Ter Ong

doi:10.1371/journal.pone.0277309

Peer Review History

Original SubmissionJune 16, 2022
21 Sep 2022 Decision Letter - Claudio Liguori, Editor PONE-D-22-17272Clinical course and risk factors for sleep disturbance in patients with ischemic strokePLOS ONE Dear Dr. Ong, 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 revise the manuscript according to the Reviewer's suggestions. Please submit your revised manuscript by Nov 05 2022 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. 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Currently, your Funding Statement reads as follows: “This research was supported by Ditmanson Medical Foundation Chia-Yi Christian Hospital Research grant (R109-14).” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 4. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide. Additional Editor Comments: I suggest the Authors to revise the manuscript according to the Reviewer's suggestions. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Authors assessed the risk of insomnia among patients with ischemic stroke and found different patterns of change in sleep habits, including new onset of insomnia and resolution of previous insomnia. Some points of the methods and the presentation of results should be clarified. 1 - There are some previous studies on the prevalence of insomnia after stroke. I suggest elaborating on the similarities and differences in methods between the present study and previous ones. 2 - Some background information should be better put in context. For example, the general discussion on the core and penumbra seems off topic. It would be better replaced by a discussion on the stroke locations that are more likely to lead to insomnia. 3 - Some factors such as the stress of hospital admission and the acute treatment of stroke may have an impact on sleep habits. This point should be further elaborated. 4 - Authors relied on subjective patient-reported outcomes, in the absence of objective measurements such as actigraphy or polysomnography. This could be a limitation to discuss. 5 - How did Authors deal with patients with cognitive or language dysfunction? Patients must have responded to questionnaires for this study. If Authors excluded from the study patients with language and/or cognitive dysfunction, this would have led to selection bias. 6 - Authors state that most cases of insomnia occurring during the acute phase of stroke tend to resolve within 3 months. For that reason, in the Authors' opinion, it is not recommended to provide sleep medication to patients with stroke in the acute phase. In my opinion, this is not a strong recommendation as some patients with stroke might need sleep medication in the acute phase even if sleep disturbances do not last long. I suggest articulating this point in a better fashion. 7 - I see from the Figure that most patients without insomnia who developed insomnia during the acute phase of stroke resolve their condition, while most patients with previous history of insomnia are likely to remain in their condition after stroke. This point should be better discussed as it has clinical relevance. It would mean that previous history of insomnia should be seeked in patients with stroke to plan adequate interventions in the long term. 8 - Did insomnia influence stroke outcomes in terms of survival and post-stroke disability? Reporting data on this aspect could identify an area of intervention that would lead to benefits in post-stroke recovery. ****** 6. PLOS authors have the option to publish the peer review history of their article (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: 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/. 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Revision 1
26 Sep 2022 Author Response 1 - There are some previous studies on the prevalence of insomnia after stroke. I suggest elaborating on the similarities and differences in methods between the present study and previous ones. Response: In introduction, we have added the sentence. “Most studies investigated prevalence of insomnia in patients with ischemic assessing sleep quality after stroke onset. Prospective data on sleep quality in ischemic stroke patients before stroke, acute stroke and subacute stroke are not available.” (Page 5 to page 6). 2 - Some background information should be better put in context. For example, the general discussion on the core and penumbra seems off topic. It would be better replaced by a discussion on the stroke locations that are more likely to lead to insomnia. Response: In introduction, we add the sentence “During the acute stroke period, two dysfunctional areas affect neurological function which may affect sleep quality in patients with ischemic stroke.” (Page 4). “Whether the neurological impairment in acute stroke phase of stroke may increase risk of insomnia and whether insomnia in acute stroke period many improves after reperfusion in penumbra requires further investigation.” (Page 5). 3 - Some factors such as the stress of hospital admission and the acute treatment of stroke may have an impact on sleep habits. This point should be further elaborated. Response: In discussion, we add the sentence “The condition could be related to anxiety, stress and treatment in acute stroke period. Whether insomnia in acute period but not in subacute or chronic stroke period related to reperfusion in penumbra area need further investigation.” (Page 14). 4 - Authors relied on subjective patient-reported outcomes, in the absence of objective measurements such as actigraphy or polysomnography. This could be a limitation to discuss. Response In discussion, we have add the limitation “The diagnosis of insomnia was based on the scores of patient self-reported scale and absence the measurement of actinography or polysomnography.” (Page 15). 5 - How did Authors deal with patients with cognitive or language dysfunction? Patients must have responded to questionnaires for this study. If Authors excluded from the study patients with language and/or cognitive dysfunction, this would have led to selection bias. Response: This is the limitation of the study, due to the study depend patient self-report their sleep quality, we have state the limitation in discussion section. “we did not include patients with aphasia, a previous stroke history, mental impairment, depression, critical medical disease, and patients who did not agree to enroll in the study, which may have selection bias. However, we have do our best to include the patients who can correctly report their sleep condition.” (Page 15). 6 - Authors state that most cases of insomnia occurring during the acute phase of stroke tend to resolve within 3 months. For that reason, in the Authors' opinion, it is not recommended to provide sleep medication to patients with stroke in the acute phase. In my opinion, this is not a strong recommendation as some patients with stroke might need sleep medication in the acute phase even if sleep disturbances do not last long. I suggest articulating this point in a better fashion. Response: We have changed to “In most cases, patients with insomnia symptoms in the acute stroke period recovered 3 months after stroke onset. Hence, pharmacotherapy for insomnia in the acute stroke period should be adopted individually34.” (Page 14). 7 - I see from the Figure that most patients without insomnia who developed insomnia during the acute phase of stroke resolve their condition, while most patients with previous history of insomnia are likely to remain in their condition after stroke. This point should be better discussed as it has clinical relevance. It would mean that previous history of insomnia should be seeked in patients with stroke to plan adequate interventions in the long term. Response: In discussion, we add the sentences “Approximately half of patients with insomnia before stroke onset experienced insomnia at 3 month after stroke onset. The result underscore the importance of obtaining information on sleep quality prior to stroke. For improving the quality of life of stroke patients, it is Important to obtain the information of sleep quality before stroke and carry individualized treatment.” (Page 13 to page 14). 8 - Did insomnia influence stroke outcomes in terms of survival and post-stroke disability? Reporting data on this aspect could identify an area of intervention that would lead to benefits in post-stroke recovery. Response: Because of the study was designed to investigate the prevalence of insomnia in stroke patients, we did not record the outcome of stroke patients. At present, we cannot report the relationship between insomnia and outcome of stroke. This will be the subject of our next research. Attachments Attachment Submitted filename: Response to Reviewer PONE-D.22-17272docx.docx https://doi.org/10.1371/journal.pone.0277309.r002
4 Oct 2022 Decision Letter - Claudio Liguori, Editor PONE-D-22-17272R1Clinical course and risk factors for sleep disturbance in patients with ischemic strokePLOS ONE Dear Dr. Ong, 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 revise the English as requested by the Reviewer and respond to the minor comments raised. Please submit your revised manuscript by Nov 18 2022 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. Please include the following items when submitting your revised manuscript: 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, Claudio Liguori Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Authors duly addressed the comments raised. Some minor points remain for improvement. 1 - I understand that the "chronic stage" of stroke is 3 months. In my opinion, it would be better to replace "chronic stage" with a more precise time indication. 2 - The lack of outcome data on stroke should be stated as a major limitation of the study. 3 - English style should be carefully revised as there are many grammatical imprecisions. ****** 7. PLOS authors have the option to publish the peer review history of their article (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: 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.0277309.r003
Revision 2
14 Oct 2022 Author Response We thank reviewer for their detail review and very important comments. Base on reviewer’s comments, we have made necessary changed point by point. 1 - I understand that the "chronic stage" of stroke is 3 months. In my opinion, it would be better to replace "chronic stage" with a more precise time indication. Response: For precise timing indication, we have used chronic stage replace subacute stroke stage. 2 - The lack of outcome data on stroke should be stated as a major limitation of the study. Response: We have add the limitation in discussion. In page 15, limitation section, we add the sentence “We did not evaluate the impact of insomnia on the outcome of patients with stroke.” 3 - English style should be carefully revised as there are many grammatical imprecisions. Response: The English style of manuscript have been edited again. Attachments Attachment Submitted filename: Response to reviewer 1. PONE-R2docx.docx https://doi.org/10.1371/journal.pone.0277309.r004
24 Oct 2022 Decision Letter - Claudio Liguori, Editor Clinical course and risk factors for sleep disturbance in patients with ischemic stroke PONE-D-22-17272R2 Dear Dr. Ong, 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 for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. 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, Claudio Liguori Academic Editor PLOS ONE Additional Editor Comments (optional): The Authors provided the requested revision. Reviewers' comments: https://doi.org/10.1371/journal.pone.0277309.r005

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