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Background: The use of face masks is part of a suite of infection prevention and control measures intended to limit the transmission of respiratory viral diseases. The use of face masks by the general public has been subject to ongoing debate, with limited direct evidence on the effectiveness of face masks in the community during the COVID-19 pandemic. The aim of this review was to synthesise direct evidence on the effectiveness of wearing face masks at reducing the transmission of SARS-CoV-2 in community settings. Methods:A rapid review was conducted. PubMed, Embase, NHS Evidence and Europe PMC were searched systematically from 1 January to 27 August 2020. Clinical trials, cohort, case control, and cross-sectional studies were included if they reported on the effectiveness of face masks in community settings at reducing the transmission of SARS-CoV-2. Studies were critically appraised and synthesised narratively. Results: Seven observational studies were identified, including one study set in households and six in community settings, that reported on the effectiveness of wearing face masks compared with not wearing face masks at reducing the transmission of SARS-CoV-2. Results suggested that face masks reduce the risk of SARS-CoV-2 infection; however, all studies were at high risk of bias and the quality of the evidence was low. Conclusions:This is to date the most comprehensive review of direct evidence on the effectiveness of wearing face masks in the community during the COVID-19 pandemic. There is limited, low certainty direct evidence that wearing face masks reduces the risk of transmission of SARS-CoV-2 in community settings. Further high quality studies are required to confirm these findings.

PRISMA checklist, systematic search strategies.

Aim The overarching aim of this thesis was to explore the bidirectional association between adherence to secondary prevention medications and cognitive impairment in stroke survivors. A secondary aim was to provide an updated account of the longer-term outcomes of cognitive impairment post-stroke. Methods and results Five interrelated studies were conducted to address these aims. Study 1 explored the association between cognitive impairment and cardiovascular medication use in an Irish sample of the general population aged 50+, finding no evidence of an independent association between use of cardiovascular medications and cognitive impairment. Study 2 systematically reviewed the existing literature on the association between cognitive impairment and medication adherence in stroke survivors, and found no significant association when all included studies were pooled, although heterogeneity was significant and the overall evidence quality poor. Studies 3, 4 and 5 were based on a 5-year follow-up of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort study. Study 3 explored the impact of cognitive impairment on subsequent medication adherence, as well as the impact of medication non-adherence on later cognitive impairment. While this study found no statistically significant associations between cognitive impairment and medication adherence, stroke survivors with cognitive impairment were significantly more likely to receive help with medication taking. Study 4 considered the impact of cognitive impairment on outcomes, finding that cognitive impairment at 6 months post-stroke was associated with significantly increased risk of mortality, further cognitive decline, worse quality of life, lower levels of independence, and increased likelihood of depressive symptoms at 5 years. Study 5 explored family caregiver psychological wellbeing, and revealed that family caregivers of stroke survivors with cognitive decline were significantly more likely to experience anxiety and depression. Conclusion Taken together, the findings from this thesis do not indicate an association between cognitive impairment and medication adherence in stroke survivors. However, a number of factors could account for this lack of consistent association, including the moderating effect of help received with medication taking, as well as the range of definitions and assessments of non-adherence and cognitive function, which make it difficult to draw comparisons across studies. Given the prevalence of both of these phenomena in stroke survivors, and their associations with poorer outcomes, the design of effective interventions to address medication non-adherence and to reduce the burden of cognitive impairment post-stroke is paramount.

Supplemental Material for Systematic review and meta-analysis of the prevalence of cognitive impairment no dementia in the first year post-stroke by Eithne Sexton, Affraic McLoughlin, David J Williams, Niamh A Merriman, Nora Donnelly, Daniela Rohde, Anne Hickey, Maev-Ann Wren and Kathleen Bennett in European Stroke Journal

The aim of this study was to profile cognitive decline within 5 years post-stroke, and to explore associations with primary healthcare service use and informal care. Patients from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort were followed up at 6 months and 5 years post-stroke. Cognitive impairment was assessed using the Montreal Cognitive Assessment (MoCA), with cognitive decline defined as a decrease of at least 2 points. Primary healthcare service use was defined as the number of general practitioner visits in the previous 12 months (up to 4 visits vs. 5 or more visits). Informal care was defined as any unpaid care received by stroke patients from family members, neighbours or friends. Ninety-seven patients had cognitive assessment at both 6 months and five years post-stroke Cognitive decline was evident in 63 (65.0%) patients at 5 years. Increasing age was significantly associated with cognitive decline [OR (95% CI): 1.04 (1.01, 1.08)]. Controlling for age and stroke severity, cognitive decline was associated with a greater number of GP visits in the previous 12 months [OR (95% CI)): 6.10 (1.52, 24.44)], but not with likelihood of receiving informal care [OR (95% CI): 1.73 (0.43, 7.03)]. Cognitive decline is evident in a significant number of patients five years post-stroke, and is associated with increased use of primary healthcare services. Further research is required to explore predictors and outcomes of cognitive decline post-stroke.

Cognitive impairment is common post-stroke, and is associated with increased levels of disability and dependency, leading to a greater burden on family members. The aim of this study was to explore associations between cognitive impairment in stroke survivors and anxious or depressive symptoms in family members five years post-stroke.tttttttttAs part of a five-year follow-up of the Action on Rehabilitation and Secondary Prevention Interventions in Stroke (ASPIRE-S) cohort of stroke patients, family members completed a self-report questionnaire. Symptoms of anxiety and depression were assessed using the HADS-A and CES-D. Cognitive impairment in stroke survivors was assessed using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE score >3.3).tt77 family members participated, of whom 71 completed the HADS-A, and 51 the CES-D. Family members were spouses/partners of stroke patients (n=49, 63.6%), adult children (n=22, 38.6%) or siblings (n=6, 7.8%). The majority was female (n=62, 80.5%). Depressive symptoms were evident in 25.5% of family members, with 19.7% reporting symptoms of anxiety. Twenty-two stroke patients (29.0%) were identified as having evidence of cognitive impairment. Family members of stroke patients with cognitive impairment were significantly more likely to report depressive [OR (95% CI): 6.80 (1.65, 28.04)] or anxious symptoms [OR (95% CI): 5.99 (1.62, 22.15)]. ttttttttCognitive impairment in stroke patients is significantly associated with depressive and anxious symptoms in family members. Family members play a key role in the care and rehabilitation of stroke patients. Enhancing their psychological wellbeing and identifying possible ways to decrease burden is thus essential.

Background and AimsWhile previous research has examined vulnerability as a predictor of mortality in general older population samples, no study to date has explored vulnerability as a predictor of mortality in a post-stroke cohort. The aim of this study was to examine predictors of mortality in patients five years post-stroke, focusing on cognitive impairment and vulnerability in addition to cardiovascular risk factors.MethodPatients from the ASPIRE-S (Action on Secondary Prevention Interventions and Rehabilitation in Stroke) cohort were followed 5 years post-ischaemic stroke. Cardiovascular risk factors were assessed at 6 months post-stroke. Cognitive impairment was assessed using a cut-off of