Association of sleep duration and sleep disorders with post-stroke depression and all-cause and cardiovascular disease mortality in US stroke survivors: Results from NHANES 2005-2018

Association of sleep duration and sleep disorders with post-stroke depression and all-cause and cardiovascular disease mortality in US stroke survivors: Results from NHANES 2005-2018 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of sleep duration and sleep disorders with post-stroke depression and all-cause and cardiovascular disease mortality in US stroke survivors: Results from NHANES 2005-2018 Weirong Chen, Yingying Shen, Shina Song, Xiaofeng Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5181770/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2025 Read the published version in European Journal of Medical Research → Version 1 posted 10 You are reading this latest preprint version Abstract Background Sleep disturbance is a common concern among stroke survivors, yet the association of sleep duration and sleep disorders with post-stroke depression and all-cause and cardiovascular disease (CVD) mortality remains elusive. We aimed to explore these associations using data from the National Health and Nutrition Examination Survey (NHANES). Methods Adult stroke survivors from NHANES 2005–2018 were included. Sleep information and stroke diagnoses were derived from self-reports on relevant questionnaires. Mortality data were collected by prospectively matching to the National Death Index. Multivariate logistic regression and Cox proportional hazards regression were used to explore these associations and calculate the odds ratio (OR) and hazard ratio (HR), respectively. Results A total of 1101 stroke participants were included. In the fully adjusted model, sleep disorders were associated with increased odds of post-stroke depression (OR 2.689, p = 0.0146). Sleep duration was inversely associated with the odds of post-stroke depression; compared to normal sleep duration, short sleep duration was associated with increased odds of post-stroke depression (OR 2.196, p = 0.0059), whereas long sleep duration was not (p = 0.1435). Sleep disorders were associated with CVD mortality (HR of 1.948, p = 0.026) but not all-cause mortality (p = 0.224) in stroke survivors. Sleep duration was positively associated with all-cause mortality in stroke survivors (HR 1.075, p = 0.042); however, neither short nor long sleep duration was associated with mortality compared to normal sleep duration. Restricted cubic spline modeling suggested that sleep duration was nonlinearly and linearly associated with post-stroke depression and all-cause mortality, respectively. Age influenced the association between sleep disorders and CVD mortality in stroke survivors. Conclusions Sleep disorders and short sleep duration were associated with increased odds of post-stroke depression, whereas sleep disorders were associated with increased CVD mortality in stroke survivors. These findings underscore that achieving normal sleep duration and improving sleep disorders may reduce the odds of post-stroke depression and mortality. sleep duration sleep disorders stroke post-stroke depression mortality Figures Figure 1 Figure 2 Figure 3 1. INTRODUCTION Stroke is an acute cerebrovascular disease (mainly classified as ischemic stroke and hemorrhagic stroke) that results from different causes of impaired blood circulation in the brain, which leads to focal neurological deficit[ 1 ]. Stroke is the leading cause of death and disability worldwide. In 2019, the global incidence of stroke is estimated at 12.2 million cases, resulting in 143 million disability-adjusted life years and 6.55 million deaths[ 2 ]. Stroke is the second leading cause of death globally, with about one-fifth of the population in some high-income countries affected by stroke in their lifetime, while about one-half of the population in low-income countries may be affected in their lifetime[ 3 ]. In addition, stroke is strongly associated with the development of several comorbidities, including post-stroke depression. Post-stroke depression is a well-recognized and common psychiatric disorder among stroke survivors, with prevalence rates reported at 27%[ 4 , 5 ]. Compared to depression-free stroke survivors, post-stroke depression is associated with higher mortality, poorer recovery, more significant cognitive deficits, and poorer quality of life[ 6 , 7 ]. Stroke places a heavy financial burden on individuals, families and society. In the United States, each stroke patient contributes about $ 60,000 per year to total medical expenditures[ 8 ]. Stroke prevention is at the center of efforts to reduce the disease burden of stroke[ 9 ]. Identifying and controlling modifiable risk factors for post-stroke depression and mortality is of great importance in public health. Sleep and stroke are widely recognized to be closely linked, and sleep-related disturbance is a common concern among stroke survivors[ 10 ]. Short sleep duration has been shown to be associated with endocrine and metabolic dysfunction and increased cardiovascular risk, while long sleep duration may be associated with increased systemic inflammation[ 11 – 13 ]. Compared with normal sleep duration, a large body of clinical evidence suggests that either short or long sleep duration is associated with an increased risk of stroke, although controversial findings exist[ 11 , 14 , 15 ]. However, the association between sleep duration and post-stroke depression is currently poorly investigated. Only two observational studies have explored the association between sleep duration and poststroke depression, and both have shown that short sleep duration (< 6 h) is associated with an increased risk of depression in stroke survivors[ 16 , 17 ]. However, these studies are limited to relatively homogeneous ethnic populations, and the association of long sleep duration with post-stroke depression remains underexplored. A recent meta-analysis demonstrated that either short or long sleep duration is associated with an increased risk of stroke mortality in the general population[ 11 ]. However, the association between sleep duration and mortality in stroke survivors remains poorly explored. A small number of cohort studies have demonstrated that long sleep duration is associated with increased all-cause mortality in stroke patients compared with normal sleep duration; however, the association of short sleep duration with all-cause mortality in stroke survivors is controversial[ 18 , 19 ]. Both studies included relatively small samples of stroke survivors and did not explore the association of sleep duration with cardiovascular mortality in stroke survivors. Furthermore, Sleep disorders such as sleep apnea, insomnia, and restless legs are common sleep problems that disturb stroke survivors. Accumulating evidence suggests that sleep disorders are associated with an increased risk of stroke[ 20 , 21 ]. However, the association of sleep disorders with depression and mortality after stroke remains poorly studied. Some sparse evidence suggests that sleep apnea is associated with an increased risk of depression after stroke[ 22 ], while the association with mortality in stroke survivors remains elusive[ 23 , 24 ]. To address these research gaps, we explored these associations in this study using nationally representative data from the National Health and Nutrition Examination Survey (NHANES). We aimed to examine the association of sleep duration and sleep disorders with depression and all-cause and cardiovascular disease (CVD) mortality among stroke survivors, and to explore potential nonlinear associations and whether they remain stable across populations with different clinical characteristics. 2. METHODS Study design and population NHANES is the major program of the National Center for Health Statistics (NCHS) established to assess the health and nutritional status of community-dwelling populations in the US. NHANES is a nationwide, population-based, multiethnic serial cross-sectional survey and is characterized by a complex multistage probability sampling study design. All NHANES cycles were approved by the NCHS Ethics Review Board and written informed consent was obtained from all participants. In addition, all data were publicly accessible and de-identified, so local institutional ethics approval was waived. First, 1659 stroke participants from NHANES 2005–2018 were included. Second, those with missing PHQ-9 data (n = 300), missing sleep questionnaire information (n = 11), and missing covariates (n = 247) were excluded. A total of 1101 eligible stroke participants were finally included (Fig. 1 ). Sleep data collection Sleep duration was obtained based on self-report in the Sleep Disorders Questionnaire[ 25 ]. Participants were asked “How much sleep do you usually get at night on weekdays or workdays?”. Sleep duration was categorized as normal sleep duration (7-8h), short sleep duration ( 8h)[ 26 ]. Sleep disorders were assessed based on participants' self-reports (only available in NHANES 2005–2014), with affirmative responses to the question “Have you ever been told by a doctor or other health professional that you have a sleep disorder? indicating the presence of a sleep disorder[ 26 ]. Assessment of stroke Stroke was assessed according to participants' self-report on the relevant medical conditions data. Participants were asked “Has a doctor or other health professional ever told you that you had a stroke?” in the home using the computer-assisted personal interviewing system, and an affirmative response to this question indicated the presence of stroke[ 27 ]. Assessment of depression Depressive symptoms were assessed according to the widely validated Patient Health Questionnaire-9 (PHQ-9), with a PHQ-9 ≥ 10 suggesting major depression[ 28 ]. PHQ-9 consists of 9 entries associated with depressive symptoms, which have high sensitivity and specificity (88%)[ 29 ]. Mortality information collection Stroke participants at baseline were followed until the death endpoint occurred or until December 31, 2019. Mortality information was obtained by prospectively matching death records from the public-use mortality file of the National Death Index database. CVD mortality data were obtained based on ICD-10 codes including I00-I09, I11, I13, I20-I51, and I60-I69. Covariates Based on previous studies, several important covariates were included, including age, gender, race/ethnicity, educational attainment, household income-poverty ratio (PIR), marital status, smoking, alcohol consumption, physical activity, body mass index (BMI), diabetes, hypertension, and history of coronary heart disease (CHD)[ 18 , 26 , 30 ]. The PIR was assessed based on self-reported family income and federally defined poverty levels[ 31 ]. Participants were categorized as never smokers (< 100 lifetime cigarettes), former smokers (≥ 100 lifetime cigarettes but no current cigarettes), and current smokers (≥ 100 lifetime cigarettes and current cigarettes) based on self-reports and prior study criteria[ 32 ]. Alcohol-related questionnaires were used to assess drinking history and were categorized as never drinkers (< 12 drinks in their lifetime), former drinkers (≥ 12 drinks in their lifetime but not in the last year), and current drinkers (further subdivided into light, moderate, and heavy drinkers based on gender-specific daily alcohol consumption)[ 33 ]. Physical activity was categorized as no, moderate, and vigorous intensity participation based on participants' self-reports. BMI was calculated based on weight (kg) divided by the square of height (m) as determined by the mobile examination center. Diabetes was diagnosed by self-reported history of diabetes, fasting blood glucose ≥ 7.0 mmol/l, oral glucose tolerance test blood glucose ≥ 11.1 mmol/l, glycated hemoglobin A1c ≥ 6.5%, or taking antidiabetic medications[ 34 ]. The diagnosis of hypertension was made according to three criteria: a history of self-reported hypertension; a blood pressure measurement of ≥ 140/90 mmHg; and the administration of antihypertensive medications[ 35 ]. The presence of a history of CHD was indicated by the participants' affirmative responses to the specific question in the interview, “Has a doctor or other health professional ever told you that you had coronary heart disease?”. Statistical analysis All statistical analyses were performed using R (version 4.2.3) and EmpowerStats and appropriately weighted in accordance with the NHANES analytic guidelines to consider the NHANES sophisticated study design, and a two-sided p-value of less than 0.05 was interpreted as statistically significant. We performed baseline analyses by grouping stroke participants according to their depression status. Continuous variables were presented as mean ± standard error and analyzed according to weighted t tests, and categorical variables were expressed as number (percentage) and tested by weighted chi-square analysis. Multivariate logistic regression analyses were used to explore the association of sleep duration and sleep disorders with the prevalence of depression in stroke survivors and calculated the odds ratios (OR) and 95% confidence intervals (CI). Multiple adjustment models were constructed, with model 1 adjusting for age, sex, race/ethnicity, education, PIR, and marital status; model 2 additionally adjusting for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 additionally adjusting for sleep duration/sleep disorders from model 2. Kaplan-Meier (KM) survival curves and log-rank tests were used to investigate differences in all-cause and CVD-related survival in stroke survivors across different sleep durations and sleep disorders (yes/no). Multivariate Cox proportional hazards regression analyses were used to explore the associations of sleep duration and sleep disorders with long-term mortality in stroke survivors and calculated the hazard ratios (HR) and 95% CI. Similarly, model 1, model 2, and model 3 were constructed with adjustment variables consistent with those in the logistic regression. Restricted cubic spline (RCS) models were constructed to explore potential nonlinear associations of sleep duration (continuous variable) with post-stroke depression and mortality, and appropriate knots were selected for smooth curve fitting. Subgroup analyses were conducted to explore whether these associations remained stable across subgroup strata (age, gender, and race/ethnicity) and to identify potential effect modifiers using interaction analyses. In the sensitivity analysis, we adopted sleep duration of 6-8h as normal, 8h as long sleep duration as classification criteria[ 30 ] to verify the consistency of the findings. 3. RESULTS Baseline characteristics A total of 1101 eligible stroke participants were enrolled with a mean age of 63.923 years. The prevalence of post-stroke depression was 18.26% (201/1101). Compared to stroke survivors without depression, participants with comorbid depression were younger, had lower PIR, higher BMI, and were more likely to be current smokers, and moderate/heavy drinkers. Of note, stroke participants with depression had lower sleep duration and a higher prevalence of sleep disorders (Table 1 ). Table 1 Baseline analysis of stroke survivors grouped according to depression status, NHANES 2005–2018. Total (n = 1101) No-depression (n = 900) Depression (n = 201) P-value Age 63.923 ± 0.616 65.104 ± 0.672 58.458 ± 1.072 < 0.0001 PIR 2.364 ± 0.066 2.468 ± 0.074 1.884 ± 0.139 < 0.001 Sleep duration 7.059 ± 0.068 7.211 ± 0.076 6.355 ± 0.186 < 0.0001 BMI 30.206 ± 0.292 29.821 ± 0.308 31.989 ± 0.602 0.001 Sleep disorder < 0.001 no 685(59.170) 584(84.154) 101(62.776) yes 142(14.516) 92(15.846) 50(37.224) Sex 0.118 male 541(44.703) 464(46.208) 77(37.737) female 560(55.297) 436(53.792) 124(62.263) Race/ethnicity 0.256 Mexican American 98(4.428) 79(4.354) 19(4.771) Non-Hispanic Black 300(14.551) 246(13.938) 54(17.388) Non-Hispanic White 565(71.330) 464(71.661) 101(69.800) Other Hispanic 72(3.102) 55(2.897) 17(4.054) Other Race 66(6.588) 56(7.150) 10(3.986) Marital Status 0.266 non-single 580(59.047) 488(59.968) 92(54.783) single 521(40.953) 412(40.032) 109(45.217) Education 0.05 high school 445(46.121) 373(48.153) 72(36.718) Smoking < 0.0001 never 423(39.965) 359(42.032) 64(30.397) former 414(36.170) 355(37.507) 59(29.983) now 264(23.865) 186(20.462) 78(39.621) Drinking 0.037 never 170(13.789) 151(15.182) 19(7.340) former 369(30.151) 297(30.168) 72(30.069) mild 345(34.043) 292(34.453) 53(32.147) moderate 106(10.459) 80(9.603) 26(14.421) heavy 111(11.558) 80(10.594) 31(16.023) Physical activity 0.208 no 737(64.772) 601(64.262) 136(67.132) moderate 223(22.414) 178(21.991) 45(24.371) vigorous 141(12.814) 121(13.747) 20(8.498) Diabetes 0.496 no 652(62.756) 535(63.358) 117(59.972) yes 449(37.244) 365(36.642) 84(40.028) Hypertension 0.914 no 215(22.230) 176(22.145) 39(22.626) yes 886(77.770) 724(77.855) 162(77.374) CHD 0.194 no 915(82.180) 756(82.984) 159(78.457) yes 186(17.820) 144(17.016) 42(21.543) Continuous variables were presented as mean ± standard error and analyzed according to weighted t tests, and categorical variables were expressed as number (percentage) and tested by weighted chi-square analysis. For sleep disorders (only accessible in NHANES 2005–2014), we present baseline data from NHANES 2005–2014 accordingly. Association of sleep duration and sleep disorders with post-stroke depression In model 1 and model 2, sleep disorders, sleep duration (treated as a continuous variable), and short sleep duration (compared to normal sleep duration) were all significantly associated with post-stroke depression. In fully adjusted model 3, sleep disorders remained significantly associated with increased odds of post-stroke depression (OR 2.689, 95% CI 1.248–5.793, p = 0.0146). Similarly, sleep duration remained inversely associated with the prevalence of post-stroke depression (OR 0.841, 95% CI 0.728–0.971, p = 0.0219). Short sleep duration (OR 2.196, 95% CI 1.284–3.756, p = 0.0059) but not long sleep duration (p = 0.1435) was associated with increased odds of post-stroke depression compared to normal sleep duration (Table 2 ). Table 2 Association of sleep duration and sleep disorders with the prevalence of post-stroke depression in US adults. Model 1 OR (95%CI) P-value Model 2 OR (95%CI) P-value Model 3 OR (95%CI) P-value Sleep Disorders No Ref. Ref. Ref. Yes 3.223 (1.526, 6.806) 0.0031 2.974 (1.438, 6.150) 0.0048 2.689 (1.248, 5.793) 0.0146 Sleep Duration 0.811 (0.716, 0.918) 0.0013 0.811 (0.719, 0.914) 0.0009 0.841 (0.728, 0.971) 0.0219 Sleep Duration 7–8 Ref. Ref. Ref. < 7 2.693 (1.658, 4.375) 0.0001 2.772 (1.747, 4.400) 8 1.196 (0.674, 2.124) 0.5426 1.197 (0.654, 2.189) 0.5613 1.711 (0.842, 3.477) 0.1435 Model 1 was adjusted for age, sex, race/ethnicity, education, PIR, and marital status; model 2 was adjusted additionally for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 was adjusted additionally for sleep duration/sleep disorders from model 2. Association of sleep duration and sleep disorders with all-cause and CVD mortality among stroke survivors After a median follow-up of 70 months (interquartile range of 40–113 months), 384 stroke survivors died, of which 140 were CVD-related deaths. In model 3, sleep disorders were not significantly associated with all-cause mortality in stroke survivors (HR 1.299, 95% CI 0.852–1.979, p = 0.224). Sleep duration (treated as a continuous variable) was significantly and positively associated with all-cause mortality after stroke (HR 1.075, 95% CI 1.003–1.153, p = 0.042). However, neither short sleep duration (p = 0.695) nor long sleep duration (p = 0.064) was associated with risk of all-cause mortality compared to normal sleep duration (Table 3 ). After adjusting for all covariates, sleep disorders were significantly associated with CVD mortality in stroke survivors (HR 1.948, 95% CI 1.083–3.504, p = 0.026). However, sleep duration was not associated with CVD mortality after stroke (all p > 0.05) (Table 4 ). Table 3 Association of sleep duration and sleep disorders with all-cause mortality in stroke survivors. All-cause Model 1 HR (95%CI) p Model 2 HR (95%CI) p Model 3 HR (95%CI) p Sleep disorders No ref ref ref ref ref ref Yes 1.421(0.949,2.126) 0.088 1.306(0.859,1.985) 0.212 1.299(0.852,1.979) 0.224 Sleep Duration 1.081(1.010,1.156) 0.024 1.076(1.004,1.153) 0.038 1.075(1.003,1.153) 0.042 Sleep Duration 7–8 ref ref ref ref ref ref 8 1.341(0.989,1.817) 0.059 1.334(0.986,1.805) 0.062 1.324(0.983,1.783) 0.064 Model 1 was adjusted for age, sex, race/ethnicity, education, PIR, and marital status; model 2 was adjusted additionally for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 was adjusted additionally for sleep duration/sleep disorders from model 2. Table 4 Association of sleep duration and sleep disorders with CVD mortality in stroke survivors. CVD Model 1 HR (95%CI) p Model 2 HR (95%CI) p Model 3 HR (95%CI) p Sleep disorders No ref ref ref ref ref ref Yes 1.948(1.120,3.390) 0.018 1.986(1.103,3.577) 0.022 1.948(1.083,3.504) 0.026 Sleep Duration 1.004(0.911,1.106) 0.938 0.992(0.896,1.097) 0.872 0.998(0.903,1.103) 0.969 Sleep Duration 7–8 ref ref ref ref ref ref 8 0.906(0.536,1.533) 0.713 0.903(0.531,1.534) 0.706 0.903(0.530,1.537) 0.706 Model 1 was adjusted for age, sex, race/ethnicity, education, PIR, and marital status; model 2 was adjusted additionally for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 was adjusted additionally for sleep duration/sleep disorders from model 2. RCS analysis RCS analysis showed a nonlinear association between sleep duration and the prevalence of post-stroke depression (p for nonlinearity < 0.0001, with an inflection point of 8.0h) (Fig. 2 A). Threshold effect analysis showed an inverse association between sleep duration and post-stroke depression only for sleep duration < 8h (OR 0.588, 95% CI 0.485–0.712, p < 0.0001) (Table 5 ). In addition, RCS analyses demonstrated that sleep duration was significantly and linearly associated with all-cause mortality in stroke survivors (p for nonlinearity 0.424) and similarly unrelated to CVD mortality (p for overall 0.6637) (Fig. 2 B and 2 C). Table 5 Threshold effect analysis of the association between sleep duration and post-stroke depression. OR (95%CI) P-value P-interaction Sleep duration < 8 0.588 (0.485, 0.712) < 0.0001 0.0001 Sleep duration ≥ 8 1.188 (0.899, 1.571) 0.2295 Stratified analysis Interaction analyses indicated that age, gender, or race/ethnicity did not significantly affect the association of sleep duration (Fig. 3 A) and sleep disorders (Fig. 3 B) with post-stroke depression (all P for interactions > 0.05). Similarly, age, sex, and race did not influence the association between sleep duration and all-cause and CVD mortality in stroke survivors (Fig. 3 C). However, age was identified as an effect modifier of the association between sleep disorders and CVD mortality among stroke survivors (p for interaction < 0.001). The association between sleep disorders and CVD mortality after stroke was only present in those < 60 years of age (HR 1.244, 95% CI 1.178–6.055, p = 0.002) (Fig. 3 D). Sensitivity analysis When 6-8h was the criterion for normal sleep duration, interestingly, both short sleep duration ( 8h, OR 1.933, p = 0.0205) were associated with an increased odds of post-stroke depression ( Table S1 ). Consistently, neither short nor long sleep duration was associated with all-cause and CVD mortality in stroke survivors (all p > 0.05) compared to normal sleep duration (6-8h) ( Tables S2 and S3 ). 4. DISCUSSIONS In this national population-based study, we found that sleep disorders were associated with significantly increased risk of post-stroke depression and CVD mortality in stroke survivors, but not with all-cause mortality in stroke survivors. Sleep duration was inversely associated with the odds of post-stroke depression in US adults. Short sleep duration, but not long sleep duration, was associated with significantly increased odds of post-stroke depression compared with normal sleep duration. Interestingly, although sleep duration was positively associated with the risk of all-cause mortality in stroke survivors, neither short nor long sleep duration was associated with all-cause and CVD mortality after stroke. Sleep duration was nonlinearly and linearly associated with depression and all-cause mortality after stroke, respectively. Of note, the association between sleep disorders and CVD mortality in stroke survivors was only present in participants < 60 years of age. To the best of our knowledge, this is the first comprehensive exploration of the association of sleep duration and sleep disorders with depression and all-cause and CVD mortality in stroke survivors in a national population-based study from NHANES. A large body of clinical evidence suggests that abnormal sleep duration is associated with an increased risk of stroke in the general population, but inconsistent findings exist. A recent umbrella review showed that short and long sleep duration increased the risk of incident stroke by 32% and 17%, respectively, compared with normal sleep duration[ 14 ]. Another recent large meta-analysis showed a U-shaped association between sleep duration at night and stroke risk, with the lowest stroke risk at a sleep duration of 7.5h[ 36 ]. Some cross-sectional evidence from NHANES suggested that compared with normal sleep duration, short sleep duration was associated with increased odds of stroke, whereas long sleep duration was not[ 37 , 38 ]. Recent cross-sectional analyses from NHANES demonstrated that sleep duration greater than 8h was associated with an increased risk of stroke, whereas < 7h was not significantly associated[ 18 , 30 ]. Another study from NHANES 2005–2008 showed that neither short nor long sleep duration was associated with stroke odds[ 26 ]. These heterogeneities may derive from variability in the number of survey cycles included and the assessment criteria for sleep duration. In addition, a cross-sectional analysis from NHANES also showed that sleep disorders are associated with increased prevalence of stroke[ 37 ]. A large body of epidemiologic evidence suggests a significant association between sleep duration and the occurrence of depression in the general population. A meta-analysis incorporating seven prospective cohort studies demonstrated that both short and long sleep duration were associated with an increased risk of depression compared to normal sleep duration (relative risks of 1.31 and 1.42, respectively)[ 39 ]. However, the association between sleep duration and post-stroke depression remains little studied. A retrospective study including 1369 stroke survivors from the Brain Attack Surveillance in Corpus Christi project demonstrated that only 8h sleep duration were not[ 17 ]. Another cross-sectional analysis from China showed that 5–6 and 7 h of sleep duration (OR 1.47 and 3.05, respectively)[ 16 ]. Our study demonstrated for the first time that sleep duration was inversely associated with reduced prevalence of post-stroke depression. Compared with normal sleep duration, short sleep duration ( 8 h) was also associated with increased odds of post-stroke depression when the normal sleep duration criterion was replaced with 6–8 h, suggesting that the association between long sleep duration and post-stroke depression needs to be focused on according to specific criteria in clinical practice. The association between sleep disorders and post-stroke depression remains poorly studied. A retrospective study including 265 in-hospital ischemic stroke patients demonstrated that severe obstructive sleep apnea (OSA) (compared to no OSA) was associated with increased odds of post-stroke depression at 3 months (OR 4.04, p = 0.036)[ 22 ]. A cross-sectional analysis including 66 outpatient stroke survivors showed insomnia to be an independent predictor of post-stroke depression (p < 0.001)[ 40 ]. Another cohort study that included 608 elderly Chinese ischemic stroke patients similarly showed that insomnia was associated with increased odds of post-stroke depression (HR 1.59, p < 0.01)[ 41 ]. Our findings suggested for the first time that a history of sleep disorders overall was significantly associated with increased odds of depression after stroke, independently of sleep duration. A large body of clinical evidence suggests that sleep duration may have a significant impact on survival in populations. A meta-analysis of prospective studies suggests that either short or long sleep duration is associated with a significantly increased risk of all-cause mortality in the general population[ 42 ]. More recent meta-analyses have shown that long sleep duration, but not short sleep duration, is associated with increased all-cause mortality[ 43 , 44 ]. A recent cohort study from the REasons for Geographic And Racial Differences in Stroke showed that long sleep duration (HR 1.46, 95% CI 1.01–2.12), but not short sleep duration (HR 1.31, 95% CI 0.90–1.91), was associated with increased all-cause mortality in stroke survivors[ 19 ]. A recent cross-sectional study utilizing NHANES 2005–2008 demonstrated that compared to normal sleep duration, short sleep duration was negatively associated with all-cause mortality in stroke survivors (HR 0.65, 95% CI 0.44–0.96), whereas long sleep duration was similarly positively associated with all-cause mortality (HR 1.58, 95% CI 1.03–2.41)[ 18 ]. Inconsistent with the findings of Wang et al[ 18 ], our study showed that each 1h increase in sleep duration was associated with a 7.5% increased risk of all-cause mortality among stroke survivors; however, short or long sleep duration was not significantly associated with all-cause mortality among stroke survivors compared to normal sleep duration. These inconsistent findings may be explained by the fact that our study incorporated a more comprehensive survey cycle and a larger stroke sample size, and thus may better reflect the associations. Interestingly, sleep duration was not significantly associated with CVD mortality in stroke survivors. In addition, our findings indicated that sleep disorders were positively associated with CVD mortality, but not all-cause mortality, in stroke survivors. There is still a lack of research on the association of sleep disorders with mortality in stroke survivors. OSA and insomnia are suggested to be associated with an increased risk of mortality in stroke survivors, however inconsistent findings exist[ 45 ]. A retrospective cohort study enrolling 989 patients with ischemic stroke demonstrated that OSA was associated with increased cardiovascular events in stroke survivors, however, with reduced neurologic injury and mortality[ 24 ]. We speculate that the strong association of sleep disorders such as sleep apnea with increased cardiovascular risk[ 45 , 46 ] may have contributed to its promotion of CVD mortality in stroke survivors. Furthermore, this association was only present in those < 60 years of age, suggesting that sleep disorders in nonelderly stroke survivors may be a warning indicator of increased CVD mortality and require close attention in clinical practice. Several possible mechanisms may explain these findings. Sleep disorders and short sleep duration may induce neuroendocrine and circadian rhythm abnormalities and further inflammatory infiltration leading to post-stroke depression[ 16 , 17 ]. In addition, sleep disorders and short sleep duration may interfere with functional recovery after stroke and increase the risk of poststroke depression through psychosocial mechanisms[ 17 ]. The mechanism by which long sleep duration is associated with a trend toward increased all-cause mortality in stroke survivors remains unclear. Some possible explanations are that longer sleep duration may be associated with poorer sleep quality, a more severe history of stroke, and less time spent socializing, which in turn leads to increased mortality[ 19 ]. Cerebral hemodynamic abnormalities and induced cardiovascular risk factors due to sleep disorders such as sleep apnea may cause chronic sympathetic hyperactivity and sleep structural dysfunction, leading to increased cardiovascular events and associated mortality[ 45 ]. There are several significant strengths of our study. First, it is a national, population-based, large-sample, multiracial study, allowing for good generalizability of the findings. We adequately adjusted for potential confounders and reduced study bias. However, our study has some potential limitations. The associations of sleep duration and sleep disorders with post-stroke depression were explored by cross-sectional analyses, and longitudinal temporal and causal associations could not be derived. As stroke was assessed by participant self-report, we were unable to assess the impact of stroke severity, lesion location, and subtype on findings. In addition, self-reported data may inherently introduce potential recall bias. However, previous studies have shown good agreement between self-reported sleep duration and results measured by wearable devices[ 37 ]. Finally, NHANES only included noninstitutionalized stroke survivors, and therefore the potential applicability of these findings to hospitalized patients with stroke still requires further elucidation. 5. CONCLUSIONS In a national population-based study, sleep disorders and short sleep duration were associated with increased odds of post-stroke depression. Sleep disorders were associated with increased CVD mortality in stroke survivors, whereas sleep duration was positively associated with all-cause mortality. Compared with normal sleep duration, short or long sleep duration was not associated with either all-cause or CVD mortality in stroke survivors. These findings suggest that maintaining normal sleep duration and improving sleep disorders may help reduce the risk of depression and mortality after stroke. Future large-sample prospective cohort studies are needed to validate these findings. Declarations Data availability : This study analyzed publicly available datasets and can be found at https://www.cdc.gov/nchs/nhanes/. Ethics statement : All protocols were approved by the NCHS Ethics Review Board, and participants have provided written informed consent. Funding : This research project was supported by the Shanxi Applied Basic Research Program (202403021212232) and the Scientific and Technological Innovation Programs of Higher Education Institutions in Shanxi (2023L105). Conflict of interest : None. Acknowledgments : None. Author contributions : WC conducted data processing and was essential to the drafting and revision of the manuscript. YS played a pivotal role in data processing and made significant contributions to the study design. SS contributed to data analysis and interpretation, secured funding. XL conceptualized the research framework and supervised the manuscript revisions. All authors collaborated in the preparation, critical editing, and review of the manuscript. References Campbell BCV, Khatri P. Stroke. Lancet. 2020;396(10244):129–42. doi: 10.1016/s0140-6736(20)31179-x . Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795–820. doi: 10.1016/s1474-4422(21)00252-0 . Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet. 2024;403(10446):2820–36. doi: 10.1016/s0140-6736(24)00642-1 . Robinson RG, Jorge RE. Post-Stroke Depression: A Review. Am J Psychiatry. 2016;173(3):221–31. doi: 10.1176/appi.ajp.2015.15030363 . Liu L, Xu M, Marshall IJ, Wolfe CD, Wang Y, O'Connell MD. Prevalence and natural history of depression after stroke: A systematic review and meta-analysis of observational studies. PLoS Med. 2023;20(3):e1004200. doi: 10.1371/journal.pmed.1004200 . Medeiros GC, Roy D, Kontos N, Beach SR. Post-stroke depression: A 2020 updated review. Gen Hosp Psychiatry. 2020;66:70–80. doi: 10.1016/j.genhosppsych.2020.06.011 . Guo J, Wang J, Sun W, Liu X. The advances of post-stroke depression: 2021 update. J Neurol. 2022;269(3):1236–49. doi: 10.1007/s00415-021-10597-4 . Strilciuc S, Grad DA, Radu C, Chira D, Stan A, Ungureanu M, et al. The economic burden of stroke: a systematic review of cost of illness studies. J Med Life. 2021;14(5):606–19. doi: 10.25122/jml-2021-0361 . Pandian JD, Gall SL, Kate MP, Silva GS, Akinyemi RO, Ovbiagele BI, et al. Prevention of stroke: a global perspective. Lancet. 2018;392(10154):1269–78. doi: 10.1016/s0140-6736(18)31269-8 . Bassetti CL. Sleep and stroke. Semin Neurol. 2005;25(1):19–32. doi: 10.1055/s-2005-867073 . Wang H, Sun J, Sun M, Liu N, Wang M. Relationship of sleep duration with the risk of stroke incidence and stroke mortality: an updated systematic review and dose-response meta-analysis of prospective cohort studies. Sleep Med. 2022;90:267–78. doi: 10.1016/j.sleep.2021.11.001 . Irwin MR, Olmstead R, Carroll JE. Sleep Disturbance, Sleep Duration, and Inflammation: A Systematic Review and Meta-Analysis of Cohort Studies and Experimental Sleep Deprivation. Biol Psychiatry. 2016;80(1):40–52. doi: 10.1016/j.biopsych.2015.05.014 . Cai C, Atanasov S. Long Sleep Duration and Stroke-Highly Linked, Poorly Understood. Neurol Int. 2023;15(3):764–77. doi: 10.3390/neurolint15030048 . Li J, Cao D, Huang Y, Chen Z, Wang R, Dong Q, et al. Sleep duration and health outcomes: an umbrella review. Sleep Breath. 2022;26(3):1479–501. doi: 10.1007/s11325-021-02458-1 . Cappuccio FP, Cooper D, D'Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J. 2011;32(12):1484–92. doi: 10.1093/eurheartj/ehr007 . Liu F, Yang Y, Wang S, Zhang XL, Wang AX, Liao XL, et al. Impact of Sleep Duration on Depression and Anxiety After Acute Ischemic Stroke. Front Neurol. 2021;12:630638. doi: 10.3389/fneur.2021.630638 . Dong L, Brown DL, Chervin RD, Case E, Morgenstern LB, Lisabeth LD. Pre-stroke sleep duration and post-stroke depression. Sleep Med. 2021;77:325–9. doi: 10.1016/j.sleep.2020.04.025 . Wang K, Ji J, Zhang H, Sun Z, Shao Q, Xu W, et al. Association of sleep characteristics with stroke incidence and all-cause mortality: A cross-sectional study in the United States. J Stroke Cerebrovasc Dis. 2024;33(10):107918. doi: 10.1016/j.jstrokecerebrovasdis.2024.107918 . Sawadogo W, Adera T, Burch JB, Alattar M, Perera R, Howard VJ. Sleep duration and all-cause mortality among stroke survivors. J Stroke Cerebrovasc Dis. 2024;33(4):107615. doi: 10.1016/j.jstrokecerebrovasdis.2024.107615 . Mims KN, Kirsch D. Sleep and Stroke. Sleep Med Clin. 2016;11(1):39–51. doi: 10.1016/j.jsmc.2015.10.009 . McDermott M, Brown DL, Chervin RD. Sleep disorders and the risk of stroke. Expert Rev Neurother. 2018;18(7):523–31. doi: 10.1080/14737175.2018.1489239 . Li C, Liu Y, Xu P, Fan Q, Gong P, Ding C, et al. Association between obstructive sleep apnea and risk of post-stroke depression: A hospital-based study in ischemic stroke patients. J Stroke Cerebrovasc Dis. 2020;29(8):104876. doi: 10.1016/j.jstrokecerebrovasdis.2020.104876 . Dharmakulaseelan L, Boulos MI. Sleep Apnea and Stroke: A Narrative Review. Chest. 2024. doi: 10.1016/j.chest.2024.04.028 . Festic N, Alejos D, Bansal V, Mooney L, Fredrickson PA, Castillo PR, et al. Sleep Apnea in Patients Hospitalized With Acute Ischemic Stroke: Underrecognition and Associated Clinical Outcomes. J Clin Sleep Med. 2018;14(1):75–80. doi: 10.5664/jcsm.6884 . Li C, Shang S. Relationship between Sleep and Hypertension: Findings from the NHANES (2007–2014). Int J Environ Res Public Health. 2021;18(15). doi: 10.3390/ijerph18157867 . Kadier K, Qin L, Ainiwaer A, Rehemuding R, Dilixiati D, Du YY, et al. Association of sleep-related disorders with cardiovascular disease among adults in the United States: A cross-sectional study based on national health and nutrition examination survey 2005–2008. Front Cardiovasc Med. 2022;9:954238. doi: 10.3389/fcvm.2022.954238 . Mao Y, Weng J, Xie Q, Wu L, Xuan Y, Zhang J, et al. Association between dietary inflammatory index and Stroke in the US population: evidence from NHANES 1999–2018. BMC Public Health. 2024;24(1):50. doi: 10.1186/s12889-023-17556-w . Brooks JM, Titus AJ, Bruce ML, Orzechowski NM, Mackenzie TA, Bartels SJ, et al. Depression and Handgrip Strength Among U.S. Adults Aged 60 Years and Older from NHANES 2011–2014. J Nutr Health Aging. 2018;22(8):938–43. doi: 10.1007/s12603-018-1041-5 . Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. doi: 10.1046/j.1525-1497.2001.016009606.x . Hassani S, Ovbiagele B, Markovic D, Towfighi A. Association Between Abnormal Sleep Duration and Stroke in the United States. Neurology. 2024;103(7):e209807. doi: 10.1212/wnl.0000000000209807 . Zhao Y, Zhao J, Xie R, Zhang Y, Xu Y, Mao J, et al. Association between family income to poverty ratio and HPV infection status among U.S. women aged 20 years and older: a study from NHANES 2003–2016. Front Oncol. 2023;13:1265356. doi: 10.3389/fonc.2023.1265356 . Zhu S, Ji L, He Z, Zhang W, Tong Y, Luo J, et al. Association of smoking and osteoarthritis in US (NHANES 1999–2018). Sci Rep. 2023;13(1):3911. doi: 10.1038/s41598-023-30644-6 . Jiang M, Tang X, Wang P, Yang L, Du R. Association between daily alcohol consumption and serum alpha klotho levels among U.S. adults over 40 years old: a cross-sectional study. BMC Public Health. 2023;23(1):1901. doi: 10.1186/s12889-023-16830-1 . Zhou L, Zhang J, Zhang D, Yu Y, Jiang M, Liu H, et al. Co-exposure to multiple vitamins and the risk of all-cause mortality in patients with diabetes. Front Endocrinol (Lausanne). 2023;14:1254133. doi: 10.3389/fendo.2023.1254133 . Li Y, Zeng L. Comparison of seven anthropometric indexes to predict hypertension plus hyperuricemia among U.S. adults. Front Endocrinol (Lausanne). 2024;15:1301543. doi: 10.3389/fendo.2024.1301543 . Huang YM, Xia W, Ge YJ, Hou JH, Tan L, Xu W, et al. Sleep duration and risk of cardio-cerebrovascular disease: A dose-response meta-analysis of cohort studies comprising 3.8 million participants. Front Cardiovasc Med. 2022;9:907990. doi: 10.3389/fcvm.2022.907990 . Wang J, Ren X. Association Between Sleep Duration and Sleep Disorder Data from the National Health and Nutrition Examination Survey and Stroke Among Adults in the United States. Med Sci Monit. 2022;28:e936384. doi: 10.12659/msm.936384 . Aggarwal S, Loomba RS, Arora RR, Molnar J. Associations between sleep duration and prevalence of cardiovascular events. Clin Cardiol. 2013;36(11):671–6. doi: 10.1002/clc.22160 . Zhai L, Zhang H, Zhang D. SLEEP DURATION AND DEPRESSION AMONG ADULTS: A META-ANALYSIS OF PROSPECTIVE STUDIES. Depress Anxiety. 2015;32(9):664–70. doi: 10.1002/da.22386 . Geusgens CAV, van Tilburg DCH, Fleischeuer B, Bruijel J. The relation between insomnia and depression in the subacute phase after stroke. Neuropsychol Rehabil. 2024:1–17. doi: 10.1080/09602011.2024.2370072 . Wang L, Tao Y, Chen Y, Wang H, Zhou H, Fu X. Association of post stroke depression with social factors, insomnia, and neurological status in Chinese elderly population. Neurol Sci. 2016;37(8):1305–10. doi: 10.1007/s10072-016-2590-1 . Cappuccio FP, D'Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep. 2010;33(5):585–92. doi: 10.1093/sleep/33.5.585 . Kwok CS, Kontopantelis E, Kuligowski G, Gray M, Muhyaldeen A, Gale CP, et al. Self-Reported Sleep Duration and Quality and Cardiovascular Disease and Mortality: A Dose-Response Meta-Analysis. J Am Heart Assoc. 2018;7(15):e008552. doi: 10.1161/jaha.118.008552 . García-Perdomo HA, Zapata-Copete J, Rojas-Cerón CA. Sleep duration and risk of all-cause mortality: a systematic review and meta-analysis. Epidemiol Psychiatr Sci. 2019;28(5):578–88. doi: 10.1017/s2045796018000379 . Hale E, Gottlieb E, Usseglio J, Shechter A. Post-stroke sleep disturbance and recurrent cardiovascular and cerebrovascular events: A systematic review and meta-analysis. Sleep Med. 2023;104:29–41. doi: 10.1016/j.sleep.2023.02.019 . Drager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S. Sleep Apnea and Cardiovascular Disease: Lessons From Recent Trials and Need for Team Science. Circulation. 2017;136(19):1840–50. doi: 10.1161/circulationaha.117.029400 . Additional Declarations No competing interests reported. Supplementary Files nhanes.sleep.stroke.supplement.docx Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2025 Read the published version in European Journal of Medical Research → Version 1 posted Editorial decision: Revision requested 03 Dec, 2024 Reviews received at journal 03 Dec, 2024 Reviewers agreed at journal 27 Nov, 2024 Reviews received at journal 26 Nov, 2024 Reviewers agreed at journal 19 Nov, 2024 Reviewers agreed at journal 10 Oct, 2024 Reviewers invited by journal 08 Oct, 2024 Editor assigned by journal 04 Oct, 2024 Submission checks completed at journal 01 Oct, 2024 First submitted to journal 30 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5181770","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":385855704,"identity":"8b3a5b66-b0e5-437c-bf2e-dd306fbb4fe3","order_by":0,"name":"Weirong Chen","email":"","orcid":"","institution":"Shanxi Provincial Integrated Traditional Chinese Medicine and Western Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Weirong","middleName":"","lastName":"Chen","suffix":""},{"id":385855705,"identity":"d54e20bb-28cd-42da-926b-1eacb4359b82","order_by":1,"name":"Yingying Shen","email":"","orcid":"","institution":"Hubei University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yingying","middleName":"","lastName":"Shen","suffix":""},{"id":385855706,"identity":"23185d5a-3fdb-4a50-9be0-d5a0fc61fe2c","order_by":2,"name":"Shina Song","email":"","orcid":"","institution":"General Hospital of TISCO","correspondingAuthor":false,"prefix":"","firstName":"Shina","middleName":"","lastName":"Song","suffix":""},{"id":385855707,"identity":"6d99a962-bae0-49db-a6dd-d3d87f8c0500","order_by":3,"name":"Xiaofeng Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYDACZiCuAGI+ZgbGBwkGEnJs7O0HCGs5A8RszAzMBh8KLIz5eM4kELYJrAWIJGd8qEicJ+FggFe1wXHmhw8OVNyxa2NnYJDmMZBIb5NgSGD4UbENpxbJZjZjgwNnniW3AV1oDNSS2ybdeICx58xtnFr4mRnMpD+2HU4G+oUhGaxF5kACM2Mbbi1szOzfJA7+g2g5DHIYm0SCAV4t/Mw8ZhIHGw7bAbUwNs4wkEggqEWymafY4MCxwwmgQGb4YCBh2AYM5IP4/GJw/vjGBwdqDtvz8x9g/5Hwp05evr394IMfFbi1wEBiAwP/BzjvAEH1QGBPjKJRMApGwSgYoQAAb0pQGGjtENsAAAAASUVORK5CYII=","orcid":"","institution":"Linfen City People’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xiaofeng","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-09-30 14:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5181770/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5181770/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40001-024-02227-2","type":"published","date":"2025-01-03T15:57:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71477887,"identity":"eefd469f-2782-4dbf-a318-2552d366c2b3","added_by":"auto","created_at":"2024-12-16 05:27:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25344,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of study population selection, NHANES 2005-2018.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5181770/v1/5e729292b6df1ce1c77464ae.png"},{"id":71477899,"identity":"e1630937-ef73-477f-88c0-4ca4d8911295","added_by":"auto","created_at":"2024-12-16 05:27:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":70294,"visible":true,"origin":"","legend":"\u003cp\u003eRCS analysis of the association of sleep duration with depression and all-cause and CVD mortality after stroke.\u003cstrong\u003e A\u003c/strong\u003e: post-stroke depression; \u003cstrong\u003eB\u003c/strong\u003e: all-cause mortality;\u003cstrong\u003e C\u003c/strong\u003e: CVD mortality.\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5181770/v1/88e3ed9bd9bc35844552d1c4.png"},{"id":71477900,"identity":"9e5eb117-74cb-4c2b-8f83-70bb2a7aa9dd","added_by":"auto","created_at":"2024-12-16 05:27:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":175449,"visible":true,"origin":"","legend":"\u003cp\u003eStratified analysis of the association of sleep duration and sleep disorders with depression and all-cause and CVD mortality after stroke.\u003cstrong\u003e A\u003c/strong\u003e: sleep duration and post-stroke depression; \u003cstrong\u003eB\u003c/strong\u003e: sleep disorders and post-stroke depression;\u003cstrong\u003e C\u003c/strong\u003e: sleep duration and all-cause and CVD mortality after stroke; \u003cstrong\u003eD\u003c/strong\u003e: sleep disorders and all-cause and CVD mortality after stroke.\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5181770/v1/80ffc2a65cf94b39df736aa9.png"},{"id":73093513,"identity":"bdb9becc-ebd1-4646-b318-43b34814f6f3","added_by":"auto","created_at":"2025-01-06 16:21:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1293278,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5181770/v1/14242874-4823-4303-bf1f-44f05709ac2d.pdf"},{"id":71477888,"identity":"84b4e40e-6e03-48c0-93ed-0b4bb340883c","added_by":"auto","created_at":"2024-12-16 05:27:05","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":18925,"visible":true,"origin":"","legend":"","description":"","filename":"nhanes.sleep.stroke.supplement.docx","url":"https://assets-eu.researchsquare.com/files/rs-5181770/v1/8ae4e6b9870cfd16d57dc884.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of sleep duration and sleep disorders with post-stroke depression and all-cause and cardiovascular disease mortality in US stroke survivors: Results from NHANES 2005-2018","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eStroke is an acute cerebrovascular disease (mainly classified as ischemic stroke and hemorrhagic stroke) that results from different causes of impaired blood circulation in the brain, which leads to focal neurological deficit[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Stroke is the leading cause of death and disability worldwide. In 2019, the global incidence of stroke is estimated at 12.2\u0026nbsp;million cases, resulting in 143\u0026nbsp;million disability-adjusted life years and 6.55\u0026nbsp;million deaths[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Stroke is the second leading cause of death globally, with about one-fifth of the population in some high-income countries affected by stroke in their lifetime, while about one-half of the population in low-income countries may be affected in their lifetime[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In addition, stroke is strongly associated with the development of several comorbidities, including post-stroke depression. Post-stroke depression is a well-recognized and common psychiatric disorder among stroke survivors, with prevalence rates reported at 27%[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Compared to depression-free stroke survivors, post-stroke depression is associated with higher mortality, poorer recovery, more significant cognitive deficits, and poorer quality of life[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Stroke places a heavy financial burden on individuals, families and society. In the United States, each stroke patient contributes about \u003cspan\u003e$\u003c/span\u003e60,000 per year to total medical expenditures[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Stroke prevention is at the center of efforts to reduce the disease burden of stroke[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Identifying and controlling modifiable risk factors for post-stroke depression and mortality is of great importance in public health.\u003c/p\u003e \u003cp\u003eSleep and stroke are widely recognized to be closely linked, and sleep-related disturbance is a common concern among stroke survivors[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Short sleep duration has been shown to be associated with endocrine and metabolic dysfunction and increased cardiovascular risk, while long sleep duration may be associated with increased systemic inflammation[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Compared with normal sleep duration, a large body of clinical evidence suggests that either short or long sleep duration is associated with an increased risk of stroke, although controversial findings exist[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, the association between sleep duration and post-stroke depression is currently poorly investigated. Only two observational studies have explored the association between sleep duration and poststroke depression, and both have shown that short sleep duration (\u0026lt;\u0026thinsp;6 h) is associated with an increased risk of depression in stroke survivors[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, these studies are limited to relatively homogeneous ethnic populations, and the association of long sleep duration with post-stroke depression remains underexplored. A recent meta-analysis demonstrated that either short or long sleep duration is associated with an increased risk of stroke mortality in the general population[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, the association between sleep duration and mortality in stroke survivors remains poorly explored. A small number of cohort studies have demonstrated that long sleep duration is associated with increased all-cause mortality in stroke patients compared with normal sleep duration; however, the association of short sleep duration with all-cause mortality in stroke survivors is controversial[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Both studies included relatively small samples of stroke survivors and did not explore the association of sleep duration with cardiovascular mortality in stroke survivors. Furthermore, Sleep disorders such as sleep apnea, insomnia, and restless legs are common sleep problems that disturb stroke survivors. Accumulating evidence suggests that sleep disorders are associated with an increased risk of stroke[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, the association of sleep disorders with depression and mortality after stroke remains poorly studied. Some sparse evidence suggests that sleep apnea is associated with an increased risk of depression after stroke[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], while the association with mortality in stroke survivors remains elusive[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address these research gaps, we explored these associations in this study using nationally representative data from the National Health and Nutrition Examination Survey (NHANES). We aimed to examine the association of sleep duration and sleep disorders with depression and all-cause and cardiovascular disease (CVD) mortality among stroke survivors, and to explore potential nonlinear associations and whether they remain stable across populations with different clinical characteristics.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003e \u003cb\u003eStudy design and population\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNHANES is the major program of the National Center for Health Statistics (NCHS) established to assess the health and nutritional status of community-dwelling populations in the US. NHANES is a nationwide, population-based, multiethnic serial cross-sectional survey and is characterized by a complex multistage probability sampling study design. All NHANES cycles were approved by the NCHS Ethics Review Board and written informed consent was obtained from all participants. In addition, all data were publicly accessible and de-identified, so local institutional ethics approval was waived. First, 1659 stroke participants from NHANES 2005\u0026ndash;2018 were included. Second, those with missing PHQ-9 data (n\u0026thinsp;=\u0026thinsp;300), missing sleep questionnaire information (n\u0026thinsp;=\u0026thinsp;11), and missing covariates (n\u0026thinsp;=\u0026thinsp;247) were excluded. A total of 1101 eligible stroke participants were finally included (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSleep data collection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSleep duration was obtained based on self-report in the Sleep Disorders Questionnaire[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Participants were asked \u0026ldquo;How much sleep do you usually get at night on weekdays or workdays?\u0026rdquo;. Sleep duration was categorized as normal sleep duration (7-8h), short sleep duration (\u0026lt;\u0026thinsp;7h), and long sleep duration (\u0026gt;\u0026thinsp;8h)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Sleep disorders were assessed based on participants' self-reports (only available in NHANES 2005\u0026ndash;2014), with affirmative responses to the question \u0026ldquo;Have you ever been told by a doctor or other health professional that you have a sleep disorder? indicating the presence of a sleep disorder[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eAssessment of stroke\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStroke was assessed according to participants' self-report on the relevant medical conditions data. Participants were asked \u0026ldquo;Has a doctor or other health professional ever told you that you had a stroke?\u0026rdquo; in the home using the computer-assisted personal interviewing system, and an affirmative response to this question indicated the presence of stroke[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eAssessment of depression\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDepressive symptoms were assessed according to the widely validated Patient Health Questionnaire-9 (PHQ-9), with a PHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;10 suggesting major depression[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. PHQ-9 consists of 9 entries associated with depressive symptoms, which have high sensitivity and specificity (88%)[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eMortality information collection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStroke participants at baseline were followed until the death endpoint occurred or until December 31, 2019. Mortality information was obtained by prospectively matching death records from the public-use mortality file of the National Death Index database. CVD mortality data were obtained based on ICD-10 codes including I00-I09, I11, I13, I20-I51, and I60-I69.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCovariates\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBased on previous studies, several important covariates were included, including age, gender, race/ethnicity, educational attainment, household income-poverty ratio (PIR), marital status, smoking, alcohol consumption, physical activity, body mass index (BMI), diabetes, hypertension, and history of coronary heart disease (CHD)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The PIR was assessed based on self-reported family income and federally defined poverty levels[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Participants were categorized as never smokers (\u0026lt;\u0026thinsp;100 lifetime cigarettes), former smokers (\u0026ge;\u0026thinsp;100 lifetime cigarettes but no current cigarettes), and current smokers (\u0026ge;\u0026thinsp;100 lifetime cigarettes and current cigarettes) based on self-reports and prior study criteria[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Alcohol-related questionnaires were used to assess drinking history and were categorized as never drinkers (\u0026lt;\u0026thinsp;12 drinks in their lifetime), former drinkers (\u0026ge;\u0026thinsp;12 drinks in their lifetime but not in the last year), and current drinkers (further subdivided into light, moderate, and heavy drinkers based on gender-specific daily alcohol consumption)[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Physical activity was categorized as no, moderate, and vigorous intensity participation based on participants' self-reports. BMI was calculated based on weight (kg) divided by the square of height (m) as determined by the mobile examination center. Diabetes was diagnosed by self-reported history of diabetes, fasting blood glucose\u0026thinsp;\u0026ge;\u0026thinsp;7.0 mmol/l, oral glucose tolerance test blood glucose\u0026thinsp;\u0026ge;\u0026thinsp;11.1 mmol/l, glycated hemoglobin A1c\u0026thinsp;\u0026ge;\u0026thinsp;6.5%, or taking antidiabetic medications[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The diagnosis of hypertension was made according to three criteria: a history of self-reported hypertension; a blood pressure measurement of \u0026ge;\u0026thinsp;140/90 mmHg; and the administration of antihypertensive medications[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The presence of a history of CHD was indicated by the participants' affirmative responses to the specific question in the interview, \u0026ldquo;Has a doctor or other health professional ever told you that you had coronary heart disease?\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003e All statistical analyses were performed using R (version 4.2.3) and EmpowerStats and appropriately weighted in accordance with the NHANES analytic guidelines to consider the NHANES sophisticated study design, and a two-sided p-value of less than 0.05 was interpreted as statistically significant. We performed baseline analyses by grouping stroke participants according to their depression status. Continuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error and analyzed according to weighted t tests, and categorical variables were expressed as number (percentage) and tested by weighted chi-square analysis. Multivariate logistic regression analyses were used to explore the association of sleep duration and sleep disorders with the prevalence of depression in stroke survivors and calculated the odds ratios (OR) and 95% confidence intervals (CI). Multiple adjustment models were constructed, with model 1 adjusting for age, sex, race/ethnicity, education, PIR, and marital status; model 2 additionally adjusting for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 additionally adjusting for sleep duration/sleep disorders from model 2. Kaplan-Meier (KM) survival curves and log-rank tests were used to investigate differences in all-cause and CVD-related survival in stroke survivors across different sleep durations and sleep disorders (yes/no). Multivariate Cox proportional hazards regression analyses were used to explore the associations of sleep duration and sleep disorders with long-term mortality in stroke survivors and calculated the hazard ratios (HR) and 95% CI. Similarly, model 1, model 2, and model 3 were constructed with adjustment variables consistent with those in the logistic regression. Restricted cubic spline (RCS) models were constructed to explore potential nonlinear associations of sleep duration (continuous variable) with post-stroke depression and mortality, and appropriate knots were selected for smooth curve fitting. Subgroup analyses were conducted to explore whether these associations remained stable across subgroup strata (age, gender, and race/ethnicity) and to identify potential effect modifiers using interaction analyses. In the sensitivity analysis, we adopted sleep duration of 6-8h as normal, \u0026lt;6h as short sleep duration, and \u0026gt;\u0026thinsp;8h as long sleep duration as classification criteria[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] to verify the consistency of the findings.\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e \u003cb\u003eBaseline characteristics\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 1101 eligible stroke participants were enrolled with a mean age of 63.923 years. The prevalence of post-stroke depression was 18.26% (201/1101). Compared to stroke survivors without depression, participants with comorbid depression were younger, had lower PIR, higher BMI, and were more likely to be current smokers, and moderate/heavy drinkers. Of note, stroke participants with depression had lower sleep duration and a higher prevalence of sleep disorders (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline analysis of stroke survivors grouped according to depression status, NHANES 2005\u0026ndash;2018.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;1101)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo-depression (n\u0026thinsp;=\u0026thinsp;900)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDepression (n\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.923\u0026thinsp;\u0026plusmn;\u0026thinsp;0.616\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.104\u0026thinsp;\u0026plusmn;\u0026thinsp;0.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.458\u0026thinsp;\u0026plusmn;\u0026thinsp;1.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePIR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.364\u0026thinsp;\u0026plusmn;\u0026thinsp;0.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.468\u0026thinsp;\u0026plusmn;\u0026thinsp;0.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.884\u0026thinsp;\u0026plusmn;\u0026thinsp;0.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.059\u0026thinsp;\u0026plusmn;\u0026thinsp;0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.211\u0026thinsp;\u0026plusmn;\u0026thinsp;0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.355\u0026thinsp;\u0026plusmn;\u0026thinsp;0.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.206\u0026thinsp;\u0026plusmn;\u0026thinsp;0.292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.821\u0026thinsp;\u0026plusmn;\u0026thinsp;0.308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.989\u0026thinsp;\u0026plusmn;\u0026thinsp;0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep disorder\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e685(59.170)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e584(84.154)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101(62.776)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142(14.516)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92(15.846)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50(37.224)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e541(44.703)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e464(46.208)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77(37.737)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e560(55.297)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e436(53.792)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e124(62.263)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRace/ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMexican American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98(4.428)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79(4.354)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(4.771)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic Black\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e300(14.551)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e246(13.938)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54(17.388)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic White\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e565(71.330)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e464(71.661)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101(69.800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72(3.102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55(2.897)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(4.054)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(6.588)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56(7.150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(3.986)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.266\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enon-single\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e580(59.047)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e488(59.968)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92(54.783)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e521(40.953)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e412(40.032)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e109(45.217)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155(8.805)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127(8.730)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28(9.153)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e501(45.073)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e400(43.117)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101(54.129)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e445(46.121)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e373(48.153)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72(36.718)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e423(39.965)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e359(42.032)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64(30.397)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eformer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e414(36.170)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e355(37.507)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59(29.983)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e264(23.865)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e186(20.462)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78(39.621)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDrinking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170(13.789)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151(15.182)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(7.340)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eformer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e369(30.151)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e297(30.168)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72(30.069)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e345(34.043)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e292(34.453)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53(32.147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emoderate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106(10.459)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(9.603)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(14.421)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eheavy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111(11.558)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80(10.594)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31(16.023)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical activity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e737(64.772)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e601(64.262)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e136(67.132)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emoderate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e223(22.414)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e178(21.991)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45(24.371)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evigorous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141(12.814)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e121(13.747)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(8.498)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e652(62.756)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e535(63.358)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117(59.972)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e449(37.244)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e365(36.642)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84(40.028)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHypertension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e215(22.230)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e176(22.145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39(22.626)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e886(77.770)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e724(77.855)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e162(77.374)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCHD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e915(82.180)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e756(82.984)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e159(78.457)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186(17.820)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144(17.016)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42(21.543)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eContinuous variables were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error and analyzed according to weighted t tests, and categorical variables were expressed as number (percentage) and tested by weighted chi-square analysis. For sleep disorders (only accessible in NHANES 2005\u0026ndash;2014), we present baseline data from NHANES 2005\u0026ndash;2014 accordingly.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAssociation of sleep duration and sleep disorders with post-stroke depression\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn model 1 and model 2, sleep disorders, sleep duration (treated as a continuous variable), and short sleep duration (compared to normal sleep duration) were all significantly associated with post-stroke depression. In fully adjusted model 3, sleep disorders remained significantly associated with increased odds of post-stroke depression (OR 2.689, 95% CI 1.248\u0026ndash;5.793, p\u0026thinsp;=\u0026thinsp;0.0146). Similarly, sleep duration remained inversely associated with the prevalence of post-stroke depression (OR 0.841, 95% CI 0.728\u0026ndash;0.971, p\u0026thinsp;=\u0026thinsp;0.0219). Short sleep duration (OR 2.196, 95% CI 1.284\u0026ndash;3.756, p\u0026thinsp;=\u0026thinsp;0.0059) but not long sleep duration (p\u0026thinsp;=\u0026thinsp;0.1435) was associated with increased odds of post-stroke depression compared to normal sleep duration (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of sleep duration and sleep disorders with the prevalence of post-stroke depression in US adults.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003cp\u003eOR (95%CI) P-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003cp\u003eOR (95%CI) P-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 3\u003c/p\u003e \u003cp\u003eOR (95%CI) P-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep Disorders\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.223 (1.526, 6.806) 0.0031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.974 (1.438, 6.150) 0.0048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.689 (1.248, 5.793) 0.0146\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.811 (0.716, 0.918) 0.0013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.811 (0.719, 0.914) 0.0009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.841 (0.728, 0.971) 0.0219\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.693 (1.658, 4.375) 0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.772 (1.747, 4.400)\u0026thinsp;\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.196 (1.284, 3.756) 0.0059\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.196 (0.674, 2.124) 0.5426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.197 (0.654, 2.189) 0.5613\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.711 (0.842, 3.477) 0.1435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModel 1 was adjusted for age, sex, race/ethnicity, education, PIR, and marital status; model 2 was adjusted additionally for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 was adjusted additionally for sleep duration/sleep disorders from model 2.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAssociation of sleep duration and sleep disorders with all-cause and CVD mortality among stroke survivors\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAfter a median follow-up of 70 months (interquartile range of 40\u0026ndash;113 months), 384 stroke survivors died, of which 140 were CVD-related deaths. In model 3, sleep disorders were not significantly associated with all-cause mortality in stroke survivors (HR 1.299, 95% CI 0.852\u0026ndash;1.979, p\u0026thinsp;=\u0026thinsp;0.224). Sleep duration (treated as a continuous variable) was significantly and positively associated with all-cause mortality after stroke (HR 1.075, 95% CI 1.003\u0026ndash;1.153, p\u0026thinsp;=\u0026thinsp;0.042). However, neither short sleep duration (p\u0026thinsp;=\u0026thinsp;0.695) nor long sleep duration (p\u0026thinsp;=\u0026thinsp;0.064) was associated with risk of all-cause mortality compared to normal sleep duration (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After adjusting for all covariates, sleep disorders were significantly associated with CVD mortality in stroke survivors (HR 1.948, 95% CI 1.083\u0026ndash;3.504, p\u0026thinsp;=\u0026thinsp;0.026). However, sleep duration was not associated with CVD mortality after stroke (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of sleep duration and sleep disorders with all-cause mortality in stroke survivors.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll-cause\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModel 3\u003c/p\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep disorders\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.421(0.949,2.126)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.306(0.859,1.985)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.299(0.852,1.979)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.081(1.010,1.156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.076(1.004,1.153)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e1.075(1.003,1.153)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.936(0.721,1.214)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.616\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.939(0.698,1.262)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.676\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.942(0.699,1.270)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.341(0.989,1.817)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.334(0.986,1.805)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.324(0.983,1.783)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModel 1 was adjusted for age, sex, race/ethnicity, education, PIR, and marital status; model 2 was adjusted additionally for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 was adjusted additionally for sleep duration/sleep disorders from model 2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of sleep duration and sleep disorders with CVD mortality in stroke survivors.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCVD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModel 3\u003c/p\u003e \u003cp\u003eHR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep disorders\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.948(1.120,3.390)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.986(1.103,3.577)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e1.948(1.083,3.504)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.004(0.911,1.106)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.992(0.896,1.097)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.998(0.903,1.103)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.969\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSleep Duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.887(0.583,1.348)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.913(0.570,1.463)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.705\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.895(0.557,1.437)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.646\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.906(0.536,1.533)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.903(0.531,1.534)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.903(0.530,1.537)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModel 1 was adjusted for age, sex, race/ethnicity, education, PIR, and marital status; model 2 was adjusted additionally for smoking, alcohol consumption, physical activity, BMI, diabetes, hypertension, and CHD based on model 1; and model 3 was adjusted additionally for sleep duration/sleep disorders from model 2.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRCS analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRCS analysis showed a nonlinear association between sleep duration and the prevalence of post-stroke depression (p for nonlinearity\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, with an inflection point of 8.0h) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Threshold effect analysis showed an inverse association between sleep duration and post-stroke depression only for sleep duration\u0026thinsp;\u0026lt;\u0026thinsp;8h (OR 0.588, 95% CI 0.485\u0026ndash;0.712, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In addition, RCS analyses demonstrated that sleep duration was significantly and linearly associated with all-cause mortality in stroke survivors (p for nonlinearity 0.424) and similarly unrelated to CVD mortality (p for overall 0.6637) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThreshold effect analysis of the association between sleep duration and post-stroke depression.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95%CI) P-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-interaction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026lt;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.588 (0.485, 0.712)\u0026thinsp;\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.188 (0.899, 1.571) 0.2295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eStratified analysis\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003cp\u003eInteraction analyses indicated that age, gender, or race/ethnicity did not significantly affect the association of sleep duration (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA) and sleep disorders (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB) with post-stroke depression (all P for interactions\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Similarly, age, sex, and race did not influence the association between sleep duration and all-cause and CVD mortality in stroke survivors (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). However, age was identified as an effect modifier of the association between sleep disorders and CVD mortality among stroke survivors (p for interaction\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The association between sleep disorders and CVD mortality after stroke was only present in those\u0026thinsp;\u0026lt;\u0026thinsp;60 years of age (HR 1.244, 95% CI 1.178\u0026ndash;6.055, p\u0026thinsp;=\u0026thinsp;0.002) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSensitivity analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhen 6-8h was the criterion for normal sleep duration, interestingly, both short sleep duration (\u0026lt;\u0026thinsp;6h, OR 3.419, p\u0026thinsp;=\u0026thinsp;0.0029) and long sleep duration (\u0026gt;\u0026thinsp;8h, OR 1.933, p\u0026thinsp;=\u0026thinsp;0.0205) were associated with an increased odds of post-stroke depression (\u003cb\u003eTable \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e). Consistently, neither short nor long sleep duration was associated with all-cause and CVD mortality in stroke survivors (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) compared to normal sleep duration (6-8h) (\u003cb\u003eTables S2 and S3\u003c/b\u003e).\u003c/p\u003e"},{"header":"4. DISCUSSIONS","content":"\u003cp\u003eIn this national population-based study, we found that sleep disorders were associated with significantly increased risk of post-stroke depression and CVD mortality in stroke survivors, but not with all-cause mortality in stroke survivors. Sleep duration was inversely associated with the odds of post-stroke depression in US adults. Short sleep duration, but not long sleep duration, was associated with significantly increased odds of post-stroke depression compared with normal sleep duration. Interestingly, although sleep duration was positively associated with the risk of all-cause mortality in stroke survivors, neither short nor long sleep duration was associated with all-cause and CVD mortality after stroke. Sleep duration was nonlinearly and linearly associated with depression and all-cause mortality after stroke, respectively. Of note, the association between sleep disorders and CVD mortality in stroke survivors was only present in participants\u0026thinsp;\u0026lt;\u0026thinsp;60 years of age.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, this is the first comprehensive exploration of the association of sleep duration and sleep disorders with depression and all-cause and CVD mortality in stroke survivors in a national population-based study from NHANES. A large body of clinical evidence suggests that abnormal sleep duration is associated with an increased risk of stroke in the general population, but inconsistent findings exist. A recent umbrella review showed that short and long sleep duration increased the risk of incident stroke by 32% and 17%, respectively, compared with normal sleep duration[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Another recent large meta-analysis showed a U-shaped association between sleep duration at night and stroke risk, with the lowest stroke risk at a sleep duration of 7.5h[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Some cross-sectional evidence from NHANES suggested that compared with normal sleep duration, short sleep duration was associated with increased odds of stroke, whereas long sleep duration was not[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Recent cross-sectional analyses from NHANES demonstrated that sleep duration greater than 8h was associated with an increased risk of stroke, whereas \u0026lt;\u0026thinsp;7h was not significantly associated[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Another study from NHANES 2005\u0026ndash;2008 showed that neither short nor long sleep duration was associated with stroke odds[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These heterogeneities may derive from variability in the number of survey cycles included and the assessment criteria for sleep duration. In addition, a cross-sectional analysis from NHANES also showed that sleep disorders are associated with increased prevalence of stroke[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA large body of epidemiologic evidence suggests a significant association between sleep duration and the occurrence of depression in the general population. A meta-analysis incorporating seven prospective cohort studies demonstrated that both short and long sleep duration were associated with an increased risk of depression compared to normal sleep duration (relative risks of 1.31 and 1.42, respectively)[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, the association between sleep duration and post-stroke depression remains little studied. A retrospective study including 1369 stroke survivors from the Brain Attack Surveillance in Corpus Christi project demonstrated that only\u0026thinsp;\u0026lt;\u0026thinsp;6h of pre-stroke sleep duration was associated with an increased odds of depression at 90 days post-stroke compared to normal sleep duration (7-8h) (OR 1.96, 95% CI 1.38\u0026ndash;2.79), whereas both 6h and \u0026gt;\u0026thinsp;8h sleep duration were not[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Another cross-sectional analysis from China showed that 5\u0026ndash;6 and \u0026lt;\u0026thinsp;5 h of sleep duration were associated with increased odds of depression after stroke compared with \u0026gt;\u0026thinsp;7 h of sleep duration (OR 1.47 and 3.05, respectively)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our study demonstrated for the first time that sleep duration was inversely associated with reduced prevalence of post-stroke depression. Compared with normal sleep duration, short sleep duration (\u0026lt;\u0026thinsp;7h) but not long sleep duration was associated with significantly increased odds of post-stroke depression, consistent with previous studies. Interestingly, long sleep duration (\u0026gt;\u0026thinsp;8 h) was also associated with increased odds of post-stroke depression when the normal sleep duration criterion was replaced with 6\u0026ndash;8 h, suggesting that the association between long sleep duration and post-stroke depression needs to be focused on according to specific criteria in clinical practice. The association between sleep disorders and post-stroke depression remains poorly studied. A retrospective study including 265 in-hospital ischemic stroke patients demonstrated that severe obstructive sleep apnea (OSA) (compared to no OSA) was associated with increased odds of post-stroke depression at 3 months (OR 4.04, p\u0026thinsp;=\u0026thinsp;0.036)[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A cross-sectional analysis including 66 outpatient stroke survivors showed insomnia to be an independent predictor of post-stroke depression (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Another cohort study that included 608 elderly Chinese ischemic stroke patients similarly showed that insomnia was associated with increased odds of post-stroke depression (HR 1.59, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01)[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Our findings suggested for the first time that a history of sleep disorders overall was significantly associated with increased odds of depression after stroke, independently of sleep duration.\u003c/p\u003e \u003cp\u003eA large body of clinical evidence suggests that sleep duration may have a significant impact on survival in populations. A meta-analysis of prospective studies suggests that either short or long sleep duration is associated with a significantly increased risk of all-cause mortality in the general population[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. More recent meta-analyses have shown that long sleep duration, but not short sleep duration, is associated with increased all-cause mortality[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. A recent cohort study from the REasons for Geographic And Racial Differences in Stroke showed that long sleep duration (HR 1.46, 95% CI 1.01\u0026ndash;2.12), but not short sleep duration (HR 1.31, 95% CI 0.90\u0026ndash;1.91), was associated with increased all-cause mortality in stroke survivors[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A recent cross-sectional study utilizing NHANES 2005\u0026ndash;2008 demonstrated that compared to normal sleep duration, short sleep duration was negatively associated with all-cause mortality in stroke survivors (HR 0.65, 95% CI 0.44\u0026ndash;0.96), whereas long sleep duration was similarly positively associated with all-cause mortality (HR 1.58, 95% CI 1.03\u0026ndash;2.41)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Inconsistent with the findings of Wang et al[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], our study showed that each 1h increase in sleep duration was associated with a 7.5% increased risk of all-cause mortality among stroke survivors; however, short or long sleep duration was not significantly associated with all-cause mortality among stroke survivors compared to normal sleep duration. These inconsistent findings may be explained by the fact that our study incorporated a more comprehensive survey cycle and a larger stroke sample size, and thus may better reflect the associations. Interestingly, sleep duration was not significantly associated with CVD mortality in stroke survivors. In addition, our findings indicated that sleep disorders were positively associated with CVD mortality, but not all-cause mortality, in stroke survivors. There is still a lack of research on the association of sleep disorders with mortality in stroke survivors. OSA and insomnia are suggested to be associated with an increased risk of mortality in stroke survivors, however inconsistent findings exist[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A retrospective cohort study enrolling 989 patients with ischemic stroke demonstrated that OSA was associated with increased cardiovascular events in stroke survivors, however, with reduced neurologic injury and mortality[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. We speculate that the strong association of sleep disorders such as sleep apnea with increased cardiovascular risk[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] may have contributed to its promotion of CVD mortality in stroke survivors. Furthermore, this association was only present in those\u0026thinsp;\u0026lt;\u0026thinsp;60 years of age, suggesting that sleep disorders in nonelderly stroke survivors may be a warning indicator of increased CVD mortality and require close attention in clinical practice.\u003c/p\u003e \u003cp\u003eSeveral possible mechanisms may explain these findings. Sleep disorders and short sleep duration may induce neuroendocrine and circadian rhythm abnormalities and further inflammatory infiltration leading to post-stroke depression[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, sleep disorders and short sleep duration may interfere with functional recovery after stroke and increase the risk of poststroke depression through psychosocial mechanisms[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The mechanism by which long sleep duration is associated with a trend toward increased all-cause mortality in stroke survivors remains unclear. Some possible explanations are that longer sleep duration may be associated with poorer sleep quality, a more severe history of stroke, and less time spent socializing, which in turn leads to increased mortality[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Cerebral hemodynamic abnormalities and induced cardiovascular risk factors due to sleep disorders such as sleep apnea may cause chronic sympathetic hyperactivity and sleep structural dysfunction, leading to increased cardiovascular events and associated mortality[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are several significant strengths of our study. First, it is a national, population-based, large-sample, multiracial study, allowing for good generalizability of the findings. We adequately adjusted for potential confounders and reduced study bias. However, our study has some potential limitations. The associations of sleep duration and sleep disorders with post-stroke depression were explored by cross-sectional analyses, and longitudinal temporal and causal associations could not be derived. As stroke was assessed by participant self-report, we were unable to assess the impact of stroke severity, lesion location, and subtype on findings. In addition, self-reported data may inherently introduce potential recall bias. However, previous studies have shown good agreement between self-reported sleep duration and results measured by wearable devices[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Finally, NHANES only included noninstitutionalized stroke survivors, and therefore the potential applicability of these findings to hospitalized patients with stroke still requires further elucidation.\u003c/p\u003e"},{"header":"5. CONCLUSIONS","content":"\u003cp\u003eIn a national population-based study, sleep disorders and short sleep duration were associated with increased odds of post-stroke depression. Sleep disorders were associated with increased CVD mortality in stroke survivors, whereas sleep duration was positively associated with all-cause mortality. Compared with normal sleep duration, short or long sleep duration was not associated with either all-cause or CVD mortality in stroke survivors. These findings suggest that maintaining normal sleep duration and improving sleep disorders may help reduce the risk of depression and mortality after stroke. Future large-sample prospective cohort studies are needed to validate these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: This study analyzed publicly available datasets and can be found at https://www.cdc.gov/nchs/nhanes/.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e: All protocols were approved by the NCHS Ethics Review Board, and participants have provided written informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research project was supported by the Shanxi Applied Basic Research Program (202403021212232) and the Scientific and Technological Innovation Programs of Higher Education Institutions in Shanxi (2023L105).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e: None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWC\u003c/strong\u003e conducted data processing and was essential to the drafting and revision of the manuscript. \u003cstrong\u003eYS\u003c/strong\u003e played a pivotal role in data processing and made significant contributions to the study design. \u003cstrong\u003eSS\u003c/strong\u003e contributed to data analysis and interpretation, secured funding. \u003cstrong\u003eXL\u003c/strong\u003e conceptualized the research framework and supervised the manuscript revisions. All authors collaborated in the preparation, critical editing, and review of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCampbell BCV, Khatri P. Stroke. Lancet. 2020;396(10244):129\u0026ndash;42. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0140-6736(20)31179-x\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(20)31179-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobal, regional, and national burden of stroke and its risk factors, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795\u0026ndash;820. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s1474-4422(21)00252-0\u003c/span\u003e\u003cspan address=\"10.1016/s1474-4422(21)00252-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet. 2024;403(10446):2820\u0026ndash;36. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0140-6736(24)00642-1\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(24)00642-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson RG, Jorge RE. Post-Stroke Depression: A Review. Am J Psychiatry. 2016;173(3):221\u0026ndash;31. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1176/appi.ajp.2015.15030363\u003c/span\u003e\u003cspan address=\"10.1176/appi.ajp.2015.15030363\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu L, Xu M, Marshall IJ, Wolfe CD, Wang Y, O'Connell MD. Prevalence and natural history of depression after stroke: A systematic review and meta-analysis of observational studies. PLoS Med. 2023;20(3):e1004200. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pmed.1004200\u003c/span\u003e\u003cspan address=\"10.1371/journal.pmed.1004200\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedeiros GC, Roy D, Kontos N, Beach SR. Post-stroke depression: A 2020 updated review. Gen Hosp Psychiatry. 2020;66:70\u0026ndash;80. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.genhosppsych.2020.06.011\u003c/span\u003e\u003cspan address=\"10.1016/j.genhosppsych.2020.06.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo J, Wang J, Sun W, Liu X. The advances of post-stroke depression: 2021 update. J Neurol. 2022;269(3):1236\u0026ndash;49. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00415-021-10597-4\u003c/span\u003e\u003cspan address=\"10.1007/s00415-021-10597-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrilciuc S, Grad DA, Radu C, Chira D, Stan A, Ungureanu M, et al. The economic burden of stroke: a systematic review of cost of illness studies. J Med Life. 2021;14(5):606\u0026ndash;19. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25122/jml-2021-0361\u003c/span\u003e\u003cspan address=\"10.25122/jml-2021-0361\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePandian JD, Gall SL, Kate MP, Silva GS, Akinyemi RO, Ovbiagele BI, et al. Prevention of stroke: a global perspective. Lancet. 2018;392(10154):1269\u0026ndash;78. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0140-6736(18)31269-8\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(18)31269-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBassetti CL. Sleep and stroke. Semin Neurol. 2005;25(1):19\u0026ndash;32. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-2005-867073\u003c/span\u003e\u003cspan address=\"10.1055/s-2005-867073\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang H, Sun J, Sun M, Liu N, Wang M. Relationship of sleep duration with the risk of stroke incidence and stroke mortality: an updated systematic review and dose-response meta-analysis of prospective cohort studies. Sleep Med. 2022;90:267\u0026ndash;78. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.sleep.2021.11.001\u003c/span\u003e\u003cspan address=\"10.1016/j.sleep.2021.11.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrwin MR, Olmstead R, Carroll JE. Sleep Disturbance, Sleep Duration, and Inflammation: A Systematic Review and Meta-Analysis of Cohort Studies and Experimental Sleep Deprivation. Biol Psychiatry. 2016;80(1):40\u0026ndash;52. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.biopsych.2015.05.014\u003c/span\u003e\u003cspan address=\"10.1016/j.biopsych.2015.05.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai C, Atanasov S. Long Sleep Duration and Stroke-Highly Linked, Poorly Understood. Neurol Int. 2023;15(3):764\u0026ndash;77. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/neurolint15030048\u003c/span\u003e\u003cspan address=\"10.3390/neurolint15030048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J, Cao D, Huang Y, Chen Z, Wang R, Dong Q, et al. Sleep duration and health outcomes: an umbrella review. Sleep Breath. 2022;26(3):1479\u0026ndash;501. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11325-021-02458-1\u003c/span\u003e\u003cspan address=\"10.1007/s11325-021-02458-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCappuccio FP, Cooper D, D'Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J. 2011;32(12):1484\u0026ndash;92. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurheartj/ehr007\u003c/span\u003e\u003cspan address=\"10.1093/eurheartj/ehr007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu F, Yang Y, Wang S, Zhang XL, Wang AX, Liao XL, et al. Impact of Sleep Duration on Depression and Anxiety After Acute Ischemic Stroke. Front Neurol. 2021;12:630638. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fneur.2021.630638\u003c/span\u003e\u003cspan address=\"10.3389/fneur.2021.630638\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDong L, Brown DL, Chervin RD, Case E, Morgenstern LB, Lisabeth LD. Pre-stroke sleep duration and post-stroke depression. Sleep Med. 2021;77:325\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.sleep.2020.04.025\u003c/span\u003e\u003cspan address=\"10.1016/j.sleep.2020.04.025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang K, Ji J, Zhang H, Sun Z, Shao Q, Xu W, et al. Association of sleep characteristics with stroke incidence and all-cause mortality: A cross-sectional study in the United States. J Stroke Cerebrovasc Dis. 2024;33(10):107918. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jstrokecerebrovasdis.2024.107918\u003c/span\u003e\u003cspan address=\"10.1016/j.jstrokecerebrovasdis.2024.107918\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSawadogo W, Adera T, Burch JB, Alattar M, Perera R, Howard VJ. Sleep duration and all-cause mortality among stroke survivors. J Stroke Cerebrovasc Dis. 2024;33(4):107615. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jstrokecerebrovasdis.2024.107615\u003c/span\u003e\u003cspan address=\"10.1016/j.jstrokecerebrovasdis.2024.107615\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMims KN, Kirsch D. Sleep and Stroke. Sleep Med Clin. 2016;11(1):39\u0026ndash;51. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jsmc.2015.10.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jsmc.2015.10.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcDermott M, Brown DL, Chervin RD. Sleep disorders and the risk of stroke. Expert Rev Neurother. 2018;18(7):523\u0026ndash;31. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14737175.2018.1489239\u003c/span\u003e\u003cspan address=\"10.1080/14737175.2018.1489239\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi C, Liu Y, Xu P, Fan Q, Gong P, Ding C, et al. Association between obstructive sleep apnea and risk of post-stroke depression: A hospital-based study in ischemic stroke patients. J Stroke Cerebrovasc Dis. 2020;29(8):104876. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jstrokecerebrovasdis.2020.104876\u003c/span\u003e\u003cspan address=\"10.1016/j.jstrokecerebrovasdis.2020.104876\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDharmakulaseelan L, Boulos MI. Sleep Apnea and Stroke: A Narrative Review. Chest. 2024. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.chest.2024.04.028\u003c/span\u003e\u003cspan address=\"10.1016/j.chest.2024.04.028\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFestic N, Alejos D, Bansal V, Mooney L, Fredrickson PA, Castillo PR, et al. Sleep Apnea in Patients Hospitalized With Acute Ischemic Stroke: Underrecognition and Associated Clinical Outcomes. J Clin Sleep Med. 2018;14(1):75\u0026ndash;80. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5664/jcsm.6884\u003c/span\u003e\u003cspan address=\"10.5664/jcsm.6884\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi C, Shang S. Relationship between Sleep and Hypertension: Findings from the NHANES (2007\u0026ndash;2014). Int J Environ Res Public Health. 2021;18(15). doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph18157867\u003c/span\u003e\u003cspan address=\"10.3390/ijerph18157867\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKadier K, Qin L, Ainiwaer A, Rehemuding R, Dilixiati D, Du YY, et al. Association of sleep-related disorders with cardiovascular disease among adults in the United States: A cross-sectional study based on national health and nutrition examination survey 2005\u0026ndash;2008. Front Cardiovasc Med. 2022;9:954238. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fcvm.2022.954238\u003c/span\u003e\u003cspan address=\"10.3389/fcvm.2022.954238\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMao Y, Weng J, Xie Q, Wu L, Xuan Y, Zhang J, et al. Association between dietary inflammatory index and Stroke in the US population: evidence from NHANES 1999\u0026ndash;2018. BMC Public Health. 2024;24(1):50. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-023-17556-w\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-17556-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrooks JM, Titus AJ, Bruce ML, Orzechowski NM, Mackenzie TA, Bartels SJ, et al. Depression and Handgrip Strength Among U.S. Adults Aged 60 Years and Older from NHANES 2011\u0026ndash;2014. J Nutr Health Aging. 2018;22(8):938\u0026ndash;43. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12603-018-1041-5\u003c/span\u003e\u003cspan address=\"10.1007/s12603-018-1041-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606\u0026ndash;13. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1046/j.1525-1497.2001.016009606.x\u003c/span\u003e\u003cspan address=\"10.1046/j.1525-1497.2001.016009606.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassani S, Ovbiagele B, Markovic D, Towfighi A. Association Between Abnormal Sleep Duration and Stroke in the United States. Neurology. 2024;103(7):e209807. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1212/wnl.0000000000209807\u003c/span\u003e\u003cspan address=\"10.1212/wnl.0000000000209807\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao Y, Zhao J, Xie R, Zhang Y, Xu Y, Mao J, et al. Association between family income to poverty ratio and HPV infection status among U.S. women aged 20 years and older: a study from NHANES 2003\u0026ndash;2016. Front Oncol. 2023;13:1265356. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fonc.2023.1265356\u003c/span\u003e\u003cspan address=\"10.3389/fonc.2023.1265356\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu S, Ji L, He Z, Zhang W, Tong Y, Luo J, et al. Association of smoking and osteoarthritis in US (NHANES 1999\u0026ndash;2018). Sci Rep. 2023;13(1):3911. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-023-30644-6\u003c/span\u003e\u003cspan address=\"10.1038/s41598-023-30644-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang M, Tang X, Wang P, Yang L, Du R. Association between daily alcohol consumption and serum alpha klotho levels among U.S. adults over 40 years old: a cross-sectional study. BMC Public Health. 2023;23(1):1901. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12889-023-16830-1\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-16830-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou L, Zhang J, Zhang D, Yu Y, Jiang M, Liu H, et al. Co-exposure to multiple vitamins and the risk of all-cause mortality in patients with diabetes. Front Endocrinol (Lausanne). 2023;14:1254133. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fendo.2023.1254133\u003c/span\u003e\u003cspan address=\"10.3389/fendo.2023.1254133\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Zeng L. Comparison of seven anthropometric indexes to predict hypertension plus hyperuricemia among U.S. adults. Front Endocrinol (Lausanne). 2024;15:1301543. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fendo.2024.1301543\u003c/span\u003e\u003cspan address=\"10.3389/fendo.2024.1301543\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang YM, Xia W, Ge YJ, Hou JH, Tan L, Xu W, et al. Sleep duration and risk of cardio-cerebrovascular disease: A dose-response meta-analysis of cohort studies comprising 3.8 million participants. Front Cardiovasc Med. 2022;9:907990. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fcvm.2022.907990\u003c/span\u003e\u003cspan address=\"10.3389/fcvm.2022.907990\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Ren X. Association Between Sleep Duration and Sleep Disorder Data from the National Health and Nutrition Examination Survey and Stroke Among Adults in the United States. Med Sci Monit. 2022;28:e936384. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12659/msm.936384\u003c/span\u003e\u003cspan address=\"10.12659/msm.936384\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAggarwal S, Loomba RS, Arora RR, Molnar J. Associations between sleep duration and prevalence of cardiovascular events. Clin Cardiol. 2013;36(11):671\u0026ndash;6. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/clc.22160\u003c/span\u003e\u003cspan address=\"10.1002/clc.22160\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhai L, Zhang H, Zhang D. SLEEP DURATION AND DEPRESSION AMONG ADULTS: A META-ANALYSIS OF PROSPECTIVE STUDIES. Depress Anxiety. 2015;32(9):664\u0026ndash;70. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/da.22386\u003c/span\u003e\u003cspan address=\"10.1002/da.22386\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeusgens CAV, van Tilburg DCH, Fleischeuer B, Bruijel J. The relation between insomnia and depression in the subacute phase after stroke. Neuropsychol Rehabil. 2024:1\u0026ndash;17. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/09602011.2024.2370072\u003c/span\u003e\u003cspan address=\"10.1080/09602011.2024.2370072\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang L, Tao Y, Chen Y, Wang H, Zhou H, Fu X. Association of post stroke depression with social factors, insomnia, and neurological status in Chinese elderly population. Neurol Sci. 2016;37(8):1305\u0026ndash;10. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10072-016-2590-1\u003c/span\u003e\u003cspan address=\"10.1007/s10072-016-2590-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCappuccio FP, D'Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep. 2010;33(5):585\u0026ndash;92. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/sleep/33.5.585\u003c/span\u003e\u003cspan address=\"10.1093/sleep/33.5.585\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwok CS, Kontopantelis E, Kuligowski G, Gray M, Muhyaldeen A, Gale CP, et al. Self-Reported Sleep Duration and Quality and Cardiovascular Disease and Mortality: A Dose-Response Meta-Analysis. J Am Heart Assoc. 2018;7(15):e008552. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/jaha.118.008552\u003c/span\u003e\u003cspan address=\"10.1161/jaha.118.008552\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Perdomo HA, Zapata-Copete J, Rojas-Cer\u0026oacute;n CA. Sleep duration and risk of all-cause mortality: a systematic review and meta-analysis. Epidemiol Psychiatr Sci. 2019;28(5):578\u0026ndash;88. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/s2045796018000379\u003c/span\u003e\u003cspan address=\"10.1017/s2045796018000379\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHale E, Gottlieb E, Usseglio J, Shechter A. Post-stroke sleep disturbance and recurrent cardiovascular and cerebrovascular events: A systematic review and meta-analysis. Sleep Med. 2023;104:29\u0026ndash;41. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.sleep.2023.02.019\u003c/span\u003e\u003cspan address=\"10.1016/j.sleep.2023.02.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S. Sleep Apnea and Cardiovascular Disease: Lessons From Recent Trials and Need for Team Science. Circulation. 2017;136(19):1840\u0026ndash;50. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/circulationaha.117.029400\u003c/span\u003e\u003cspan address=\"10.1161/circulationaha.117.029400\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"sleep duration, sleep disorders, stroke, post-stroke depression, mortality","lastPublishedDoi":"10.21203/rs.3.rs-5181770/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5181770/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSleep disturbance is a common concern among stroke survivors, yet the association of sleep duration and sleep disorders with post-stroke depression and all-cause and cardiovascular disease (CVD) mortality remains elusive. We aimed to explore these associations using data from the National Health and Nutrition Examination Survey (NHANES).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAdult stroke survivors from NHANES 2005\u0026ndash;2018 were included. Sleep information and stroke diagnoses were derived from self-reports on relevant questionnaires. Mortality data were collected by prospectively matching to the National Death Index. Multivariate logistic regression and Cox proportional hazards regression were used to explore these associations and calculate the odds ratio (OR) and hazard ratio (HR), respectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 1101 stroke participants were included. In the fully adjusted model, sleep disorders were associated with increased odds of post-stroke depression (OR 2.689, p\u0026thinsp;=\u0026thinsp;0.0146). Sleep duration was inversely associated with the odds of post-stroke depression; compared to normal sleep duration, short sleep duration was associated with increased odds of post-stroke depression (OR 2.196, p\u0026thinsp;=\u0026thinsp;0.0059), whereas long sleep duration was not (p\u0026thinsp;=\u0026thinsp;0.1435). Sleep disorders were associated with CVD mortality (HR of 1.948, p\u0026thinsp;=\u0026thinsp;0.026) but not all-cause mortality (p\u0026thinsp;=\u0026thinsp;0.224) in stroke survivors. Sleep duration was positively associated with all-cause mortality in stroke survivors (HR 1.075, p\u0026thinsp;=\u0026thinsp;0.042); however, neither short nor long sleep duration was associated with mortality compared to normal sleep duration. Restricted cubic spline modeling suggested that sleep duration was nonlinearly and linearly associated with post-stroke depression and all-cause mortality, respectively. Age influenced the association between sleep disorders and CVD mortality in stroke survivors.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSleep disorders and short sleep duration were associated with increased odds of post-stroke depression, whereas sleep disorders were associated with increased CVD mortality in stroke survivors. These findings underscore that achieving normal sleep duration and improving sleep disorders may reduce the odds of post-stroke depression and mortality.\u003c/p\u003e","manuscriptTitle":"Association of sleep duration and sleep disorders with post-stroke depression and all-cause and cardiovascular disease mortality in US stroke survivors: Results from NHANES 2005-2018","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 05:26:33","doi":"10.21203/rs.3.rs-5181770/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-03T19:50:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-03T19:18:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74631644839802376350638838902471857341","date":"2024-11-27T14:08:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-26T19:22:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19056132008536109220955882219380280420","date":"2024-11-19T15:35:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258998794678019308159314225588771240016","date":"2024-10-10T16:32:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-08T16:19:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-04T09:08:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-01T08:32:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2024-09-30T14:39:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0eade381-7cde-4ad4-b525-4672adb8e665","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T16:05:22+00:00","versionOfRecord":{"articleIdentity":"rs-5181770","link":"https://doi.org/10.1186/s40001-024-02227-2","journal":{"identity":"european-journal-of-medical-research","isVorOnly":false,"title":"European Journal of Medical Research"},"publishedOn":"2025-01-03 15:57:26","publishedOnDateReadable":"January 3rd, 2025"},"versionCreatedAt":"2024-12-16 05:26:33","video":"","vorDoi":"10.1186/s40001-024-02227-2","vorDoiUrl":"https://doi.org/10.1186/s40001-024-02227-2","workflowStages":[]},"version":"v1","identity":"rs-5181770","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5181770","identity":"rs-5181770","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}