Safety and efficacy of fluoxetine on functional outcome after acute stroke (AFFINITY): a randomised, double-blind, placebo-controlled trial

Background Trials of fluoxetine for recovery after stroke report conflicting results. The Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) trial aimed to show if daily oral fluoxetine for 6 months after stroke improves functional outcome in an ethnically diverse population. Methods AFFINITY was a randomised, parallel-group, double-blind, placebo-controlled trial done in 43 hospital stroke units in Australia (n=29), New Zealand (four), and Vietnam (ten). Eligible patients were adults (aged ≥18 years) with a clinical diagnosis of acute stroke in the previous 2–15 days, brain imaging consistent with ischaemic or haemorrhagic stroke, and a persisting neurological deficit that produced a modified Rankin Scale (mRS) score of 1 or more. Patients were randomly assigned 1:1 via a web-based system using a minimisation algorithm to once daily, oral fluoxetine 20 mg capsules or matching placebo for 6 months. Patients, carers, investigators, and outcome assessors were masked to the treatment allocation. The primary outcome was functional status, measured by the mRS, at 6 months. The primary analysis was an ordinal logistic regression of the mRS at 6 months, adjusted for minimisation variables. Primary and safety analyses were done according to the patient's treatment allocation. The trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12611000774921. Findings Between Jan 11, 2013, and June 30, 2019, 1280 patients were recruited in Australia (n=532), New Zealand (n=42), and Vietnam (n=706), of whom 642 were randomly assigned to fluoxetine and 638 were randomly assigned to placebo. Mean duration of trial treatment was 167 days (SD 48·1). At 6 months, mRS data were available in 624 (97%) patients in the fluoxetine group and 632 (99%) in the placebo group. The distribution of mRS categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio 0·94, 95% CI 0·76–1·15; p=0·53). Compared with patients in the placebo group, patients in the fluoxetine group had more falls (20 [3%] vs seven [1%]; p=0·018), bone fractures (19 [3%] vs six [1%]; p=0·014), and epileptic seizures (ten [2%] vs two [<1%]; p=0·038) at 6 months. Interpretation Oral fluoxetine 20 mg daily for 6 months after acute stroke did not improve functional outcome and increased the risk of falls, bone fractures, and epileptic seizures. These results do not support the use of fluoxetine to improve functional outcome after stroke

Spectrum of MECP2 mutations in Vietnamese patients with RETT syndrome

Abstract Background Rett syndrome (RTT) is a severe neurodevelopmental disorder in children characterized by a normal neurodevelopmental process in the first 6–18 months followed by a period of motor and vocal deterioration with stereotypic hand movements. Incidence of RTT is mostly due to de novo mutation in the MECP2 gene (methyl-CpG-binding protein 2). Methods The study assessed 27 female patients presented with classical RTT phenotype age range from 18 months to 48 months. Specialist carried out the clinical evaluation and diagnosis according to RTT diagnosis criteria. Blood samples from patients were then collected for genomic DNA extraction. We next performed MECP2 gene amplification and sequencing of the whole coding region to screen for mutations. Result MECP2 mutation was found in 20 patients (74%) including: 2 missense, 4 nonsense, 6 frameshift and 2 deletion mutation. The study identified 14 pathogenic mutations which we found 4 mutation, to our knowledge and extensive search, not priory reported in any mutation database or publication: c.1384-1385DelGT, c.1205insT, c.717delC and c.1132_1207del77. High percentage of C > T (70%) in CpG sites mutation was found. Conclusion Our result reveals a high percentage of C > T mutation in CpG hot spot, which is more prone to modification and more likely to be detected in RTT as a disorder is strictly due to de novo mutations. The study is the first to identify the mutation spectrum of MECP2 gene in Vietnamese patients and also an important step toward better diagnosis and care for RTT patients in Vietnam

Hepatitis C virus in Vietnam: high prevalence of infection in dialysis and multi-transfused patients involving diverse and novel virus variants.

Hepatitis C virus (HCV) is a genetically diverse pathogen infecting approximately 2-3% of the world's population. Herein, we describe results of a large, multicentre serological and molecular epidemiological study cataloguing the prevalence and genetic diversity of HCV in five regions of Vietnam; Ha Noi, Hai Phong, Da Nang, Khanh Hoa and Can Tho. Individuals (n=8654) with varying risk factors for infection were analysed for the presence of HCV Ab/Ag and, in a subset of positive specimens, for HCV RNA levels (n=475) and genotype (n=282). In lower risk individuals, including voluntary blood donors, military recruits and pregnant women, the prevalence of infection was 0.5% (n=26/5250). Prevalence rates were significantly higher (p<0.001) in intravenous drug users (IDUs; 55.6%, n=556/1000), dialysis patients (26.6%, n=153/575) commercial sex workers (CSWs; 8.7%, n=87/1000), and recipients of multiple blood transfusions (6.0%, n=32/529). The prevalence of HCV in dialysis patients varied but remained high in all regions (11-43%) and was associated with the receipt of blood transfusions [OR: 2.08 (1.85-2.34), p=0.001], time from first transfusion [OR: 1.07 (1.01-1.13), p=0.023], duration of dialysis [OR: 1.31 (1.19-1.43), p<0.001] and male gender [OR: 1.60 (1.06-2.41), p=0.026]. Phylogenetic analysis revealed high genetic diversity, particularly amongst dialysis and multi-transfused patients, identifying subtypes 1a (33%), 1b (27%), 2a (0.4%), 3a (0.7%), 3b (1.1%), 6a (18.8%), 6e (6.0%), 6h (4.6%), 6l (6.4%) and 2 clusters of novel genotype 6 variants (2.1%). HCV genotype 1 predominated in Vietnam (60%, n=169/282) but the proportion of infections attributable to genotype 1 varied between regions and risk groups and, in the Southern part of Vietnam, genotype 6 viruses dominated in dialysis and multi-transfused patients (73.9%). This study confirms a high prevalence of HCV infection in Vietnamese IDUs and, notably, reveals high levels of HCV infection associated with dialysis and blood transfusion

Molecular Characterisation of HCV Genotypes in Vietnamese Dialysis and Multi-transfused Patients.

<p>Analysis of HCV patient (n = 113) and reference sequences was performed on a 329-bp fragment of the HCV <i>NS5B</i> gene (nucleotides 8282–8610, numbering based on H77). A neighbour joining tree was constructed using the Kimura-2-parameter model of evolution with gamma distribution and a proportion of invariable sites. Bootstrap values over 70% are shown at the respective nodes. The scale bar indicates an evolutionary distance of 0.1 nucleotide substitutions per site. Reference sequences are annotated with their confirmed genotype and subtype, country of isolation where known and Genbank accession number. Sequences from dialysis and multi-transfused patients are represented in colour, differing by location - red for Ha Noi, orange for Hai Phong, purple for Da Nang, blue for Khanh Hoa and green for Can Tho. Open triangles are used to denote sequences from dialysis patients, open circles are used to denote sequences from multi-transfused patients and filled squares are used where a patient fits both of these criteria. Brackets select the subtypes in which sequences were identified in this study. Two unassigned groups of sequences were identified – a group of sequences obtained from four dialysis patients in Can Tho and sequences obtained from two multi transfused patients in Khanh Hoa and these are labelled as unclassified groups 1 and 2. For 6 additional specimens, 6a genotypes (5 Ha Noi and 1 Can Tho) were identified by <i>core/E1</i> sequencing.</p

Seroepidemiology of HCV in Dialysis Patients.

<p>This figure depicts HCV prevalence in relation to duration of dialysis in years. Increased duration of dialysis is strongly associated with an increase in HCV infection (<i>p</i><0.001).</p

Phylogenetic Analysis of the HCV <i>NS5B</i> Gene.

<p>Vietnamese HCV gene sequences from the present study (n = 259 <i>NS5B</i>) are presented with reference sequences (n = 74) downloaded from the Los Alamos database. Analysis was based on a 329-bp of the HCV <i>NS5B</i> gene (nucleotides 8282–8610 relative to H77 NC004102). “A” depicts a midpoint rooted radial phylogenetic tree constructed using the neighbour joining distance method under a Kimura-2-paramter model of evolution. Bootstrap values >70% were obtained for all major nodes separating the confirmed genotypes (not shown). The scale bar indicates an evolutionary distance of 0.08 nucleotide substitutions per site. Branches and annotations are colour coded for all HCV subtypes identified in this study, with reference sequences shown in black. Sequences are annotated by the study cohort from which they were obtained, namely: IDU, intravenous drug user; SW, commercial sex worker; DIA, dialysis patient; MT, multi-transfused patient; ES, elective surgery patient; MR, military recruit. Reference sequences are annotated by subtype name. “B” represents all obtained HCV genotypes/subtypes in the varying risk groups. In total, genotypes were identified for 282 specimens - 201 based on both the <i>NS5B</i> and <i>core/E1</i> regions, 58 from the <i>NS5B</i> region alone and 23 from the <i>core/E1</i> region only. Genbank accession numbers are JX102664–JX103137.</p

Seroepidemiology of HCV in 8 Different Vietnamese Risk Groups, n = 8654.

<p>The total percentage of HCV Ab/Ag positives in each population group is shown at the end of each bar. The number of samples tested from each group is listed below. 59.7% of CSWs testing positive for HCV also reported intravenous drug use.</p

Maximum Likelihood Phylogenetic Analysis of Novel HCV Genotype 6 Sequences in both <i>NS5B</i> and <i>core/E1</i> Genes.

<p>HCV sequences identified in this study (coloured and marked by brackets) and reference sequences for all currently recognised subtypes of HCV genotype 6 are analysed with A) a 329-bp fragment of the HCV <i>NS5B</i> gene corresponding to nucleotides 8282 to 8610 of the H77 strain and B) a 446-bp fragment of the HCV <i>core</i> and <i>E1</i> genes corresponding to nucleotides 860 to 1305 of the H77 strain. Rooted trees were constructed using submodels of the general time reversible (GTR) model, a gamma distribution and a proportion of invariant sites. Bootstrap values over 70% are shown on the corresponding branches. Scale bar indicates an evolutionary distance of 0.2 substitutions per site. “Unassigned group 1” sequences were obtained from 4 dialysis patients in Can Tho and the sequences in unassigned group 2 were from multi-transfused patients in Khanh Hoa.</p