Wake-up ischemic stroke associated with short sleep duration and sleep behavior: A stratified analysis according to risk of obstructive sleep apnea

OBJECTIVE

Wake-up stroke (WUS) is an ischemic stroke occurring during nocturnal sleep with neurological deficits observed upon awakening. Our study aimed to investigate the association between WUS, sleep curtailment, and sleep behavior according to the obstructive sleep apnea (OSA) risk in patients with acute ischemic stroke.

METHODS

This single-centered, retrospective study included hospitalized subjects with acute ischemic stroke occurring within 30 days. A total of 250 participants were classified as WUS or not and enquired about their sleep habits concerning sleep time on weekdays and weekends, demographic factors, and assessed comorbid medical conditions. Weekend catch-up sleep (CUS) was defined as the extension of sleep duration during weekends. The average weekly sleep duration and chronotype were assessed. The association between WUS and sleep factors was analyzed.

RESULTS

WUS was observed in 70 patients (28.0%) with acute ischemic stroke. There were no significant differences in the demographic and stroke-related variables between the WUS and non-WUS (NWUS) groups. Upon stratified analysis based on risk of OSA, average weekly sleep duration (odds ratio, [OR] = 0.60, 95% confidence interval, [CI] = 0.41-0.89; p = 0.011), the presence of weekend CUS (OR = 0.07, 95% CI = 0.01-0.97; p = 0.047), and chronotype (OR = 0.62, 95% CI = 0.39-0.98; p = 0.041) were independently associated with WUS in low-risk group with OSA, but not in the high-risk group.

CONCLUSIONS

Short sleep duration and lack of compensation are significantly associated with WUS in low-risk OSA group. Insufficient sleep and sleep behaviors could play a different role in causing ischemic stroke during sleep when patients are stratified by their risk of sleep apnea.

Quantitative electroencephalographic analysis of delirium tremens development following alcohol-withdrawal seizure based on a small number of male cases

INTRODUCTION

Seizures and delirium tremens (DTs) are recognized as severe alcohol-withdrawal symptoms. Prolonged admission and serious complications associated with alcohol withdrawal are responsible for increased costs and use of medical and social resources. This study investigated the predictive value of quantitative electroencephalography (QEEG) for developing alcohol-related DTs after alcohol-withdrawal seizure (AWS).

METHODS

We compared differences in QEEG in patients after AWS (n = 13). QEEG was performed in the intensive care unit within 48 h of admission, including in age- and sex-matched healthy controls. We also investigated the prognostic value of QEEG for the development of alcohol DTs after AWS in a retrospective, case-control study. The spectral power of each band frequency and the ratio of the theta to alpha band (TAR) in the electroencephalogram were analyzed using iSyncBrain^® (iMediSync, Inc., Korea).

RESULTS

The beta frequency and the alpha frequency band power were significantly higher and lower, respectively, in patients than in age- and sex-matched healthy controls. In AWS patients with DTs, the relative beta-3 power was lower, particularly in the left frontal area, and the TAR was significantly higher in the central channel than in those without DTs.

CONCLUSION

Quantitative EEG showed neuronal excitability and decreased cognitive activities characteristic of AWS associated with alcohol-withdrawal state, and we demonstrated that quantitative EEG might be a helpful tool for detecting patients at a high risk of developing DTs during an alcohol-dependence period.

Real-world experience with 240 mg of galcanezumab for the preventive treatment of cluster headache

Background

Galcanezumab of 300 mg monthly is the FDA approved preventive medication for cluster headache (CH) during the cluster period. Compared to the 120 mg galcanezumab syringe for the treatment of migraines, the 100 mg syringe for CH has globally not been as widely available. The aim of our study was to investigate the preventive efficacy and tolerability of two 120 mg galcanezumab doses for episodic CH in clinical practices.

Methods

We evaluated patients with CH who received at least 1 dose of 240 mg (2 prefilled syringe of 120 mg) of galcanezumab in the 3 university hospitals from February 2020 to September 2021. In the patients with episodic CH, the efficacy and safety data of galcanezumab were analyzed regarding to the presence of the conventional preventive therapy at the timing of therapy of galcanezumab. The data of other subtypes of CH were separately described.

Results

In 47 patients with episodic CH, galcanezumab was started median 18 days after the onset of current bout (range 1–62 days) and 4 patients (10.8%) received second dose of galcanezumab. The median time to the first occurrence of 100% reduction from baseline in CH attacks per week after galcanezumab therapy was 17 days (25% to 75% quartile range: 5.0 ~ 29.5) in all patients with episodic CH, 15.5 days (3.8 ~ 22.1) in 36 patients with galcanezumab therapy add-on conventional preventive therapy, 21.0 days (12.0 ~ 31.5) in 11 patients started galcanezumab as initial preventive therapy. Among 33 patients with headache diary, the proportion of patients with 50% or more reduction in weekly CH attacks at week 3 from baseline were 78.8%. There was no significant difference in the proportion of patients with a reduction of at least 50% in weekly frequency of CH attacks at week 3 between 24 patients received galcanezumab therapy add-on conventional preventive therapy and 9 patient who received initial galcanezumab therapy. (83.3%, vs 66.7%, p = 0.36). There were no significant differences in proportion of “very much better or “much better” between 36 patients received galcanezumab therapy add-on conventional preventive therapy and 11 patient who received initial GT (86.1%, vs 63.6%, p = 0.18).

Conclusion

One 240 mg dose of galcanezumab with/without conventional therapy for the prevention of CH is considered effective and safe in clinical practices, as seen in the clinical trial of galcanezumab.

Oxygen Therapy in Cluster Headache, Migraine, and Other Headache Disorders

Oxygen therapy (OT) can relieve head pain in certain primary headache disorders, including cluster headache (CH). The exact underlying mechanism is currently uncertain, but suggested mechanisms include inhibition of the trigeminoautonomic reflex, modulation of neurotransmitters, and cerebral vasoconstriction. OT is the standard for acute treatment of CH, but patients with CH often experience considerable difficulties accessing home OT due to problems with insurance coverage. Inhalation of 100% oxygen at 6–12 L/min for 15–30 min using a non-rebreather face mask is one of the most effective acute therapies for CH, but several trials have indicated the superiority of higher oxygen flow rates of up to 15 L/min and/or using a demand-valve oxygen mask that can produce very high flow rates. Two randomized controlled trials have demonstrated the efficacy of OT in migraine, but obtaining reliable evidence is considered difficult because of different inhalation protocols, varying outcome measures, and small samples. There are some reports on the efficacy of OT as an adjuvant therapy in hypnic headache, primary headache in the emergency department, and even postdural puncture headache. The goal of this review article is to expand the knowledge regarding the use of oxygen in the treatment of headache disorders.

Myelin Oligodendrocyte Glycoprotein-Immunoglobulin G in the CSF: Clinical Implication of Testing and Association With Disability

Background and Objective

To investigate the clinical relevance of CSF myelin oligodendrocyte glycoprotein-immunoglobulin G (MOG-IgG) testing in a large multicenter cohort.

Methods

In this multicenter cohort study, paired serum-CSF samples from 474 patients with suspected inflammatory demyelinating disease (IDD) from 11 referral hospitals were included. After serum screening, patients were grouped into seropositive myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD, 31), aquaporin-4-IgG-positive neuromyelitis optica spectrum disorder (AQP4-IgG + NMOSD, 60), other IDDs (217), multiple sclerosis (MS, 45), and non-IDDs (121). We then screened CSF for MOG-IgG and compared the clinical and serologic characteristics of patients uniquely positive for MOG-IgG in the CSF to seropositive patients with MOGAD.

Results

Nineteen patients with seropositive MOGAD (61.3%), 9 with other IDDs (CSF MOG + IDD, 4.1%), 4 with MS (8.9%), but none with AQP4-IgG + NMOSD nor with non-IDDs tested positive in the CSF for MOG-IgG. The clinical, pathologic, and prognostic features of patients uniquely positive for CSF MOG-IgG, with a non-MS phenotype, were comparable with those of seropositive MOGAD. Intrathecal MOG-IgG synthesis, observed from the onset of disease, was shown in 12 patients: 4 of 28 who were seropositive and 8 who were uniquely CSF positive, all of whom had involvement of either brain or spinal cord. Both CSF MOG-IgG titer and corrected CSF/serum MOG-IgG index, but not serum MOG-IgG titer, were associated with disability, CSF pleocytosis, and level of CSF proteins.

Discussion

CSF MOG-IgG is found in IDD other than MS and also in MS. In IDD other than MS, the CSF MOG-IgG positivity can support the diagnosis of MOGAD. The synthesis of MOG-IgG in the CNS of patients with MOGAD can be detected from the onset of the disease and is associated with the severity of the disease.

Classification of Evidence

This study provides Class II evidence that the presence of CSF MOG-IgG can improve the diagnosis of MOGAD in the absence of an MS phenotype, and intrathecal synthesis of MOG-IgG was associated with increased disability.

Predicting Functional Outcome Based on Linked Data After Acute Ischemic Stroke: S-SMART Score

Prediction of outcome after stroke may help clinicians provide effective management and plan long-term care. We aimed to develop and validate a score for predicting good functional outcome available for hospitals after ischemic stroke using linked data. A total of 22,005 patients with acute ischemic stroke from the Clinical Research Center for Stroke Registry between July 2007 and December 2014 were included in the derivation group. We assessed functional outcomes using a modified Rankin scale (mRS) score at 3 months after ischemic stroke. We identified predictors related to good 3-month outcome (mRS score ≤ 2) and developed a score. External validations (geographic and temporal validations) of the developed model were performed. The prediction model performance was assessed using the area under the receiver operating characteristic curve (AUC) and the calibration test. Stroke severity, sex, stroke mechanism, age, pre-stroke mRS, and thrombolysis/thrombectomy treatment were identified as predictors for 3-month good functional outcomes in the S-SMART score (total 34 points). Patients with higher S-SMART scores had an increased likelihood of a good outcome. The AUC of the prediction score was 0.805 (0.798-0.811) in the derivation group and 0.812 (0.795-0.830) in the geographic validation group for good functional outcome. The AUC of the model was 0.812 (0.771-0.854) for the temporal validation group. Moreover, they had good calibration. The S-SMART score is a valid and useful tool to predict good functional outcome following ischemic stroke. This prediction model may assist in the estimation of outcomes to determine care plans after stroke.

Abstract TP206: Effects of Smoking Status on the Onset Age of the First-Ever Stroke: Data From Korean Stroke Registry

Background: There is evidence that smoking increases stroke risk. However, the impact of smoking status on age at onset of ischemic stroke has not been studied. The aim of this study is to explore the effect of smoking status on the age at onset of first-ever ischemic stroke using the Korean Stroke Registry(KSR), the nation-wide, multicenter, hospital-based stroke registry in Republic of Korea.

Methods: This study used individual data of first-ever ischemic stroke patients from the KSR, between 2014 and 2018. We divided the patients into four groups according to their smoking status; current smokers, past-smokers - quit in recent 5 years, past smokers - quit over than 5 years, and never-smokers.

Results: A total of 27,942 patients were included in the analysis. The mean age at onset of the first-ever stroke were 60.0±11.9 in current smokers, 65.9±11.9 past-smokers - quit in recent 5 years, 70.1±10.8 in past smoker - quit over than 5 years, and 70.5±12.8 in never-smokers (p<0.001). In the stroke subtypes analysis, the mean age at onset of the first-ever stroke were 60.9±12.5, 66.7±11.2, 70.7±10.8, and 71.1±11.9 in large artery atherosclerosis group, 58.8±10.8, 63.8±11.1, 68.2±10.4, and 68.6±12.0 in small vessel occlusion group, and 64.1±11.9, 67.7±11.6, 71.8±10.3, and 73.8±11.4 in cardioembolism group, respectively (all p<0.001).

Conclusions: The smoking status of patients was associated with an earlier onset age of the first-ever stroke. The onset age tends to be delayed with the longer duration of cessation period.

Characteristics and management of stroke in Korea: 2014–2018 data from Korean Stroke Registry

Background

Lifestyle changes and evolving healthcare practices in Korea have influenced disease patterns and medical care. Since strokes have high disease burden in countries with aging populations, it is necessary to evaluate the associated recent disease characteristics and patient care patterns. The Korean Stroke Registry is a nationwide, multicenter, prospective, hospital-based stroke registry in Korea used to monitor these changes across the population.

Aims

We aimed to evaluate the recent status of clinical characteristics and management of stroke cases in order to identify changes in the Korean population across time.

Methods

This study used Korean Stroke Registry data from patients experiencing ischemic stroke or transient ischemic attack patients, between 2014 and 2018. We analyzed data on demographics, risk factors, stroke subtypes, and treatments that included thrombolysis.

Results

A total of 39,291 patients (mean age 68.0 ± 13.0, 58.3% male) were analyzed. The proportions of hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, and prior stroke were 63.4%, 30.9%, 27.7%, 19.4%, and 17.1%, respectively. In the stroke subtype analysis, the frequency of large artery atherosclerosis was highest (32.6%), followed by cardioembolism (21.3%) and small vessel occlusion (19.9%). Acute reperfusion therapy was conducted in 15.3% of cases (11.7% using intravenous tPA and 7.3% using intra-arterial thrombectomy). Intra-arterial thrombectomy also demonstrated a steep increasing trend over time (RR 1.095 (1.060–1.131), p < 0.001).

Conclusions

This study provided analysis of nationwide, hospital-based, quality-controlled data from the Korean Stroke Registry database regarding changes in the characteristics, risk factors, and treatments of strokes in Korea.

Acute Ischemic Stroke Mimicking Non-Convulsive Status Epilepticus

Status epilepticus and stroke are occasionally characterized by indistinguishable symptoms. Diffusion-weighted imaging (DWI) could not only help differentiating seizure from stroke, but also assist in localizing a focus of seizure and reflect resolution of seizure. We report a case of non-convulsive status epilepticus that presented as acute ischemic stroke, mimicking the latter's clinical manifestations. A 77-year-old right-handed man visited the emergency room with complaints of impaired awareness and fluency with right hemiparesis. Moreover, he presented with first-onset focal to bilateral tonic-clonic seizure with eyeball deviation to the right for 1 minute. Magnetic resonance imaging showed hyperintensity on DWI with a reduced apparent diffusion coefficient (ADC) value in the left pulvinar and left temporo-occipital areas. However, eyeball deviation to the right was not matched with left hemispheric stroke. Electroencephalography (EEG) confirmed ictal discharges in the left temporal area, which were compatible with impaired awareness, ictal aphasia, and eyeball deviation to the right. In cases of conflicting results from neurological examination and DWI/ADC findings, clinicians should consider employing EEG for diagnosing and treating non-convulsive status epilepticus.

Abstract P5-04-09: Not presented

This abstract was not presented at the conference.

Citation Format: Mo H, Wang X, Qian Z, Xu B, Ma F. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-04-09.

Abstract WP552: Post-stroke Dementia Incidence and Risk Factors in Korea: Linked Big Data Between the Clinical Research Center for Stroke Data and the Health Insurance Review & Assessment Service Data Analysis

Background: Post-stroke dementia is an important factor of poor functional outcome following stroke. However, few longitudinal studies on the incidence and risk factors of dementia after stroke have been performed.

Hypothesis: We aimed to investigate the incidence and clinical factors related to dementia after ischemic stroke.

Methods: A total of 47,779 patients with acute ischemic stroke (within 7 days after stroke onset) were enrolled, who were registered in the Clinical Research Center for Stroke (CRCS) registry from 2006 to 2014 and successfully linked the Health Insurance Review and Assessment Service (HIRA) big database. All included patients did not have dementia before index stroke. The incidence of post-stroke dementia was identified using International Classification of Diseases, Tenth Revision, dementia diagnosis codes (F00, F01, F02, F03, and G30) with prescription of an anti-dementia medications after index stroke based on linked big data.

Results: Of the 47,779 patients, 10,357 patients (21.7%) had post-stroke dementia. The cumulative incidence of dementia after stroke was 10.4% after 1 year, 15.6 % after 3 years, 19.5% after 5 years, 22.9% after 7 years, and 27.1% after 10 years. The crude incidence rate of post-stroke dementia was 40.03 cases per 1000 person-years in this stroke registry based linkage big data. Post-stroke dementia groups were older, more frequently female, and were more likely to have severe stroke, history of stroke, lower education level, dependency before stroke.

Conclusions: Our study demonstrated that about 22% of ischemic stroke patients were demented after stroke, particularly were associated with history of stroke, and stroke severity. These patients with high risk of dementia should be controlled risk factors for preventing cognitive impairment following stroke.

Abstract TMP59: Recent Trends of Stroke Characteristics and Treatment in Korea: Data From Korean Stroke Registry

Introduction: Dynamic changes in lifestyle or healthcare system due to industrialization lead to changes in the pattern of disease. This study investigates the recent trends of acute ischemic stroke characteristics and treatment in Korea, a rapidly developed country.

Methods: We analyzed individual data of ischemic stroke and transient ischemic attack patients from the Korean Stroke Registry (KSR), a nationwide hospital-based stroke database, between August 2014 and May 2018 (2nd generation KSR). We collected demographic data, risk factors, treatment including thrombolysis, and stroke subtypes. Linear or log-linear Poisson regression analyses were performed to assess the changes. Finally, we compared this data from January 2002 to November 2010 (1st generation KSR).

Results: A total 39,291 patients of 2nd generation KSR were included in the analysis. The mean±SD age was 68.0±13.0 years, and 58.3% of the patients were male. Over the 5-year period, the mean age of the patients steadily increased by 0.21 year annually (p<0.001). Proportions of hypertension and diabetes remained stable, but frequency of dyslipidemia increased and prior stroke decreased. Proportion of intravenous thrombolysis remained stable (p=0.147), but intra-arterial thrombectomy increased (p<0.001). Relative proportions of stroke subtypes over the 5 years, small vessel occlusion increased, cardioembolism decreased, and large artery atherosclerosis remained stable. Compared with 46,098 patients of 1st generation KSR, the proportion of arrival within 3 hours increased from 25.6% to 33.9%, and any reperfusion therapy increased 6.8% to 15.3%, especially intravenous thrombolysis increased 5.6% to 11.7%. The proportions of stroke subtype also considerably changed compared with 1st generation KSR (large artery atherosclerosis; 36.1% to 32.6%; cardioembolism; 25.4% to 19.9%; small vessel occlusion; 17.1% to 21.3%).

Conclusions: Stroke characteristics in Korea changed during the first two decades of 21st century. It is likely because of increased lifespan, westernized lifestyle, changed treatment modality and improved public awareness.

Abstract TP386: The Risk Score to Predict Functional Outcome Following Acute Ischemic Stroke Based on the Linked Big Data between theClinical Research Center for Stroke Data and the Health Insurance Review and Assessment Service Data

Introduction: Prediction of outcome after stroke may help clinicians provide effective stroke management and plan long-term care for patients.

Hypothesis: We aimed to develop and validate a risk score for predicting functional outcome available at hospital after ischemic stroke using linked big data.

Methods: A total of 24,907 cases with acute ischemic stroke (within 7 days after onset) were enrolled, who were registered in the Clinical Research Center for Stroke (CRCS) registry from 2006 to 2014 and successfully linked the Health Insurance Review and Assessment Service (HIRA) database. Among them, 22,005 cases were derivation and internal validation group, and 2,902 cases were external validation group. We assessed the functional outcome using a modified Rankin Scale (mRS) at 3-month after onset ischemic stroke. We evaluated the predictive value of variables associated with the favorable 3-month outcome (mRS ≤ 2) and developed the score using the logistic regression coefficients. The prediction model performance was assessed by the area under the receiver-operating characteristic curve (AUC).

Results: Proportion of cases with favorable outcome were 67.0% (n=14,748) in the derivation and internal validation group, and 68.4% (n=1,986) in the external validation group. Multivariable predictors of functional outcome at 3-month included age, gender, stroke severity, body mass index, stroke subtype, previous functional status, recanalization treatment, pre-stroke antiplatelet or anticoagulation therapy, fasting glucose level, history of stroke, hyperlipidemia, diabetes mellitus, hypertension, congestive heart failure, kidney disease on dialysis, cancer before the stroke. The AUC of the prediction model was 0.855 (0.850 - 0.860) in the derivation group and 0.854 (0.849 - 0.860) in the internal validation group for 3-month functional outcome. In addition, the AUC of the model was 0.860 (0.846 - 0.874) in the external validation group for outcome at 3-month.

Conclusions: This prediction of functional outcome model is a valid clinical tool to predict functional outcome following ischemic stroke and reliable externally. This prediction model may assist to estimate functional outcome after stroke and to decide the care plan after stroke.

Abstract WP253: Cystatin C and the Risk of Cardioembolic Stroke in Patients Without Chronic Kidney Disease

Background and Objectives: Atrial fibrillation (AF) is well-established risk factor for cardioembolic stroke. Epidemiological evidence indicates that there is increased risk of AF with chronic kidney disease (CKD) and impaired renal function. Cystatin C (Cys-C) is now considered as a specific marker for detection of renal impairment. However, there are no data about the potential association of Cys-C with AF and cardioembolic stroke in the subjects without evident CKD. We investigated whether serum Cys-C level is associated with development of cardioembolic stroke in patients with AF.

Methods: Consecutive data were collected retrospectively at the Seoul National University Hospital (SNUH). Patients with ischemic stroke with subtypes of large artery atherosclerosis, small vessel occlusion and cardioembolism who admitted at the SNUH between November 2014 and November 2017 were screened. We excluded the patient who have a history of secondary hypertension, CKD (estimated glomerular filtration rate < 60 mL/min/1.73 m 2 ), valvular heart disease, congenital heart disease, dilated or hypertrophy cardiomyopathy and thyroid disease.

Results: Among the total 627 patients, 61.8% were male, with a mean age of 67.9 years. Compared to the other stroke mechanisms, a stepwise logistic regression analysis showed that AF was independently associated with size of left atrium (OR, 1.196, 95% CI: 1.160-1.266), initial stroke severity (NIH Stroke Scale) (OR, 1.126, 95% CI: 1.083-1.189), and Cys-C (OR, 2.472, 95% CI: 1.255-15.129), but not with eGFR (OR 0.993, 95% CI: 0.977-1.009).

Conclusion: Cys-C is a superior predictor for cardioembolic stroke due to AF in patients without evident CKD.

Building Linked Big Data for Stroke in Korea: Linkage of Stroke Registry and National Health Insurance Claims Data

BACKGROUND

Linkage of public healthcare data is useful in stroke research because patients may visit different sectors of the health system before, during, and after stroke. Therefore, we aimed to establish high-quality big data on stroke in Korea by linking acute stroke registry and national health claim databases.

METHODS

Acute stroke patients (n = 65,311) with claim data suitable for linkage were included in the Clinical Research Center for Stroke (CRCS) registry during 2006-2014. We linked the CRCS registry with national health claim databases in the Health Insurance Review and Assessment Service (HIRA). Linkage was performed using 6 common variables: birth date, gender, provider identification, receiving year and number, and statement serial number in the benefit claim statement. For matched records, linkage accuracy was evaluated using differences between hospital visiting date in the CRCS registry and the commencement date for health insurance care in HIRA.

RESULTS

Of 65,311 CRCS cases, 64,634 were matched to HIRA cases (match rate, 99.0%). The proportion of true matches was 94.4% (n = 61,017) in the matched data. Among true matches (mean age 66.4 years; men 58.4%), the median National Institutes of Health Stroke Scale score was 3 (interquartile range 1-7). When comparing baseline characteristics between true matches and false matches, no substantial difference was observed for any variable.

CONCLUSION

We could establish big data on stroke by linking CRCS registry and HIRA records, using claims data without personal identifiers. We plan to conduct national stroke research and improve stroke care using the linked big database.

[A multi-center cross-sectional survey of medicine application in patients with osteoarthritis in China]

OBJECTIVE

To investigate the clinical characteristics, the medicine application and to evaluate the disease activity in patients with osteoarthritis (OA) in China.

METHODS

This was a cross-sectional study. Totally 1 066 cases of OA from 40 hospitals in China from April to October 2017 were retrospectively enrolled. Demographic characteristics, clinical data, medicine application, and joint function were evaluated. All the data were analyzed by SPSS software 19.0. t test, Mann-Whitney U test and chi-square test were used for statistical analysis.

RESULTS

In the 1 066 cases, the male-to-female ratio was 1:3.6 and the average age was (61.9±11.0) years, with an age range from 36 to 94 years. The incidence of knee OA, hip OA, and hand OA were respectively 81.9% (873/1 066), 14.1% (150/1 066), and 36.3% (387/1 066). In the study, 242 (22.7%) cases had two kinds of joint areas involved and three joint areas were involved in 51 cases (4.8%), and 56.6% (603/1 066) of the patients used more than one kind of non-steroid anti-inflammatory drugs (NSAIDs) while 61.2% (652/1 066) used disease modifying osteoarthritis drugs (DMOADs), including glucosamine (37.5%, 400/1 066), chondroitin sulfate (2.0%, 21/1 066), diacetate (5.9%, 63/1 066), and the combination of these drugs (15.8%, 168/1 066). 8.6% (92/1 066) patients only took analgesics to relieve the pain, not using any kind of NSAIDs or DMOADs. And 232 patients (21.7%) had intra-articular injections, including 9.2% (98/1 066) sodium hyaluronate, 4.5%(48/1 066) glucocorticoid, and 8.1% (86/1 066) combination of the two drugs. The proportion of the patients taking topical drugs accounted for 26.5% (283/1 066) and physical therapy accounted for 15.8% (168/1 066). Compared with those who suffered from knee OA, the patients who suffered from hip OA had more severe disease assessment. Moreover, there were significant differences in pain (Z=-7.625, P<0.001), morning stiffness (Z=-6.229, P<0.001), and joint function (Z=-6.777, P<0.001) between the two groups of the patients who suffered from knee or hip OA with The Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. Furthermore, patients with hip OA took more analgesics (χ²=24.838, P<0.001).

CONCLUSION

Oral NSAIDs and DMOADs are wildly used in patients with OA in China. However, the treatment of some patients still need to be improved. Patients with hip OA are more seriously ill and require aggressive treatment.

Clopidogrel may decrease the risk of post-stroke infection after ischaemic stroke

BACKGROUND AND PURPOSE

The P2Y12 receptor, a well-known factor in the platelet activation pathway, plays a role in thrombosis as well as systemic inflammation. Clopidogrel, a prototype P2Y12 receptor antagonist, reportedly decreases inflammation and systemic infection. The aim of this study was to evaluate whether clopidogrel use decreases the risk of post-stroke infection following ischaemic stroke.

METHODS

A total of 1643 patients with acute ischaemic stroke (within 7 days after onset) were included for analysis between March 2010 and December 2015. Patients were categorized into two groups (clopidogrel users versus clopidogrel non-users), and clinical characteristics and risks of post-stroke infection were compared between the two groups. The inverse probability of treatment weighting using propensity scores for baseline imbalance adjustments was applied.

RESULTS

Of the included patients (mean age 67.7 years; men 60.6%), 670 (40.8%) patients were clopidogrel users and 164 (10.0%) patients had post-stroke infection. The proportion of patients with post-stroke infection was significantly lower in clopidogrel users compared to clopidogrel non-users (6.7% vs. 12.2%, P ≤ 0.001). Moreover, clopidogrel users were less likely to be admitted to the intensive care unit (13.3% vs. 35.3%, P = 0.006). A multivariate analysis with inverse probability of treatment weighting revealed that clopidogrel users exhibited a lower risk of post-stroke infection (odds ratio 0.56, 95% confidence interval 0.42-0.75) and intensive care unit admission (odds ratio 0.34, 95% confidence interval 0.22-0.53).

CONCLUSIONS

The study suggested that clopidogrel users exhibit a lower risk of infection and develop less severe infections after ischaemic stroke. Further prospective studies are needed.

Tocotrienol supplementation suppressed bone resorption and oxidative stress in postmenopausal osteopenic women: a 12-week randomized double-blinded placebo-controlled trial

Tocotrienols have shown bone-protective effect in animals. This study showed that a 12-week tocotrienol supplementation decreased concentrations of bone resorption biomarker and bone remodeling regulators via suppressing oxidative stress in postmenopausal osteopenic women.

INTRODUCTION

Tocotrienols (TT) have been shown to benefit bone health in ovariectomized animals, a model of postmenopausal women. The purpose of this study was to evaluate the effect of 12-week TT supplementation on bone markers (serum bone-specific alkaline phosphatase (BALP), urine N-terminal telopeptide (NTX), serum soluble receptor activator of nuclear factor-kappaB ligand (sRANKL), and serum osteoprotegerin (OPG)), urine calcium, and an oxidative stress biomarker (8-hydroxy-2'-deoxyguanosine (8-OHdG)) in postmenopausal women with osteopenia.

METHODS

Eighty-nine postmenopausal osteopenic women (59.7 ± 6.8 year, BMI 28.7 ± 5.7 kg/m²) were randomly assigned to three groups: (1) placebo (430 mg olive oil/day), (2) low TT (430 mg TT/day, 70% purity), and (3) high TT (860 mg TT/day, 70% purity). TT, an extract from annatto seed with 70% purity, consisted of 90% delta-TT and 10% gamma-TT. Overnight fasting blood and urine samples were collected at baseline, 6, and 12 weeks for biomarker analyses. Eighty-seven subjects completed the 12-week study.

RESULTS

Relative to the placebo group, there were marginal decreases in serum BALP level in the TT-supplemented groups over the 12-week study period. Significant decreases in urine NTX levels, serum sRANKL, sRANKL/OPG ratio, and urine 8-OHdG concentrations and a significant increase in BALP/NTX ratio due to TT supplementation were observed. TT supplementation did not affect serum OPG concentrations or urine calcium levels throughout the study period. There were no significant differences in NTX level, BALP/NTX ratio, sRANKL level, and sRANKL/OPG ratio between low TT and high TT groups.

CONCLUSIONS

Twelve-week annatto-extracted TT supplementation decreased bone resorption and improved bone turnover rate via suppressing bone remodeling regulators in postmenopausal women with osteopenia. Such osteoprotective TT's effects may be, in part, mediated by an inhibition of oxidative stress.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02058420.

TITLE

Tocotrienols and bone health of postmenopausal women.

Intrapatient viral diversity and treatment outcome in patients with genotype 3a hepatitis C virus infection on sofosbuvir-containing regimens

Treatment with the direct-acting antiviral agent (DAA) sofosbuvir (SOF), an NS5B inhibitor, and velpatasvir (VEL), an NS5A inhibitor, demonstrates viral cure rates of ≥95% in hepatitis C virus (HCV) genotypes (GT) 1-6. Here, we investigated intrapatient HCV diversity in NS5A and NS5B using Shannon entropy to examine the relationship between viral diversity and treatment outcome. At baseline, HCV diversity was lowest in patients infected with HCV GT3 as compared to the other GTs, and viral diversity was greater in NS5A than NS5B (P < .0001). Treatment outcome with SOF/VEL or the comparator regimen of SOF with ribavirin (RBV) was not correlated with baseline diversity. However, among persons treated with SOF/VEL, a decrease in diversity from baseline was observed at relapse in the majority virologic failures, consistent with a viral bottleneck event at relapse. In contrast, an increase in diversity was observed in 27% of SOF+RBV virologic failures. We investigated whether the increase in diversity was due to an increase in the transition rate, one mode of potential RBV-mediated mutagenesis; however, we found no evidence of this mechanism. Overall, we did not observe that viral diversity at baseline influenced treatment outcome, but the diversity changes observed at relapse can improve our understanding of RBV viral suppression in vivo.

Resistance characterization of ledipasvir and velpatasvir in hepatitis C virus genotype 4

HCV genotype 4 (GT4) has often been overlooked in drug development, even though it infects ~20 million people worldwide. Ledipasvir/sofosbuvir and sofosbuvir/velpatasvir were highly efficacious in GT4 HCV-infected patients from GS-US-337-1119 and GS-US-342-1138. Here, we characterize the resistance profile of ledipasvir (LDV) and velpatasvir (VEL) in patients with GT4 HCV infection. NS5A deep-sequencing was performed for 454 patients infected with HCV GT4 at baseline, including 44 patients enrolled in GS-US-337-1119 and 116 patients enrolled in GS-US-342-1138, and at relapse for patients with virologic failure. LDV and VEL susceptibilities of 56 patient isolates were determined. In GS-US-337-1119, SVR12 rates were 100% for all subtypes except 4b and 4r. Phenotypic assessment of 56 HCV NS5A patient isolates from various GT4 subtypes indicated that LDV had high potency for the common subtypes 4a/d, and subtypes 4c/f/k/l/m/n/o/p/r/t despite the presence of resistance-associated substitutions (RASs). For the rare GT4b, LDV median EC₅₀ was higher, but with a broad range of individual values. Importantly, all GT4b isolates tested had 2-4 NS5A RASs, some including Y93H. Similarly, the 2 GT4r infected patients who had virologic relapse had rare triple RASs. Reversion of these substitutions to the consensus residue significantly increased LDV susceptibility. In GS-US-342-1138, all patients achieved SVR12, regardless of their subtype or presence of RASs. In vitro data confirmed that VEL is potent against all GT4 isolates tested. LDV and VEL are potent antiviral drugs, estimated to be effective against >95% and >99%, respectively, of GT4 HCV isolates.

Nonstructural protein 5A resistance profile in patients with chronic hepatitis C treated with ledipasvir-containing regimens without sofosbuvir

The study aimed to evaluate the effects of baseline hepatitis C virus (HCV) nonstructural protein 5A (NS5A) resistance-associated substitutions (RASs) on sustained virologic response to ledipasvir (LDV)-containing regimens in the absence of sofosbuvir (SOF) in patients with HCV genotype (GT) 1 infection across 6 phase 2 clinical studies. We analysed data from 1103 patients who received either LDV + vedroprevir (NS3 protease inhibitor) + tegobuvir (NS5B inhibitor) ± ribavirin or LDV + ribavirin + pegylated interferon. Population sequencing of HCV NS5A was performed at baseline and at virologic failure from patient plasma samples. Of 1045 patients with available baseline sequences, 747 (67.7%) had GT1a, and 298 (26.9%) had GT1b infection. The overall prevalence of NS5A RASs at baseline was 9.4%; 7.6% (57/747) and 13.8% (41/298) of patients with GT1a and GT1b infection, respectively. The majority of GT1a-infected patients with NS5A RASs at baseline had a single NS5A RAS (78.9%) at NS5A positions K24R, M28T, Q30H/L, L31M and Y93H/N/C/S. The spectrum of NS5A RASs detected in GT1b patients was much less diverse compared to GT1a patients, with all patients harbouring a single NS5A RAS either L31M or Y93H/C. For patients treated with LDV-containing regimens in the absence of SOF, the presence of baseline NS5A RASs was associated with low SVR rates. In patients with virologic failure, nearly all had either pre-existing and/or emergent NS5A RASs: 287/287 (100%) and 40/42 (95.2%) patients with GT1a and GT1b infection, respectively. Three novel NS5A substitutions were identified as emergent NS5A RASs: K26E and S38F in GT1a; and L31I in GT1b. In conclusion, the presence of NS5A RASs at baseline reduced the SVR rate in patients treated with LDV in combination vedroprevir + tegobuvir ± ribavirin or ribavirin + pegylated interferon. Virologic failure was associated with the detection of NS5A RASs in nearly all patients. These results suggest that the resistance barrier may differ depending on HCV drug combination and may be more important than that of the individual DAAs.

Abstract WP137: Premorbid Malnutrition as Assessed by Nutritional Risk Index is Associated With Poor Short-Term Outcome in Patients With Ischemic Stroke

Introduction: Malnutrition has negative consequences for stroke patients. However, impact of poor nutritional status before stroke onset on the functional outcome in patients with ischemic stroke remains unclear.

Hypothesis: Therefore, we investigated the prognostic role of premorbid undernutrition using objective assessment method, Nutritional Risk Index (NRI), in patients with ischemic stroke.

Methods: A consecutive 1,248 patients who were admitted within 7 days after ischemic stroke onset between March 2010 and December 2015 were included. We assessed initial nutritional status using NRI, and NRI formula as follows: NRI = (1.519 х serum albumin, g/dL) + {41.7 х present weight/ideal body weight (kg)}. The patients were categorized into three groups on the basis of NRI [No risk (NRI >97.5), Moderate risk (NRI 83.5–97.5), and Severe risk (NRI <83.5)]. We evaluated the short-term outcomes using a modified Rankin Scale (mRS) at three-months after stroke onset. We divided patients into two groups with favorable outcome (mRS score ≤2) and unfavorable outcome (mRS score ≥3). We compared the clinical characteristics and NRI between two groups.

Results: Among the included patients (mean age, 67 years, male, 63.1%), 322 (25.8%) patients had unfavorable outcome. The unfavorable outcome group was older and more likely to have atrial fibrillation, lower body mass index, and higher initial NIHSS. The lower NRI patients (Moderate risk and Severe risk) were more frequent in unfavorable outcome group (50.7% vs. 32.0% and 12.7% vs. 2.7%, P <0.001). After adjustment for covariates, lower NRI groups were independently associated with a higher risk of unfavorable outcome [Odds ratio (95% confidence interval); Moderate risk 2.75 (1.23 – 6.13); Severe risk 4.29 (1.93 – 9.62), P for trend <0.001].

Conclusion: This study demonstrated that the lower NRIs predicted unfavorable outcome at 3 months following ischemic stroke. This suggests that premorbid undernutrition could be a modifiable risk factor for prognosis following stroke.

Nocturnal Desaturation is Associated With Neurological Deterioration Following Ischemic Stroke: A Retrospective Observational Study

STUDY OBJECTIVES

The mechanism of early neurological deterioration (END) in patients with stroke remains unclear. We assessed the relationship between nocturnal oxygen desaturation (NOD) in the stroke unit (SU) and END, especially occurring at nighttime, following acute stroke.

METHODS

A retrospective analysis was performed on a total of 276 patients with ischemic stroke who were admitted to the SU between July 2013 and June 2015. The oxygen desaturation index was calculated from pulse oximetry data sampled every 1 minute during 9 hours on the first night (10:00 PM to 7:00 AM) after admission, and NOD was defined as oxygen desaturation index ≥ 5 events/h. END was defined as an increase of ≥ 2 points from the baseline National Institutes of Health Stroke Scale during 7 days after onset. We compared clinical characteristics and NOD between patients with and without END.

RESULTS

Among the included patients (mean age 69.2; male 55.4%), 42 patients (15.2%) experienced END. The proportion of NOD was significantly greater in the END group (45.2% versus 12.8%, P < .001). After adjusting for confounders, NOD was independently associated with END (odds ratio 7.57; 95% confidence interval 3.14-18.27). Among END patients, 47.6% patients (n = 20) had END during nighttime. Moreover, NOD was more frequent in patients with END during nighttime compared to those with END during daytime (73.7% versus 26.1%, P = .002).

CONCLUSIONS

NOD in the SU was associated with END, especially during nighttime, after ischemic stroke. This suggests that treatment of sleep-disordered breathing could be a modifiable factor to possibly reduce the risk of neurological worsening among acute stroke patients.

Predictors of 30-day mortality and the risk of recurrent systemic thromboembolism in cancer patients suffering acute ischemic stroke

BACKGROUND

Stroke in cancer patients is not rare but is a devastating event with high mortality. However, the predictors of mortality in stroke patients with cancer have not been well addressed. D-dimer could be a useful predictor because it can reflect both thromboembolic events and advanced stages of cancer.

AIM

In this study, we evaluate the possibility of D-dimer as a predictor of 30-day mortality in stroke patients with active cancer.

METHODS

We included 210 ischemic stroke patients with active cancer. The 30-day mortality data were collected by reviewing medical records. We also collected follow-up D-dimer levels in 106 (50%) participants to evaluate the effects of treatment response on D-dimer levels.

RESULTS

Of the 210 participants, 30-day mortality occurred in 28 (13%) patients. Higher initial NIHSS scores, D-dimer levels, and CRP levels as well as frequent cryptogenic mechanism, systemic metastasis, multiple vascular territory lesion, hemorrhagic transformation, and larger infarct volume were related to 30-day mortality. In the multivariate analysis, D-dimer [adjusted OR (aOR) = 2.19; 95% CI, 1.46-3.28, P < 0.001] predicted 30-day mortality after adjusting for confounders. The initial NIHSS score (aOR = 1.07; 95% CI, 1.00-1.14, P = 0.043) and hemorrhagic transformation (aOR = 3.02; 95% CI, 1.10-8.29, P = 0.032) were also significant independent of D-dimer levels. In the analysis of D-dimer changes after treatment, the mortality group showed no significant decrease in D-dimer levels, despite treatment, while the survivor group showed the opposite response.

CONCLUSIONS

D-dimer levels may predict 30-day mortality in acute ischemic stroke patients with active cancer.

Abstract WP168: Neutrophil to Lymphocyte Ratio is a Useful Predictor of Short-term Functional Outcome in Patients With Acute Ischemic Stroke

Introduction: Inflammation is associated with the initiation and progression of cardiovascular diseases. The neutrophil-to-lymphocyte ratio (NLR) has recently emerged as a prognostic marker in cardiovascular diseases. However, impact of NLR on the functional outcome in patients with ischemic stroke remains unclear.

Hypothesis: The aim of the study was to investigate the prognostic role of the NLR in patients with acute ischemic stroke.

Methods: A consecutive 1,113 patients who were admitted within 7 days after ischemic stroke onset between March 2010 and December 2014 were included for analysis. The patients were categorized into tertiles on the basis of NLR. We evaluated the short-term outcomes using a modified Rankin Scale (mRS) at three-months after onset of ischemic stroke. We divided patients into two groups with favorable outcome (mRS score ≤2) and unfavorable outcome (mRS score ≥3). We compared the clinical characteristics and NLR between two groups.

Results: From all the patients included in this study (mean age, 67.8 years; men, 60.0%), 284 (25.5%) patients had unfavorable outcome. The patients with unfavorable outcome were older and more likely to have atrial fibrillation, history of previous stroke, and diabetes mellitus. In addition, participants with unfavorable outcome tended to have lower body mass index and higher initial NIHSS. The percentage values of the tertile 3 were significantly higher in the unfavorable outcome group (28.3% vs. 47.9%, P < 0.001). After adjustment for covariates, the highest tertile were at an exaggerated risk for unfavorable outcome [Odds ratio (95% confidence interval); tertile 3, 1.75 (1.17 - 2.63), P = 0.007].

Conclusions: This study demonstrated that higher NLR predicted worse outcome at 3 months following acute ischemic stroke. This suggests that NLR could be a useful and reliable prognostic biomarker following acute ischemic stroke.

Abstract TP410: Beneficial Effect in Preventing the Risk of Aspiration Pneumonia in Patients With Acute Ischemic Stroke

Introduction: Platelet activation is an important mediator in acute thrombosis as well as systemic inflammation. Therefore, modulating P2Y12 receptor, a well-known platelet activation pathway, may influence inflammation process. Clopidogrel, a prototype P2Y12 receptor antagonist, is reported to decrease neutrophil infiltration and decrease inflammation.

Hypothesis: The aim of this study is to evaluate whether clopidogrel use may decrease the risk of aspiration pneumonia, a common infection, in patients with acute ischemic stroke.

Methods: A consecutive patients with acute ischemic stroke (within 7 days after onset) were screened between March 2010 and December 2015, and a total of 1,578 patients were included for the analysis. Patients were categorized into two groups (clopidogrel user vs. non-user), and the clinical characteristics and the risk of aspiration pneumonia were compared in two groups.

Results: Among the included patients (mean age, 67.6 years; men, 60.7%), 642 (40.7%) were clopidogrel user, and 132 (8.2%) patients had aspiration pneumonia. The proportion of patients with aspiration pneumonia was significantly higher in clopidogrel non-user (9.9%) compared to clopidogrel user (6.1%), (P = 0.006). Moreover, clopidogrel users had lower proportion of ICU care (12.8 % vs. 38.7 %, P =0.03) and had less chances of having sepsis [defined as quick SOFA (sepsis related organ failure) score of 2 and more) ( 15.4 % vs. 32.4 %, P= 0.047) compared with clopidogrel non-users. The patients with aspiration pneumonia were more likely to have atrial fibrillation, diabetes mellitus, and higher initial NIHSS. On multivariate analysis with an application of inverse probability of treatment weighting based on a propensity score of clopidogrel use, clopidogrel users had lower risk of aspiration pneumonia [Odds ratio (95% confidence interval); 0.747(0.573-0.974), P = 0.007].

Conclusions: This study suggested that clopidogrel users had lower risk of aspiration pneumonia and less severe infection following acute ischemic stroke. This suggests that clopidogrel may decrease the chances of infection, especially aspiration pneumonia, after stroke.

Cystatin C is a useful predictor of early neurological deterioration following ischaemic stroke in elderly patients with normal renal function

Introduction

Cystatin C has been suggested as a sensitive marker of renal function. A high level of cystatin C is related to cardiovascular disease and stroke in elderly patients. We investigated the relationship between levels of cystatin C and early neurological deterioration with acute ischaemic stroke in elderly patients without chronic kidney disease.

Patients and methods

We evaluated a total of 771 elderly patients (mean age, 72.2; male, 59.0%) without chronic kidney disease who were admitted following acute ischaemic stroke between March 2010 and January 2015. The patients were divided into four groups based on the quartiles of serum cystatin C values. Early neurological deterioration was defined as an increase of ≥2 points from the baseline National Institutes of Health Stroke Scale score during the 7 days following onset. We compared the clinical characteristics and cystatin C concentrations between patients with and without early neurological deterioration.

Results

Eighty-six patients (11.2%) experienced early neurological deterioration. The percentage values of the higher (third and fourth) quartiles were significantly higher in the early neurological deterioration group (30.2% vs. 24.4% and 34.9% vs. 23.8%, P = 0.002). After adjustment for covariates, higher cystatin C levels were independently associated with a higher risk of early neurological deterioration: odds ratio (95% confidence interval) for second quartile 1.59 (0.70-3.58), third quartile 2.75 (1.25-6.04), fourth quartile 3.12 (1.36-7.16); P for trend 0.026.

Discussion and conclusions

This study demonstrated that cystatin C concentrations in elderly patients without chronic kidney disease were associated with early neurological deterioration following acute stroke. This suggests that cystatin C level could be a useful predictor for early neurological deterioration following acute stroke.

Resistance Analyses of Japanese Hepatitis C-Infected Patients Receiving Sofosbuvir or Ledipasvir/Sofosbuvir Containing Regimens in Phase 3 Studies

High rates of sustained virologic response (SVR) has been achieved in Japanese patients with chronic hepatitis C virus (HCV) genotype (GT)1 and GT2 infection treated with ledipasvir/sofosbuvir (LDV/SOF) ±ribavirin (RBV) and SOF+RBV, respectively. We evaluated the effect of baseline HCV NS5A and NS5B resistance-associated variants (RAVs) on treatment outcome and characterized variants at virologic failure. Baseline deep sequencing for NS5A and NS5B genes was performed for all GT1 patients. Deep sequencing of NS5A (GT1 only) and NS5B (GT1 and GT2) was performed for patients who failed treatment or discontinued early with detectable HCV RNA (i.e., >25 IU/mL). In patients with HCV GT1 infection, 22.3% (GT1a: 2/11; GT1b: 74/330) had ≥1 baseline NS5A RAV. The most frequent NS5A RAVs in GT1b were Y93H (17.9%, 59/330) and L31M (2.4%, 8/330). Despite the presence of NS5A RAVs at baseline, 100% and 97% of patients achieved SVR12, compared with 100% and 99% for those with no NS5A RAVs with LDV/SOF and LDV/SOF+RBV, respectively. All patients with NS5B RAVs at baseline achieved SVR12. Of the 153 patients with GT2 infection (GT2a 60.1%, GT2b 39.9%), 3.3% (5/153) experienced viral relapse. No S282T or other NS5B RAVs were detected at baseline or relapse; no change in susceptibility to SOF or RBV was observed at relapse. In conclusion, LDV/SOF and SOF+RBV demonstrate a high barrier to resistance in Japanese patients with HCV GT1 and GT2 infection. The presence of baseline NS5A RAVs did not impact treatment outcome in GT1 Japanese patients treated with LDV/SOF for 12 weeks.

Risk of hip fracture following stroke, a meta-analysis of 13 cohort studies

This study systematically reviews prospective and retrospective cohort studies evaluating the risk of hip fracture following stroke. Stroke survivors are at high risk of hip fracture and had a 1.5-fold increased risk compared to stroke-free men and women of the same age. Hip fracture often occurs in ageing and female stroke patients. We performed a meta-analysis to summarize evidence from prospective and retrospective cohort studies about the risk of hip fracture following stroke. We identified English and non-English publications in MEDLINE and EMBASE using stroke and fracture as keywords to 31 December 2015. The data of the incidence of hip fracture were extracted to calculate raw incident rate in stroke survivors as well as risk of hip fractures in strokes comparing populations using a random-effects model. Subgroup analyses were performed to identify the potential influence of some factors. Six prospective and seven retrospective cohort studies were included, involving 512,214 stroke patients with 22,559 hip fractures. The pooled prevalence of hip fractures was 4.87 % (95 % CI, 4.05 to 5.68 %) in stoke patients. We conducted subgroup analysis according to sex, age, duration of follow-up, study design, and region, which showed that female (vs. male) stroke patients older than 70 years (vs. those less than 70 years) and duration of follow-up more than 2 years (vs. those less than 2 years) have higher proportions of hip fractures. Four studies showed that stroke patients had a significantly higher risk of hip fracture compared with the general population, while the other study had a non-significant higher risk. The overall prevalence of hip fracture was 3.28 % (3431 of 104,646) in stroke patients and 2.83 % (36,493 of 1,287,726) in general population, respectively, and the unadjusted combined relative risk of hip fracture was 1.54 (95 % CI, 1.06-2.25). Hip fractures often occur in ageing and female stroke patients.

Antiviral response and resistance analysis of treatment-naïve HCV-infected patients receiving single and multiple doses of GS-9190

GS-9190 is a NS5B non-nucleoside analogue with demonstrated effectiveness in a Phase 1 monotherapy study and in combination with other DAAs for treatment of chronic HCV infection. Here, the resistance profile of GS-9190 monotherapy in a Phase 1b study was investigated. Resistance analysis was performed by population sequencing and allele-specific PCR (AS-PCR) for Y448H with an assay cut-off of 0.5%. Phenotypic susceptibility analyses were performed on patient isolates as well as site-directed mutagenesis of mutations selected during monotherapy. No resistance-associated variants were observed in patients before or after receiving single doses of GS-9190 by population sequencing. In contrast, in patients who received GS-9190 for 8 days, mutations Y448H and Y452H in NS5B were observed by population sequencing in 21/36 (58%) and 2/36 (5.6%) patients, respectively, at Day 8 or Day 14. Among the remaining 15 patients who had no detectable Y448H at Day 8 or Day 14 by population sequencing, low frequencies of Y448H ranging from 1.3 to 9.7% were detected in 14 of 15 patients by AS-PCR. By AS-PCR, Y448H remained detectable at reduced frequency in the majority of patients analysed through 4-6 months of follow-up. Chimeric HCV replicons constructed with the NS5B sequence from patients with Y448H and Y448H + Y452H/Y demonstrated 27-fold and 78.5-fold reduced susceptibility to GS-9190. In conclusion, Y448H was rapidly selected in the majority of patients receiving multiple doses of GS-9190 as monotherapy, despite undetectable levels in pretreatment samples. Y448H confers reduced susceptibility to GS-9190 and other NNIs and persisted in most patients for months post-treatment.

A phase 3b study of sofosbuvir plus ribavirin in treatment-naive and treatment-experienced Korean patients chronically infected with genotype 2 hepatitis C virus

In Korea, patients with chronic hepatitis C virus (HCV) infection are typically treated with pegylated interferon-alpha plus ribavirin, but interferons are contraindicated in many patients and are often poorly tolerated, particularly by the elderly and those with advanced liver disease. No interferon-free treatment regimens are approved in Korea. Sofosbuvir is an oral nucleotide analog inhibitor of the HCV nonstructural 5B RNA polymerase. It is approved in the USA, European Union and Japan for treating a number of HCV genotypes, including genotype 2. Genotype 2 has a seroprevalence of 38-46% in Korea. This single-arm, phase 3b study (NCT02021643) examined the efficacy and safety of sofosbuvir plus ribavirin (12-week duration) in chronic genotype 2 HCV-infected treatment-naive and treatment-experienced Korean patients with and without cirrhosis. The proportion of patients with sustained virologic response 12 weeks after treatment discontinuation (SVR12) was 97% (125/129), with 96% (101/105) of treatment-naive and 100% (24/24) of treatment-experienced patients achieving SVR12. Two patients experienced virologic failure (n = 1, on-treatment failure; n = 1, relapse). No patient discontinued study treatment due to an adverse event (AE). The most common treatment-emergent AEs were headache (18%, 23/129) and pruritus (15%, 19/129). Few patients had grade 3 AEs (5%, 6/129) or grade 3 laboratory abnormalities (12%, 15/129). No grade 4 AE was reported. These data suggest that 12 weeks of treatment with the all-oral, interferon-free regimen of sofosbuvir plus ribavirin is effective and well tolerated in Korean patients with chronic genotype 2 HCV infection.

Sofosbuvir plus ribavirin for the treatment of patients with chronic genotype 1 or 6 hepatitis C virus infection in Hong Kong

BACKGROUND

In Hong Kong, most patients with hepatitis C virus (HCV) have either genotype 6a or 1b infection.

AIM

To evaluate the efficacy and safety of sofosbuvir with ribavirin in treatment-naïve patients in Hong Kong with HCV genotype 1 or 6.

METHODS

In an open-label study, patients were randomised to sofosbuvir 400 mg once daily plus ribavirin 1000-1200 divided twice daily for 12 (n = 10), 16 (n = 11) or 24 (n = 10) weeks. The primary endpoint was the percentage of patients with HCV RNA < LLOQ (lower limit of quantification, 25 IU/mL) 12 weeks after cessation of therapy (SVR12).

RESULTS

All 31 patients (20 HCV genotype 1 and 11 genotype 6) had HCV RNA < LLOQ by Week 4 of treatment and at their last on-treatment visit. SVR12 rates were high in all treatment groups: 100% (10/10) for 12 weeks, 100% (11/11) for 16 weeks and 90% (9/10) for 24 weeks of therapy. The only patient who did not reach SVR12 had genotype 1 HCV and relapsed at post-treatment Week 4. Sofosbuvir with ribavirin was generally well tolerated. The most common adverse events were malaise (13%) and upper respiratory tract infection (13%), followed by anaemia (10%). No patients experienced serious adverse events. One patient discontinued treatment at Week 16 because of an adverse event. The event, upper respiratory tract infection, was not considered treatment related by the investigator. This subject achieved SVR12.

CONCLUSIONS

The all-oral regimen sofosbuvir plus ribavirin is effective in treatment-naïve patients in Hong Kong with genotype 1 or 6 HCV.

TRIAL REGISTRATION NUMBER

NCT02021643.

A phase 1, randomized, dose-ranging study of GS-5816, a once-daily NS5A inhibitor, in patients with genotype 1-4 hepatitis C virus

GS-5816 is an inhibitor of the hepatitis C virus (HCV) NS5A protein that has demonstrated pan-genotypic activity and a high barrier to resistance in HCV replicon assays. The aim of this study was to evaluate the safety, antiviral activity and pharmacokinetics of once-daily doses of GS-5816 in patients with genotype 1-4 HCV infection. Patients with genotype 1-4 HCV infection were randomized to 3 days of GS-5816 at doses ranging from 5 to 150 mg or placebo. Adverse events were recorded, and plasma samples obtained for analysis of pharmacokinetics, HCV RNA and NS5A sequencing studies. GS-5816 5-150 mg for 3 days was well tolerated and resulted in rapid declines in HCV RNA that were sustained over the dosing period. In patients treated with the 150 mg dose of GS-5816, the mean maximal HCV RNA declines were 4.0, 4.0, 4.4, 3.3 and 3.5 log10 IU/mL in patients with genotype 1a, 1b, 2, 3 and 4 HCV infection, respectively. Pretreatment NS5A resistance-associated polymorphisms were detected in 31% (22/70) of patients. Genotype 1 and 3 HCV-infected patients without pretreatment NS5A resistance-associated polymorphisms had greater declines in HCV RNA than patients with resistance-associated polymorphisms. Plasma pharmacokinetics were supportive of once-daily dosing. GS-5816 demonstrated pangenotypic antiviral activity in patients with genotype 1-4 HCV infection. It will be further evaluated in combination with other pangenotypic direct-acting antivirals to achieve the goal of developing a well-tolerated, highly effective treatment for all HCV genotypes.

Evolution of the HCV viral population from a patient with S282T detected at relapse after sofosbuvir monotherapy

Clinical phase II/III studies of the nucleotide analogue HCV NS5B inhibitor sofosbuvir (SOF) have demonstrated high efficacy in HCV-infected patients in combination therapy. To date, resistance to SOF (S282T in NS5B) has rarely been detected in patients. In this study, we investigated the evolution of S282T viral variants detected in one HCV genotype 2b-infected patient who relapsed following 12 weeks of SOF monotherapy. Deep sequencing of the NS5B gene was performed on longitudinal plasma samples at baseline, days 2 and 3 on SOF, and longitudinal samples post-SOF treatment through week 48. Intrapatient HCV evolution was analysed by maximum-likelihood phylogenetic analysis. Deep sequencing analysis revealed a low level pre-existence of S282T at 0.05% of viral sequences (4/7755 reads) at baseline and 0.03% (6/23 415 reads) at day 2 on SOF. Viral relapse was detected at week 4 post-treatment where 99.8% of the viral population harboured S282T. Follow-up analysis determined that S282T levels diminished post-treatment reaching undetectable levels 24-48 weeks post-SOF. Phylogenetic analysis together with the persistence of unique post-treatment mutations in all post-SOF samples suggested that growth of wild type resulted from reversion of the S282T mutant to a wild type and not outgrowth of the baseline wild-type population. Our data suggest that a very low level of pre-existing S282T at baseline in this patient was enriched and transiently detected following SOF monotherapy. Despite relapse with drug resistance to SOF, this patient was successfully retreated with SOF plus ribavirin for 12 weeks and is now cured from HCV infection.

All-oral therapy with nucleotide inhibitors sofosbuvir and GS-0938 for 14 days in treatment-naive genotype 1 hepatitis C (nuclear)

Sofosbuvir and GS-0938 are distinct nucleotide analogues with activity against hepatitis C virus (HCV) in vitro. We evaluated the antiviral activity and safety of sofosbuvir and GS-0938 alone and in combination in HCV genotype 1 patients. In this double-blind study, 40 treatment-naïve patients were randomly assigned to 4 treatment cohorts: (i) GS-0938 for 14 days, (ii) GS-0938 for 7 days followed by GS-0938 plus sofosbuvir for 7 days, (iii) sofosbuvir for 7 days followed by GS-0938 plus sofosbuvir for 7 days and (iv) GS-0938 plus sofosbuvir for 14 days. In each arm, 8 patients received active drug and 2 placebo. After 7 days of dosing, patients in all 4 dose groups experienced substantial reductions in HCV RNA, with median declines (Q1, Q3) of -4.50 (-4.66, -4.24) in Cohort 1, -4.55 (-4.97, -4.13) in Cohort 2, -4.65 (-4.78, -4.17) in Cohort 3 and -4.43 (-4.81, -4.13) in Cohort 4; patients receiving placebo had essentially no change in HCV RNA (+0.07 log(10) IU/mL). Seven days after the end of treatment, the proportions of patients with HCV RNA <15 IU/mL were 4 (50%), 8 (100%), 7 (88%) and 5 (63%) for Cohorts 1-4, respectively, vs 0 for placebo. No viral breakthrough or resistance mutations were observed. No serious adverse events or Grade 3 or 4 adverse events were reported. Sofosbuvir and GS-0938-alone and in combination--were well tolerated and led to substantial reductions in viral load. Sofosbuvir is undergoing further investigation as a possible backbone of an all-oral regimen for chronic HCV.