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- Adam, M., et al.
(författare)
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Antimalarial drug efficacy and resistance in malaria-endemic countries in HANMAT-PIAM_net countries of the Eastern Mediterranean Region 2016-2020: Clinical and genetic studies
- 2023
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Ingår i: Tropical Medicine & International Health. - 1360-2276. ; 28:10, s. 817-829
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Tidskriftsartikel (refereegranskat)abstract
- Introduction The World Health Organization recommends regular monitoring of the efficacy of nationally recommended antimalarial drugs. We present the results of studies on the efficacy of recommended antimalarials and molecular markers of artemisinin and partner resistance in Afghanistan, Pakistan, Somalia, Sudan and Yemen.Methods Single-arm prospective studies were conducted to evaluate the efficacy of artesunate-sulfadoxine-pyrimethamine (ASSP) in Afghanistan and Pakistan, artemether-lumefantrine (AL) in all countries, or dihydroartemisinin-piperaquine (DP) in Sudan for the treatment of Plasmodium falciparum. The efficacy of chloroquine (CQ) and AL for the treatment of Plasmodium vivax was evaluated in Afghanistan and Somalia, respectively. Patients were treated and monitored for 28 (CQ, ASSP and AL) or 42 (DP) days. Polymerase chain reaction (PCR)-corrected cure rate and parasite positivity rate at Day 3 were estimated. Mutations in the P. falciparum kelch 13 (Pfk13) gene and amplifications of plasmepsin (Pfpm2) and multidrug resistance-1 (Pfmdr-1) genes were also studied.Results A total of 1680 (249 for ASSP, 1079 for AL and 352 for DP) falciparum cases were successfully assessed. A PCR-adjusted ASSP cure rate of 100% was observed in Afghanistan and Pakistan. For AL, the cure rate was 100% in all but four sites in Sudan, where cure rates ranged from 92.1% to 98.8%. All but one patient were parasite-free at Day 3. For P. vivax, cure rates were 98.2% for CQ and 100% for AL. None of the samples from Afghanistan, Pakistan and Yemen had a Pfk13 mutation known to be associated with artemisinin resistance. In Sudan, the validated Pfk13 R622I mutation accounted for 53.8% (14/26) of the detected non-synonymous Pfk13 mutations, most of which were repeatedly detected in Gadaref. A prevalence of 2.7% and 9.3% of Pfmdr1 amplification was observed in Pakistan and Yemen, respectively.Conclusion High efficacy of ASSP, AL and DP in the treatment of uncomplicated falciparum infection and of CQ and AL in the treatment of P. vivax was observed in the respective countries. The repeated detection of a relatively high rate of Pfk13 R622I mutation in Sudan underscores the need for close monitoring of the efficacy of recommended ACTs, parasite clearance rates and Pfk13 mutations in Sudan and beyond. Registration numbers of the trials: ACTRN12622000944730 and ACTRN12622000873729 for Afghanistan, ACTRN12620000426987 and ACTRN12617001025325 for Pakistan, ACTRN12618001224213 for Somalia, ACTRN12617000276358, ACTRN12622000930785 and ACTRN12618001800213 for Sudan and ACTRN12617000283370 for Yemen.
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| 7. |
- Fuchs, A., et al.
(författare)
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Minimum Information about T Regulatory Cells: A Step toward Reproducibility and Standardization
- 2018
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Ingår i: Frontiers in Immunology. - : Frontiers Media SA. - 1664-3224. ; 8
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Tidskriftsartikel (refereegranskat)abstract
- Cellular therapies with CD4+ T regulatory cells (Tregs) hold promise of efficacious treatment for the variety of autoimmune and allergic diseases as well as posttransplant complications. Nevertheless, current manufacturing of Tregs as a cellular medicinal product varies between different laboratories, which in turn hampers precise comparisons of the results between the studies performed. While the number of clinical trials testing Tregs is already substantial, it seems to be crucial to provide some standardized characteristics of Treg products in order to minimize the problem. We have previously developed reporting guidelines called minimum information about tolerogenic antigen-presenting cells, which allows the comparison between different preparations of tolerance-inducing antigen-presenting cells. Having this experience, here we describe another minimum information about Tregs (MITREG). It is important to note that MITREG does not dictate how investigators should generate or characterize Tregs, but it does require investigators to report their Treg data in a consistent and transparent manner. We hope this will, therefore, be a useful tool facilitating standardized reporting on the manufacturing of Tregs, either for research purposes or for clinical application. This way MITREG might also be an important step toward more standardized and reproducible testing of the Tregs preparations in clinical applications.
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- Warsame, Marian, et al.
(författare)
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High therapeutic efficacy of artemether-lumefantrine and dihydroartemisinin-piperaquine for the treatment of uncomplicated falciparum malaria in Somalia
- 2019
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Ingår i: Malaria Journal. - : Springer Science and Business Media LLC. - 1475-2875. ; 18
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Tidskriftsartikel (refereegranskat)abstract
- Background: Artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DHA/PPQ) are the recommended first- and second-line treatments, respectively, for uncomplicated falciparum malaria in Somalia. The studies reported here were conducted to assess the efficacy of these artemisinin-based combinations and the mutations in Plasmodium falciparum K13-propeller (Pfk13) domain and amplification in Pfplasmepsin 2 (Pfpm2) gene in Somalia. Methods: One-arm prospective studies were conducted to assess the clinical and parasitological responses to DHA/PPQ and AL at two sites in 2016 and 2017, respectively, using the standard WHO protocol. The patterns of molecular markers associated with artemisinin and PPQ resistance were investigated for the first time in Somalia. Results: A total of 339 patients were enrolled with 139 for AL and 200 for DHA/PPQ. With AL, no parasite recurrence was observed among patients treated at either site, corresponding to 100% clinical and parasitological responses. For DHA-PPQ, an adequate clinical and parasitological response rate > 97% was observed. All study patients on both treatments at both sites were parasite-free on day 3. Of the 138 samples with interpretable results for the polymorphism in Pfk13, only one (0.7%), from Bosaso, contained a non-synonymous mutation (R622I), which is not one of the known markers of artemisinin resistance. No Pfpm2 amplification was observed among the 135 samples with interpretable results. Conclusions: AL and DHA/PPQ were highly effective in the treatment of uncomplicated falciparum malaria, and there was no evidence of resistance to artemisinin or PPQ. These two combinations are thus relevant in the chemotherapeutic strategy for malaria control in Somalia.
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| 10. |
- Romano, K. A., et al.
(författare)
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Gut Microbiota-Generated Phenylacetylglutamine and Heart Failure
- 2023
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Ingår i: Circulation-Heart Failure. - : Ovid Technologies (Wolters Kluwer Health). - 1941-3289 .- 1941-3297. ; 16:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: The gut microbiota-dependent metabolite phenylacetylgutamine (PAGln) is both associated with atherothrombotic heart disease in humans, and mechanistically linked to cardiovascular disease pathogenesis in animal models via modulation of adrenergic receptor signaling.Methods: Here we examined both clinical and mechanistic relationships between PAGln and heart failure (HF). First, we examined associations among plasma levels of PAGln and HF, left ventricular ejection fraction, and N-terminal pro-B-type natriuretic peptide in 2 independent clinical cohorts of subjects undergoing coronary angiography in tertiary referral centers (an initial discovery US Cohort, n=3256; and a validation European Cohort, n=829). Then, the impact of PAGln on cardiovascular phenotypes relevant to HF in cultured cardiomyoblasts, and in vivo were also examined.Results: Circulating PAGln levels were dose-dependently associated with HF presence and indices of severity (reduced ventricular ejection fraction, elevated N-terminal pro-B-type natriuretic peptide) independent of traditional risk factors and renal function in both cohorts. Beyond these clinical associations, mechanistic studies showed both PAGln and its murine counterpart, phenylacetylglycine, directly fostered HF-relevant phenotypes, including decreased cardiomyocyte sarcomere contraction, and B-type natriuretic peptide gene expression in both cultured cardiomyoblasts and murine atrial tissue.Conclusions: The present study reveals the gut microbial metabolite PAGln is clinically and mechanistically linked to HF presence and severity. Modulating the gut microbiome, in general, and PAGln production, in particular, may represent a potential therapeutic target for modulating HF.Registration: URL: ; Unique identifier: NCT00590200 and URL: ; Unique identifier: DRKS00020915.
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| 11. |
- Maffi, P., et al.
(författare)
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Targeting CXCR1/2 Does Not Improve Insulin Secretion After Pancreatic Islet Transplantation: A Phase 3, Double-Blind, Randomized, Placebo-Controlled Trial in Type 1 Diabetes
- 2020
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Ingår i: Diabetes Care. - : American Diabetes Association. - 0149-5992 .- 1935-5548. ; 43:4, s. 710-718
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE Reparixin is an inhibitor of CXCR1/2 chemokine receptor shown to be an effective anti-inflammatory adjuvant in a pilot clinical trial in allotransplant recipients. RESEARCH DESIGN AND METHODS A phase 3, multicenter, randomized, double-blind, parallel-assignment study () was conducted in recipients of islet allotransplants randomized (2:1) to reparixin or placebo in addition to immunosuppression. Primary outcome was the area under the curve (AUC) for C-peptide during the mixed-meal tolerance test at day 75 +/- 5 after the first and day 365 +/- 14 after the last transplant. Secondary end points included insulin independence and standard measures of glycemic control. RESULTS The intention-to-treat analysis did not show a significant difference in C-peptide AUC at both day 75 (27 on reparixin vs. 18 on placebo, P = 0.99) and day 365 (24 on reparixin vs. 15 on placebo, P = 0.71). There was no statistically significant difference between treatment groups at any time point for any secondary variable. Analysis of patient subsets showed a trend for a higher percentage of subjects retaining insulin independence for 1 year after a single islet infusion in patients receiving reparixin as compared with patients receiving placebo (26.7% vs. 0%, P = 0.09) when antithymocyte globulin was used as induction immunosuppression. CONCLUSIONS In this first double-blind randomized trial, islet transplantation data obtained with reparixin do not support a role of CXCR1/2 inhibition in preventing islet inflammation-mediated damage.
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| 12. |
- Nemet, I., et al.
(författare)
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Atlas of gut microbe-derived products from aromatic amino acids and risk of cardiovascular morbidity and mortality
- 2023
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Ingår i: European Heart Journal. - 0195-668X. ; 44:32
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Tidskriftsartikel (refereegranskat)abstract
- Aims Precision microbiome modulation as a novel treatment strategy is a rapidly evolving and sought goal. The aim of this study is to determine relationships among systemic gut microbial metabolite levels and incident cardiovascular disease risks to identify gut microbial pathways as possible targets for personalized therapeutic interventions.Methods and results Stable isotope dilution mass spectrometry methods to quantitatively measure aromatic amino acids and their metabolites were used to examine sequential subjects undergoing elective diagnostic cardiac evaluation in two independent cohorts with longitudinal outcome data [US (n = 4000) and EU (n = 833) cohorts]. It was also used in plasma from humans and mice before vs. after a cocktail of poorly absorbed antibiotics to suppress gut microbiota. Multiple aromatic amino acid-derived metabolites that originate, at least in part, from gut bacteria are associated with incident (3-year) major adverse cardiovascular event (MACE) risks (myocardial infarction, stroke, or death) and all-cause mortality independent of traditional risk factors. Key gut microbiota-derived metabolites associated with incident MACE and poorer survival risks include: (i) phenylacetyl glutamine and phenylacetyl glycine (from phenylalanine); (ii) p-cresol (from tyrosine) yielding p-cresol sulfate and p-cresol glucuronide; (iii) 4-OH-phenyllactic acid (from tyrosine) yielding 4-OH-benzoic acid and 4-OH-hippuric acid; (iv) indole (from tryptophan) yielding indole glucuronide and indoxyl sulfate; (v) indole-3-pyruvic acid (from tryptophan) yielding indole-3-lactic acid and indole-3-acetyl-glutamine, and (vi) 5-OH-indole-3-acetic acid (from tryptophan).Conclusion Key gut microbiota-generated metabolites derived from aromatic amino acids independently associated with incident adverse cardiovascular outcomes are identified, and thus will help focus future studies on gut-microbial metabolic outputs relevant to host cardiovascular health.
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| 13. |
- Sawicki, M., et al.
(författare)
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Homogeneous and heterogeneous magnetism in (Zn,Co)O : From a random antiferromagnet to a dipolar superferromagnet by changing the growth temperature
- 2013
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Ingår i: Physical Review B. Condensed Matter and Materials Physics. - 1098-0121 .- 1550-235X. ; 88:8
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Tidskriftsartikel (refereegranskat)abstract
- A series of (Zn,Co)O layers with Co contents x up to 40% grown by atomic layer deposition have been investigated. All structures deposited at 160 degrees C show magnetic properties specific to II-VI dilute magnetic semiconductors with localized spins S = 3/2 coupled by strong but short-range antiferromagnetic interactions resulting in low-temperature spin-glass freezing for x = 0.16 and 0.4. At higher growth temperature (200 degrees C) metallic Co nanocrystals precipitate in two locations giving rise to two different magnetic responses: (i) a superparamagnetic contribution coming from volume disperse nanocrystals; (ii) a ferromagneticlike behavior brought about by nanocrystals residing at the (Zn,Co)O/substrate interface. It is shown that the dipolar coupling within the interfacial two-dimensional dense dispersion of nanocrystals is responsible for the ferromagneticlike behavior.
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| 14. |
- Blicharska, Malgorzata, 1979-, et al.
(författare)
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Between biodiversity conservation and sustainable forest management - A multidisciplinary assessment of the emblematic Bialowieza Forest case
- 2020
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Ingår i: Biological Conservation. - : Elsevier BV. - 0006-3207 .- 1873-2917. ; 248
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Tidskriftsartikel (refereegranskat)abstract
- The tension between biodiversity conservation and multipurpose forest management may lead to conflicts. An internationally prominent example is the Bialowieza Forest Massif (BFM), an extensive forest complex with high levels of naturalness. We apply a systematic, multidisciplinary assessment process to review empirical evidence on different dimensions of the BFM conflict. While there is broad consensus that this forest massif is an exceptional place worth conserving and that a way forward is a zonation system combining conservation with management, exactly how this should be done has yet to be agreed upon. Our assessment shows that the key reasons for the BFM controversy go beyond the availability of knowledge on the ecological status of the BFM and include: 1) evidence stemming from different sources, which is often contradictory and prone to different interpretations; 2) knowledge gaps, particularly with regard to socio-economic drivers and beneficiaries as well as uncertainties about future trends; 3) fundamentally different values and priorities among stakeholder groups, resulting in power struggles, and an overall lack of trust. We conclude that evidence-based knowledge alone is insufficient to cope with complex conservation conflicts. While more evidence may help assess the consequences of decisions, the actual management decisions depend on different actors' worldviews, which are rooted in their professional identities and power, and their political and legal realities. This calls for conflict management through a well-organized participatory process organized and supervised by a body deemed legitimate by the groups involved.
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- Farronato, M., et al.
(författare)
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New Quadratic Self-Assembly of Double-Decker Phthalocyanine on Gold(111) Surface : From Macroscopic to Microscopic Scale
- 2018
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Ingår i: The Journal of Physical Chemistry C. - : American Chemical Society (ACS). - 1932-7447 .- 1932-7455. ; 122:46, s. 26480-26488
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Tidskriftsartikel (refereegranskat)abstract
- Unveiling the self-organization mechanism of semiconducting organic molecules onto metallic surfaces is the first step to design hybrid devices in which the self-assembling is exploited to tailor magnetic properties. In this study, double-decker rare-earth phthalocyanines, namely, lutetium phthalocyanine (LuPc2), are deposited on Au(111) gold surface forming large-scale self-assemblies. Global and local experimental techniques, namely, grazing incidence X-ray diffraction and scanning tunneling microscopy, supplemented by density functional theory calculations with van der Waals corrections, give insight into the molecular structural arrangement of the thin film and the self organization at the surface. Our results show unambiguously that the two plateaus of the double-decker phthalocyanine present a different rotation than the isolated molecule. This is evidenced by density functional theory simulations of optimized LuPc2 monolayer showing a perfect agreement with experimental findings. Moreover, the stabilized structure of double layers reveals an eclipsed configuration of the molecules in the stacking, having the ligand plateaus parallel to the gold surface. The high crystallinity of the molecular assembly and its weak electronic coupling with the metallic substrate is expected to open new perspective in magnetic devices.
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- Riaux-Gobin, C., et al.
(författare)
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Planothidium juandenovense sp. nov. (Bacillariophyta) from Juan de Nova (Scattered Islands, Mozambique Channel) and other tropical environments: A new addition to the Planothidium delicatulum complex
- 2018
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Ingår i: Fottea. - : Palacky University Olomouc. - 1802-5439 .- 1805-4927. ; 18:1, s. 106-119
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Tidskriftsartikel (refereegranskat)abstract
- Planothidium juandenovense sp. nov. (Bacillariophyta) is described from the marine tropical environments of Juan de Nova I. (Mozambique Channel), Rodrigues I. (Mascarene Archipelago) and from Guam (Northern Mariana Is., Pacific). This small and relatively rare taxon has short multiseriate striae on the sternum valve (SV), hooked raphe valve (RV) terminal raphe endings and no SV cavum or hoof-shaped area. This taxon has similarities with Planothidium delicatulum (Kütz.) Round et Bukht. and Planothidium septentrionale (Østrup) Round et Bukht. ex Rumrich et al., but also differences: e.g. a relatively narrow and rhombic SV sternum, void of areolae, with vestigial radiate structures and an uninterrupted marginal SV elevated crest or ‘crista marginalis’. P. juandenovense sp. nov. is compared to some other Achnanthales with short SV striae. Cocconeis quarnerensis var. lanceolata Jurilj and Planothidium quarnerense f. rhombica (Giffen) comb. nov. may be close to our new taxon. © Czech Phycological Society (2018).
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| 18. |
- Tang, W. H. Wilson, et al.
(författare)
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Prognostic value of gut microbe-generated metabolite phenylacetylglutamine in patients with heart failure
- 2024
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Ingår i: EUROPEAN JOURNAL OF HEART FAILURE. - 1388-9842 .- 1879-0844.
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Tidskriftsartikel (refereegranskat)abstract
- AimPhenylacetylglutamine (PAGln) is a phenylalanine-derived metabolite produced by gut microbiota with mechanistic links to heart failure (HF)-relevant phenotypes. We sought to investigate the prognostic value of PAGln in patients with stable HF.Methods and resultsFasting plasma PAGln levels were measured by stable-isotope-dilution liquid chromatography-tandem mass spectrometry (LC-MS/MS) in patients with stable HF from two large cohorts. All-cause mortality was assessed at 5-year follow-up in the Cleveland cohort, and HF, hospitalization, or mortality were assessed at 3-year follow-up in the Berlin cohort. Within the Cleveland cohort, median PAGln levels were 4.2 (interquartile range [IQR] 2.4-6.9) mu M. Highest quartile of PAGln was associated with 3.09-fold increased mortality risk compared to lowest quartile. Following adjustments for traditional risk factors, as well as race, estimated glomerular filtration rate, amino-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, left ventricular ejection fraction, ischaemic aetiology, and HF drug treatment, elevated PAGln levels remained predictive of 5-year mortality in quartile comparisons (adjusted hazard ratio [HR] [95% confidence interval, CI] for Q4 vs Q1: 1.64 [1.07-2.53]). In the Berlin cohort, a similar distribution of PAGln levels was observed (median 3.2 [IQR 2.0-4.8] mu M), and PAGln levels were associated with a 1.92-fold increase in 3-year HF hospitalization or all-cause mortality risk (adjusted HR [95% CI] for Q4 vs Q1: 1.92 [1.02-3.61]). Prognostic value of PAGln appears to be independent of trimethylamine N-oxide levels.ConclusionHigh levels of PAGln are associated with adverse outcomes independent of traditional cardiac risk factors and cardio-renal risk markers.
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| 20. |
- Boudet, S., et al.
(författare)
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Growth mode and self-organization of LuPc2 on Si(001)-2 x 1 vicinal surfaces : An optical investigation
- 2012
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Ingår i: Physical Review B. Condensed Matter and Materials Physics. - 1098-0121 .- 1550-235X. ; 86:11, s. 115413-
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Tidskriftsartikel (refereegranskat)abstract
- We report an investigation of the initial growth and of the self-organization of lutetium biphthalocyanine LuPc2 on Si(001)-2 x 1 vicinal surfaces. Using surface-sensitive optical spectroscopies, namely, surface-difference-reflectance spectroscopy (SDRS) and reflectance-anisotropy spectroscopy (RAS), together with local-probe microscopies, we are able to propose a scenario for the growth mode up to about 20 nm. We demonstrate that the growth mode initially proceeds through the formation of a wetting layer, followed by the formation of clusters whose sizes increase while keeping a constant shape in which the molecules are inclined. Moreover, the LuPc2 molecules are self-organized along the step edges, and we are able to estimate that about 30% to 100% of the molecules are aligned when considering that the molecules are tilted by 45 degrees to 63 degrees with respect to the surface normal.
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| 21. |
- Guziewicz, E., et al.
(författare)
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Synchrotron photoemission study of (Zn,Co)O films with uniform Co distribution
- 2011
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Ingår i: Radiation Physics and Chemistry. - : Elsevier BV. - 0969-806X. ; 80:10, s. 1046-1050
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Konferensbidrag (refereegranskat)abstract
- We present results of a resonant photoemission study of (Zn,Co)O films with Co content between 2% and 7%. The films were grown by Atomic Layer Deposition (ALD) at low temperature of 160 degrees C and show fully paramagnetic behavior. The Co ions are uniformly distributed in the ZnO matrix and are free of foreign phases and metal accumulations as indicated by TEM data. The electronic structure of (Zn,Co)O films was studied by Resonant Photoemission Spectroscopy across the Co3p-Co3d photoionization threshold. We have observed that the resonant enhancement of the photoemission intensity from the Co3d shell is not the same for samples with different cobalt content. We suggest that the Co3d contribution to the valence band depends on both Co and H content. (C) 2011 Elsevier Ltd. All rights reserved.
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- Kageyama, Shigetaka, et al.
(författare)
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Geographic disparity in 10-year mortality after coronary artery revascularization in the SYNTAXES trial
- 2022
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Ingår i: International Journal of Cardiology. - : Elsevier. - 0167-5273 .- 1874-1754. ; 368, s. 28-38
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Tidskriftsartikel (refereegranskat)abstract
- Aims: To investigate geographic disparity in long-term mortality following revascularization in patients with complex coronary artery disease (CAD).Methods and results: The SYNTAXES trial randomized 1800 patients with three-vessel and/or left main CAD to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and assessed their survival at 10 years. Patients were stratified according to the region of recruitment: North America (N-A, n = 245), Eastern Europe (E-E, n = 189), Northern Europe (N-E, n = 425), Southern Europe (S-E, n = 263), and Western Europe (W-E, n = 678), which also served as the reference group. Compared to W-E, patients were younger in E-E (62 vs 65 years, p < 0.001), and less frequently male in N-A (65.3% vs 79.6%, p < 0.001). Diabetes (16.0% vs 25.4%, p < 0.001) and peripheral vascular disease (6.8% vs 10.9%, p = 0.025) were less frequent in N-E than W-E. Ejection fraction was highest in W-E (62% vs 56%, p < 0.001). Compared to W-E, the mean anatomic SYNTAX score was higher in S-E (29 vs 31, p = 0.008) and lower in N-A (26, p < 0.001). Crude ten-year mortality was similar in N-A (31.6%), and W-E (30.7%), and significantly lower in E-E (22.5%, p = 0.041), N-E (21.9%, p = 0.003) and S-E (22.0%, p = 0.014). Compared to W-E, adjusted mortality in N-E (HR 0.85, p = 0.019) and S-E (HR 0.72, p = 0.043) remain significantly lower after adjustment for pre-and peri-procedural factors, but no significant interaction (Pinteraction = 0.728) between region and modality of revascularization was seen.Conclusion: In the era of globalization, knowledge, and understanding of geographic disparity are of paramount importance for the correct interpretation of global studies.
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| 25. |
- Mega, JL, et al.
(författare)
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Rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46: a randomised, double-blind, phase II trial
- 2009
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Ingår i: Lancet. - 0140-6736. ; 374:9683, s. 29-38
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Tidskriftsartikel (refereegranskat)abstract
- Rivaroxaban is an oral direct factor Xa inhibitor that has been effective in prevention of venous thromboembolism in patients undergoing elective orthopaedic surgery. However, its use after acute coronary syndromes has not been investigated. In this setting, we assessed the safety and efficacy of rivaroxaban and aimed to select the most favourable dose and dosing regimen. METHODS: In this double-blind, dose-escalation, phase II study, undertaken at 297 sites in 27 countries, 3491 patients stabilised after an acute coronary syndrome were stratified on the basis of investigator decision to use aspirin only (stratum 1, n=761) or aspirin plus a thienopyridine (stratum 2, n=2730). Participants were randomised within each strata and dose tier with a block randomisation method at 1:1:1 to receive either placebo or rivaroxaban (at doses 5-20 mg) given once daily or the same total daily dose given twice daily. The primary safety endpoint was clinically significant bleeding (TIMI major, TIMI minor, or requiring medical attention); the primary efficacy endpoint was death, myocardial infarction, stroke, or severe recurrent ischaemia requiring revascularisation during 6 months. Safety analyses included all participants who received at least one dose of study drug; efficacy analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00402597. FINDINGS: Three patients in stratum 1 and 26 in stratum 2 never received the study drug. The risk of clinically significant bleeding with rivaroxaban versus placebo increased in a dose-dependent manner (hazard ratios [HRs] 2.21 [95% CI 1.25-3.91] for 5 mg, 3.35 [2.31-4.87] for 10 mg, 3.60 [2.32-5.58] for 15 mg, and 5.06 [3.45-7.42] for 20 mg doses; p<0.0001). Rates of the primary efficacy endpoint were 5.6% (126/2331) for rivaroxaban versus 7.0% (79/1160) for placebo (HR 0.79 [0.60-1.05], p=0.10). Rivaroxaban reduced the main secondary efficacy endpoint of death, myocardial infarction, or stroke compared with placebo (87/2331 [3.9%] vs 62/1160 [5.5%]; HR 0.69, [95% CI 0.50-0.96], p=0.0270). The most common adverse event in both groups was chest pain (248/2309 [10.7%] vs 118/1153 [10.2%]). INTERPRETATION: The use of an oral factor Xa inhibitor in patients stabilised after an acute coronary syndrome increases bleeding in a dose-dependent manner and might reduce major ischaemic outcomes. On the basis of these observations, a phase III study of low-dose rivaroxaban as adjunctive therapy in these patients is underway.
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