Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors

BACKGROUND

Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented.

METHODS

Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society of Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome.

RESULTS

There were 479 patients enrolled (mean age, 78 years; 54% male, 86% White; 81% anticoagulated for atrial fibrillation at a median time of 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 patients (10%); in 16 patients, this occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors.

CONCLUSIONS

In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02329327.

Plastic Burning Impacts on Atmospheric Fine Particulate Matter at Urban and Rural Sites in the USA and Bangladesh

To better understand the impact of plastic burning on atmospheric fine particulate matter (PM_2.5), we evaluated two methods for the quantification of 1,3,5-triphenylbenzene (TPB), a molecular tracer of plastic burning. Compared to traditional solvent-extraction gas chromatography mass spectrometry (GCMS) techniques, thermal-desorption (TD) GCMS provided higher throughput, lower limits of detection, more precise spike recoveries, a wider linear quantification range, and reduced solvent use. This method enabled quantification of TPB in fine particulate matter (PM_2.5) samples collected at rural and urban sites in the USA and Bangladesh. These analyses demonstrated a measurable impact of plastic burning at 5 of the 6 study locations, with the largest absolute and relative TPB concentrations occurring in Dhaka, Bangladesh, where plastic burning is expected to be a significant source of PM_2.5. Background-level contributions of plastic burning in the USA were estimated to be 0.004-0.03 μg m^-3 of PM_2.5 mass. Across the four sites in the USA, the lower estimate of plastic burning contributions to PM_2.5 ranged 0.04-0.8%, while the median estimate ranged 0.3-3% (save for Atlanta, Georgia, in the wintertime at 2-7%). The results demonstrate a consistent presence of plastic burning emissions in ambient PM_2.5 across urban and rural sites in the USA, with a relatively small impact in comparison to other anthropogenic combustion sources in most cases. Much higher TPB concentrations were observed in Dhaka, with estimated plastic burning impacts on PM_2.5 ranging from a lower estimate of 0.3-1.8 μg m^-3 (0.6-2% of PM_2.5) and the median estimate ranging 2-35 μg m^-3 (5-15% of PM_2.5). The methodological advances and new measurements presented herein help to assess the air quality impacts of burning plastic more broadly.

[Cardiac rehabilitation, a proven intervention underutilized in the French-speaking part of Switzerland]

Cardiac rehabilitation is associated with a reduced risk of recurrence and mortality after an acute coronary syndrome. Cardiac rehabilitation is a multidisciplinary approach which starts during the acute hospital phase, then followed by a four to six weeks home-based or stationary program, in order to maintain long-term lifestyle changes. Despite the important health benefits of cardiac rehabilitation and its cost-effectiveness, only half of the patients in Europe will achieve a cardiovascular prevention program after an acute coronary syndrome. In the French part of Switzerland, one explanation for this low adherence might be the lack of both stationary and home-based program facilities.

[Electrically assisted bicycles: health enhancement or "green" gadget?]

Electrically assisted bicycles (EAB) are flourishing in cities throughout the world and capitalize on ecological and practical advantages, helping in the fight against pollution, CO2 emissions and traffic jam. Human power is necessary to activate the electrical support, so that it equals to a moderate intensity physical activity (> 3 MET), or a vigorous one on hilly courses (>6 MET). The ecological benefits are obvious and transportation departments tend to support citizens who purchase one. EAB offer increased mobility at speeds of 15 to 25 km/h depending on hills and fitness of the rider, but could cause more accidents. EAB is linked to a real physical activity beneficial for health, but potentially more dangerous than a traditional bicycle.

Phantom force induced by tunneling current: a characterization on Si(111)

Simultaneous measurements of tunneling current and atomic forces provide complementary atomic-scale data of the electronic and structural properties of surfaces and adsorbates. With these data, we characterize a strong impact of the tunneling current on the measured force on samples with limited conductivity. The effect is a lowering of the effective gap voltage through sample resistance which in turn lowers the electrostatic attraction, resulting in an apparently repulsive force. This effect is expected to occur on other low-conductance samples, such as adsorbed molecules, and to strongly affect Kelvin probe measurements when tunneling occurs.

Evaluation of hexaflumuron for controlling the subterranean termite Coptotermes curvignathus (Isoptera: Rhinotermitidae) in Malaysia

Cellulosic bait matrices containing 0.5% hexaflumuron were tested against field colonies of the subterranean termite Coptotermes curvignathus Holmgren in Malaysia. Foraging activities of the termites were first monitored for several months by using survey stakes and wood bundles placed in underground monitoring traps. Infested stakes were replaced with bait devices. Termite workers to act as recruits were collected from infested stakes and placed in the bait devices. Subsequent activities of the termites were monitored by examining and weighing the wood in the monitoring traps. Data show that the four colonies had populations of 166,288-709,052 foragers and mean wood consumption rates of 305.9-508.2 g/mo per trap. These colonies ceased their activities at all monitoring devices 25-44 d after baiting had commenced. Colonies consumed approximately 27-79 g of bait matrix or 137.5-395 mg of hexaflumuron. Thus, C. curvignathus colonies could be monitored, characterized, baited, and foraging eliminated by using a bait matrix containing hexaflumuron.

The effect of rapid thoracoabdominal compressions on intracranial pressure in newborn lambs

Measurements of forced expiratory flow in infants can be obtained with the rapid thoracoabdominal compression (RTC) technique. To assess the transmission of the chest wall compression pressure into the cerebrum, we have performed intracranial pressure (ICP) measurements during RTCs in newborn lambs. Thirteen lambs were studied during the first 8 d of life. An epidural pressure transducer was implanted under general anesthesia. Respiratory measurements were performed under sedation with ketamine. RTCs were induced through an inflatable jacket wrapped around the lamb's trunk. RTCs were started with a pressure of 30 cm H2O. The compression pressure was increased in steps of 20 cm H2O up to 250 cm H2O. Flow and volume were determined with a pneumotachograph attached to a face mask. Transpulmonary pressure (Ptp) was measured with an esophageal balloon placed in the lower esophagus. RTCs resulted in proportional increases of Ptp and ICP. ICP was lower or equal to Ptp in all measurements. No changes in baseline ICP occurred throughout the study period. The maximal ICP observed during RTCs was within the range of pressures observed during crying in newborn infants. These data suggest that the RTC technique can be considered safe even at high compression pressures.

Morphology of antennal motoneurons in the brains of two crickets, Gryllus bimaculatus and Gryllus campestris

The morphology of the antennal muscles of two cricket species, Gryllus campestris and G. bimaculatus, and their innervation are described. The motoneurons innervating the five tentorio-scapal muscles M4 and M5 and the two scapo-pedicellar muscles M6 and M7 were stained with cobalt chloride introduced via the cut axonal endings in the muscle. The seven antennal muscles are innervated by a total of 17 excitatory motoneurons and one common inhibitory neuron. These neurons branch in the dorsal neuropil of the deuto- and tritocerebrum. No difference in the morphology of the motoneurons between the two species was evident. Two dorsal-unpaired-medial (DUM) neurons located in the suboesophageal ganglion also innervate the antennal muscles. Intracellular recordings of some motoneurons combined with Lucifer Yellow injections corroborated the motoneuron morphology obtained by cobalt backfilling from the muscles. The recordings showed that the motoneurons are either of the fast or the slow type.