Efficacy and safety of alogliptin added to pioglitazone in Japanese patients with type 2 diabetes: a randomized, double-blind, placebo-controlled trial with an open-label long-term extension study

AIM

To assess the efficacy and safety of alogliptin added to pioglitazone versus pioglitazone monotherapy, in Japanese patients with type 2 diabetes who achieved inadequate glycaemic control on pioglitazone plus diet/exercise.

METHODS

Patients were stabilized on pioglitazone 15 or 30 mg/day plus diet/exercise during a 16-week screening period. Patients with HbA1c of 6.9-10.4% were randomized to 12 weeks' double-blind treatment with alogliptin 12.5 or 25 mg once daily or placebo, added to their stable pioglitazone regimen. The primary endpoint was the change in HbA1c from baseline to week 12. Patients had an option to continue in a 40-week, open-label extension study, with those originally randomized to alogliptin remaining on the same dosage regimen while patients treated with placebo were randomly allocated to alogliptin 12.5 or 25 mg (added to their stable pioglitazone).

RESULTS

The change from baseline in HbA1c after 12 weeks was significantly greater with alogliptin 12.5 mg added to pioglitazone and alogliptin 25 mg added to pioglitazone than with placebo added to pioglitazone (-0.91 and -0.97% vs. -0.19%; p < 0.0001). Responder rates (HbA1c <6.9% and HbA1c <6.2%) and changes in fasting and postprandial blood glucose levels showed a similar positive trend in terms of glycaemic control. The benefits seen with alogliptin were sustained during the 40-week extension period. Alogliptin added to pioglitazone was generally well tolerated; hypoglycaemia was infrequent and increases in body weight were minor.

CONCLUSIONS

Once-daily alogliptin was effective and generally well tolerated when given as add-on therapy to pioglitazone in Japanese patients with type 2 diabetes who achieved inadequate glycaemic control on pioglitazone plus lifestyle measures. Clinical benefits were maintained for 52 weeks.

Anti-MuSK autoantibodies block binding of collagen Q to MuSK

OBJECTIVE

Muscle-specific receptor tyrosine kinase (MuSK) antibody-positive myasthenia gravis (MG) accounts for 5%-15% of autoimmune MG. MuSK mediates the agrin-signaling pathway and also anchors the collagenic tail subunit (ColQ) of acetylcholinesterase (AChE). The exact molecular target of MuSK-immunoglobulin G (IgG), however, remains elusive. As acetylcholine receptor (AChR) deficiency is typically mild and as cholinesterase inhibitors are generally ineffective, we asked if MuSK-IgG interferes with binding of ColQ to MuSK.

METHODS

We used 3 assays: in vitro overlay of the human ColQ-tailed AChE to muscle sections of Colq-/- mice; in vitro plate-binding assay to quantitate binding of MuSK to ColQ and to LRP4; and passive transfer of MuSK-IgG to mice.

RESULTS

The in vitro overlay assay revealed that MuSK-IgG blocks binding of ColQ to the neuromuscular junction. The in vitro plate-binding assay showed that MuSK-IgG exerts a dose-dependent block of MuSK binding to ColQ by but not to LRP4. Passive transfer of MuSK-IgG to mice reduced the size and density of ColQ to ∼10% of controls and had a lesser effect on the size and density of AChR and MuSK.

CONCLUSIONS

As lack of ColQ compromises agrin-mediated AChR clustering in Colq-/- mice, a similar mechanism may lead to AChR deficiency in MuSK-MG patients. Our experiments also predict partial AChE deficiency in MuSK-MG patients, but AChE is not reduced in biopsied NMJs. In humans, binding of ColQ to MuSK may be dispensable for clustering ColQ, but is required for facilitating AChR clustering. Further studies will be required to elucidate the basis of this paradox.

Changes in beef sensory traits as somatic-cell-cloned Japanese black steers increased in age from 20 to 30 months

Changes in sensory traits of longissimus muscle (LM) from 20-30-month-old cattle were investigated using somatic cell clones of Japanese black steers slaughtered at 20-, 25- and 30-months-old (n=3, 4 and 4 respectively). The fat content of LM samples at 20, 25 and 30 months were 23.7, 38.7 and 41.1%, respectively. Soluble collagen content and collagen solubility at 20 months was greater than at 25 and 30 months. In terms of sensory traits, initial tenderness and juiciness at 25 months was greater than at 20 months, and fattiness at 25 and 30 months was greater than at 20 months. These results demonstrate that the changes in physicochemical traits of beef accompanying the differences in slaughter age affect the sensory traits although the desirable effects of the sensory traits do not continue throughout the entire fattening period.

138 TIME-LAPSE CINEMATOGRAPHY-COMPATIBLE INJECTION-MOLDED MICROWELL CULTURE SYSTEM FOR TRACKING THE DEVELOPMENT OF INDIVIDUAL BOVINE EMBRYOS

We have developed a polystyrene-based well of-the-well system (WOW) using injection moulding to track individual embryos throughout culture using time-lapse cinematography (TLC). The WOW-cultured bovine embryos following in vitro fertilization (IVF) were compared with conventional droplet (control)-cultured embryos on in vitro and in vivo development. Twenty-five of zygotes were cultured in each culture system containing 125 μL of CR1aa medium supplemented with 5% calf serum for 168 h after IVF. No differences between control- and WOW-cultured embryos were observed during development to the blastocyst stage. Morphological quality, inner cell mass (ICM), and trophectoderm (TE) cell numbers and post-vitrification survival rates were not different between control- and WOW-derived blastocysts; however, incidence of apoptosis in the ICM and TE cells was reduced in WOW culture (P < 0.01). Oxygen consumption in WOW-derived blastocysts was closer to physiological level than that of control-derived blastocysts. Moreover, WOW culture improved embryo viability, as indicated by increased pregnancy rates at days 30 and 60 after embryo transfer (P < 0.05). The TLC monitoring was performed to evaluate the cleavage pattern and the duration of the first cell cycle of embryos from oocytes collected by ovum pick-up; correlations with success of pregnancy were determined. Logistic regression analysis indicated that the cleavage pattern correlated with success of pregnancy (P < 0.05), but cell cycle length did not. Higher pregnancy rates (66.7%) were observed for animals in which transferred blastocysts had undergone normal cleavage, identified by the presence of 2 blastomeres of the same size without fragmentation, than among those with abnormal cleavage (33.3%). These results suggest that our microwell culture system is a powerful tool for producing and selecting healthy embryos and for identifying viability biomarkers. This work was supported by the Research and Developmental Program for New Bio-Industry Initiatives.

212 EFFECT OF CONSECUTIVE SUPERSTIMULATORY TREATMENT-INDUCED FOLLICULAR WAVE SYNCHRONIZATION TO OPTIMIZE OOCYTE RETRIEVAL AND EMBRYO PRODUCTION BY OVUM PICKUP AND IN VITRO FERTILIZATION IN COWS

We previously reported that superstimulatory (SS) treatment-induced follicular wave synchronization after ovum pickup (OPU) was effective in enhancing the quality of obtained oocytes and blastocysts derived from in vitro maturation (IVM) and fertilization (IVF; Imai et al. 2010 Reprod. Fertil. Dev. 22, 296). The present study was designed to examine the efficiency of embryo production by 4 sessions of OPU-IVF using a series of the SS treatment-induced follicular wave synchronizations. For the SS protocols, 3 consecutive SS (3CSS) and 2 separated SS (2SSS) were used. In the 3CSS group, the first OPU was performed on random days of the oestrous cycle (Day 0) and all follicles larger than 2 mm in diameter were aspirated. On Day 5, follicles larger than 8 mm in diameter were aspirated and a CIDR (InterAg, Hamilton, New Zealand) was inserted. The cows then received 20 armour units of FSH (Kawasaki-Seiyaku, Kawasaki, Japan) in twice-daily decreasing doses by IM injection from Day 7 to 10. Cloprostenol (PGF; 0.75 mg, Fujita-Pharm, Tokyo, Japan) was administered on the morning of Day 9. The second OPU was performed 48 h after PGF administration on Day 11; the CIDR was removed from the cows just before OPU. After the second OPU, donors were treated consecutively with the SS protocol mentioned above for the third and fourth OPU sessions. In the 2SSS group, donors received 2 sets of the SS treatment mentioned above, with an interval of 11 days between the second and the third OPU session. Four OPU sessions were performed every 11 days on all cows. In this study, 8 Japanese Black cows were divided into the 3CSS and 2SSS groups, and the treatment for each group was reversed after a 65-day interval as crossover trials. After OPU, Grade 1 and 2 oocytes were used for IVM and IVF, and putative zygotes were cultured as described by (Imai et al. 2006 J. Reprod. Dev. 52, S19–S29 suppl.). A part of the zygotes were cultured in a micro-well system. Data were analysed by Student’s t-test and chi-square test. There were differences (P < 0.05) in the mean (±SD) number of follicles, collected oocytes, and cultured oocytes in the 3CSS (35.0 ± 8.6 and 24.4 ± 11.2, respectively) and 2SSS (30.8 ± 10.5 and 20.2 ± 9.0, respectively) groups. There were no differences in mean percentage of blastocyst formation and Grade 1 blastocyst rates between the 3CSS (38.5 and 55.8%, respectively) and 2SSS (34.8 and 54.8%, respectively) groups. However, the mean number of blastocysts produced per OPU session was significantly (P < 0.05) higher in the 3CSS group (8.1 ± 6.3) compared with the 2SSS group (5.8 ± 4.4). These results indicate that a series of 3 consecutive SS treatments had greater efficiency in producing OPU-IVF embryos. This work was supported in part by the Research and Development Program for New Bio-industry Initiatives.

Prediction of reactivity to noninherited maternal antigen in MHC-mismatched, minor histocompatibility antigen-matched stem cell transplantation in a mouse model

The immunologic effects of developmental exposure to noninherited maternal Ags (NIMAs) are quite variable. Both tolerizing influence and inducing alloreaction have been observed on clinical transplantation. The role of minor histocompatibility Ags (MiHAs) in NIMA effects is unknown. MiHA is either matched or mismatched in NIMA-mismatched transplantation because a donor of the transplantation is usually limited to a family member. To exclude the participation of MiHA in a NIMA effect for MHC (H-2) is clinically relevant because mismatched MiHA may induce severe alloreaction. The aim of this study is to understand the mechanism of NIMA effects in MHC-mismatched, MiHA-matched hematopoietic stem cell transplantation. Although all offsprings are exposed to the maternal Ags, the NIMA effect for the H-2 Ag was not evident. However, they exhibit two distinct reactivities, low and high responder, to NIMA in utero and during nursing depending on the degree of maternal microchimerism. Low responders survived longer with less graft-versus-host disease. These reactivities were correlated with Foxp3 expression of peripheral blood CD4(+)CD25(+) cells after graft-versus-host disease induction and the number of IFN-γ-producing cells stimulated with NIMA pretransplantation. These observations are clinically relevant and suggest that it is possible to predict the immunological tolerance to NIMA.

Pupillary autonomic dysfunction in multiple system atrophy and Parkinson's disease: an assessment by eye-drop tests

PURPOSE

To compare pupillary autonomic dysfunction in multiple system atrophy (MSA) and Parkinson's disease (PD).

METHODS

We administered eye-drop tests to 40 MSA patients, 40 PD patients with similar disease duration, and 20 age-matched healthy controls. Pupillary supersensitivity to a parasympathomimetic agent (0.05% pilocarpine hydrochloride) and to a sympathomimetic agent (0.02% dipivefrine hydrochloride) was examined by assessing changes in pupil diameter.

RESULTS

Pupillary supersensitivity to a parasympathomimetic agent (0.05% pilocarpine hydrochloride) and to a sympathomimetic agent (0.02% dipivefrine hydrochloride) was examined by assessing changes in pupil diameter. Pupillary supersensitivity to 0.05% pilocarpine was greatest among the PD patients (PD -23.1 +/- 14.4%, MSA -12.4 +/- 11.5%, control -9.5 +/- 8.2%, p < 0.05) but was not correlated with disease duration. Pupillary sensitivity to 0.02% dipivefrine was significantly greater in the PD and MSA patients versus controls (PD 10.5 +/- 12.0%, MSA 11.8 +/- 11.0%, control 3.1 +/- 5.8%, p < 0.05). MSA patients had pupillary sympathetic dysfunction from an early stage, whereas in PD patients it tended to gradually accelerate as the disease advanced. In MSA patients, pupillary sympathetic sensitivity to 0.02% dipivefrine was correlated with the severity of orthostatic hypotension during a head-up tilt test and with the elevation of systolic blood pressure during a noradrenaline infusion test. In PD patients, pupillary sympathetic sensitivity to 0.02% dipivefrine was correlated with a reduction of the heart-to-mediastinum (H/M) ratio using delayed-phase iodine-123 meta-iodobenzylguanidine ((123)I-MIBG) myocardial scintigraphy.

CONCLUSION

These data indicate that eye-drop tests can reveal differences in the progression of pupillary autonomic dysfunction in patients with MSA and PD.

Outcome of recurrent or refractory acute lymphoblastic leukemia in infants with MLL gene rearrangements: A report from the Japan Infant Leukemia Study Group

BACKGROUND

Despite the poor outcome of recurrent or refractory acute lymphoblastic leukemia (ALL) in infants with MLL gene rearrangement, few studies have focused on this specific group. We conducted a retrospective analysis of infants with recurrent or refractory ALL from two previous consecutive Japanese studies to clarify the characteristics and prognostic factors among these patients

PROCEDURE

All recurrent or refractory ALL infants with MLL gene rearrangement (MLL-R) who were registered in two consecutive Japanese nation-wide multicentric trials (MLL96 and MLL98; between 1995 and 2001) were eligible for the study.

RESULTS

Among 80 MLL-R ALL infants, 34 cases of recurrence and 5 induction failures occurred. The median duration of first remission was 5 months (range, 0-28 months). All patients underwent various salvage chemotherapies; remission was achieved in 40.5% (15/37). A total of 23 patients received subsequent hematopoietic stem cell transplantations (HSCT): 9 in remission, 12 without remission, and 2 with unknown status. With median follow-up period of 5.5 years, the 5-year overall survival (OS) rate after the second-line treatment was 25.6% +/- 6.9%. Young age (<3 months) and central nervous system involvement at initial diagnosis were associated with poor outcome; however, failure to achieve remission after salvage therapy was the sole independent poor prognostic factor in multivariate analysis (P = 0.01).

CONCLUSIONS

The prognosis of infants with recurrent or refractory MLL-R ALL is extremely poor despite alternative treatments including HSCT; therefore, it is necessary to develop novel treatment strategies.

Long-term phenotypic, functional and genetic stability of cancer-specific T-cell receptor (TCR) alphabeta genes transduced to CD8+ T cells

In adoptive T-cell transfer as an intervention for malignant diseases, retroviral transfer of T-cell receptor (TCR) genes derived from CD8(+) cytotoxic T-lymphocyte (CTL) clones provides an opportunity to generate a large number of T cells with the same antigen specificity. We cloned the TCR-alphabeta genes from a human leukocyte antigen (HLA)-A(*)2402-restricted CTL clone specific for MAGE-A4(143-151). The TCR-alphabeta genes were transduced to 99.2% of non-TCR expressing SupT1, a human T-cell line, and to 12.7-32.6% of polyclonally activated CD8(+) T cells by retroviral transduction. As expected, TCR-alphabeta gene-modified CD8(+) T cells showed cytotoxic activity and interferon-gamma production in response to peptide-loaded T2-A(*)2402 and tumor cell lines expressing both MAGE-A4 and HLA-A(*)2402. A total of 24 clones were established from TCR-alphabeta gene-transduced peripheral blood mononuclear cells and all clones were functional on a transduced TCR-dependent manner. Four clones were kept in culture over 6 months for analyses in detail. The transduced TCR-alphabeta genes were stably maintained phenotypically, functionally and genetically. Our results indicate that TCR-transduced alphabeta T cells by retroviral transduction represent an efficient and promising strategy for adoptive T-cell transfer for long term.

Ataxic vs painful form of paraneoplastic neuropathy

OBJECTIVE

To characterize the clinicopathologic features of ataxic and painful forms of paraneoplastic neuropathy.

METHODS

Clinical, electrophysiologic, and histopathologic findings were assessed in 17 patients with paraneoplastic neuropathy.

RESULTS

Clinical features can be categorized into two groups: one group (13 patients) with predominantly deep sensory disturbance and a second group (4 patients) with predominantly superficial sensory disturbance. The former group showed severe sensory ataxia and predominantly large myelinated fiber loss in the sural nerve. The latter group showed marked pain, in particular, severe mechanical hyperalgesia, and predominantly small myelinated and unmyelinated fiber loss. Nerve conduction assessment indicated an axonal neuropathy pattern in both groups, while sensory action potentials were more markedly diminished in the sensory ataxic form. Anti-Hu antibodies were detected in half of the patients in both groups. Treatment for cancer was effective to improve or stabilize neuropathic symptoms in some cases from both groups. Immunotherapy was effective only for a short time.

CONCLUSIONS

Paraneoplastic neuropathy can be characterized into two groups by the presence of sensory ataxia or severe spontaneous pain and severe mechanical hyperalgesia. Preferential small myelinated and unmyelinated fiber loss correlated to the cases of severe pain.

Hematopoietic engraftment in recipients of unrelated donor umbilical cord blood is affected by the CD34+ and CD8+ cell doses

Umbilical cord blood (UCB) transplantation is limited by the low number of hematopoietic stem cells in UCB units, which results in a low engraftment rate in transplant recipients. Here, we measured the total nucleated cell count and CD34(+), CD3(+), CD4(+), CD8(+), CD14(+), and CD16(+)/56(+) cell doses in each UCB unit and evaluated their influence on engraftment and other outcomes in 146 recipients. Multivariate analysis showed a significant association between a higher incidence of successful engraftment and a dose of CD34(+) and CD8(+) cells above the median (1.4 x 10(5) and 15.7 x 10(5) cells/kg, respectively). Engraftment occurred 4 days earlier in patients who received UCB with more than the median dose of CD34(+) cells than those receiving UCB at or below the median. Stratification of the group according to CD34(+) cell dose revealed a significant influence of the CD8(+) cell dose on the time to achieve neutrophil engraftment in patients receiving a lower CD34(+) cell dose, whereas there was no significant influence in the patients receiving a higher CD34(+) cell dose. These results suggest that consideration of CD34(+) and CD8(+) cell doses in UCB units may improve the engraftment in recipients of UCB transplantation.

42 PREPARTUM HORMONAL CHANGES IN RECIPIENT COWS FOR SOMATIC CELL CLONED FETUSES

Placental estrogens are associated with fetal growth and development, and play important roles in the initiation of the parturition process. In the delivery of somatic cell-cloned (SC) calves, recipient cows show a weak and unclear symptom of parturition, although large offspring syndrome (LOS) frequently occurs. The mortality of calves by dystocia decreases the efficiency of SC cattle production. In this study, we examined peripheral estrone (E1), estradiol-17� (E2), estrone sulfate (E1S), and progesterone (P4) levels during preparturition in recipients of SC and in vivo calves. Recipients were administered 20 mg dexamethasone (DEX) at Days 276-288 of pregnancy, followed by 0.75-1 mg cloprostenol (PG) and 20 mg estriol 24 h later. Calves (Japanese black cattle) were delivered 2 or 3 days after the DEX administration. SC calves were delivered by cesarean section (C-sec) when LOS was suspected by rectal palpation. Blood samples of recipients [vaginal delivery of SC (Vag): n = 13; C-sec of SC: n = 8; vaginal delivery of in vivo calves (Control): n = 4] were taken at Days 257 and 271 of pregnancy, and just before DEX (-2P), PG (-1P), and parturition (0P). Blood samples of calves were taken just after delivery to analyze cortisol level. The statistical significance was analyzed by the Steel-Dwass test. Birth weight of calves was the heaviest (P &lt; 0.05) in C-sec (62 � 3 kg; n = 12); Vag calves (43 � 2 kg; n = 19) were also heavier (P &lt; 0.05) than Control calves (29 � 2 kg; n = 9). E1 levels in Control calves remained low (&lt;629 � 111 pg mL-1) until Day 271 and then increased progressively (&gt;2156 � 599 pg mL-1). E1 levels tended to be lower in Vag (&lt;1968 � 299 pg mL-1) and C-sec (&lt;1268 � 385 pg mL-1) calves at -2P, -1P, and 0P; E1 levels in C-sec calves were significantly lower (P &lt; 0.05) than in Control calves at -2P (512 � 85 pg/mL-1) and -1P (725 � 91 pg mL-1). The E2 level in Control calves increased and reached a plateau at -2P. Vag and C-sec calves showed lower E2 levels, except that the Vag level at 0P was similar to that in Control calves. The E2 level of C-sec calves (61.8 � 25.3 pg mL-1) at 0P was significantly lower (P &lt; 0.05) than that of Control calves (247.5 � 102.8 pg mL-1). E1S levels in Vag and C-sec calves increased progressively from -2P to 0P, whereas the E1S level in Control calves increased at 0P. The E1S level in Vag calves (41.1 � 4.1 ng mL-1) was significantly higher (P &lt; 0.05) than in Control calves (19.4 � 5.1 ng mL-1) at -1P. P4 levels decreased from -2P in Vag and Control calves, and from -1P in C-sec calves. The cortisol level in C-sec calves (60.1 � 19.1 ng mL-1) tended to be low compared with that in Vag (104.4 � 23.1 ng mL-1) and Control (93.4 � 15.0 ng mL-1) calves. This study revealed fetoplacental dysfunction of estrogen synthesis in the SC fetus during preparturition. Elevated E1S levels in recipients of the SC fetus, which correlated with high birth weight and agreed with previous reports for normal or plural pregnancy, might cause the reduction of E1 level. The comparable level of cortisol in Vag and Control calves indicated that SC calves had normal adrenal cortex function. Further analysis on placental estrogen synthesis and cortisol secretion in the SC fetus is necessary to clarify the cause of the prolonged gestation.

Development of a dendritic cell vaccine against measles for patients following hematopoietic cell transplantation

Most patients who have undergone hematopoietic cell transplantation (HCT) lose specific immunity to measles. However, due to its immunosuppressive potential, it has been recommended that a live attenuated measles vaccination be administered two years following HCT. Measles virus (MV) glycoproteins including hemagglutinin (HA) are expressed on MV-infected dendritic cells (DCs), and they impair efficient antigen presentation between the DC and T cell. We produced a DC-based vaccine against MV by loading DCs with MV-infected autologous DCs. MV in the infected DCs was inactivated using ultraviolet-B. The DC-based vaccine neither expressed HA nor inhibited allogeneic T cell proliferation, while it induced the production of interferon-gamma (IFN-gamma) by autologous CD4 and CD8 naive T cells ex vivo. Importantly, the vaccine derived from patients who had undergone HCT also efficiently induced IFN-gamma producing cells. These findings indicate that our DC-based MV vaccine induces MV-specific immunity even in post-HCT patients without causing immunosuppression.

Detection of new anti-neutral glycosphingolipids antibodies and their effects on Trk neurotrophin receptors

We screened sera from patients with various neurological disorders for the presence of anti-neutral glycosphingolipids antibodies and only found them in sera from relapsing polychondritis with limbic encephalitis patients. Neutral glycosphingolipids are resident in membrane lipid rafts where high affinity nerve growth factor (NGF) receptor, Trk is co-localized. Therefore, we examined whether these antibodies influence the action of NGF in NGF-responsive cells. The results strongly suggest that these antibodies enhance NGF-induced Trk autophosphorylation and neurite outgrowth as well as neurofilament M expression. These data strongly indicate that these anti-neutral glycosphingolipids antibodies have a functional impact on NGF-Trk-mediated intracellular signal transduction pathway.