Safety and Efficacy of Lemborexant in Patients With Irregular Sleep-Wake Rhythm Disorder and Alzheimer's Disease Dementia: Results From a Phase 2 Randomized Clinical Trial.

BACKGROUND: Irregular sleep-wake rhythm disorder (ISWRD) is a common sleep disorder in individuals with Alzheimer's disease dementia (AD-D). OBJECTIVES: This exploratory phase 2 proof-of-concept and dose-finding clinical trial evaluated the effects of lemborexant compared with placebo on circadian rhythm parameters, nighttime sleep, daytime wakefulness and other clinical measures of ISWRD in individuals with ISWRD and mild to moderate AD-D. DESIGN: Multicenter, randomized, double-blind, placebo-controlled, parallel-group study. SETTING: Sites in the United States, Japan and the United Kingdom. PARTICIPANTS: Men and women 60 to 90 years of age with documentation of diagnosis with AD-D and Mini-Mental State Exam (MMSE) score 10 to 26. INTERVENTION: Subjects were randomized to placebo or one of four lemborexant treatment arms (2.5 mg, 5 mg, 10 mg or 15 mg) once nightly at bedtime for 4 weeks. MEASUREMENTS: An actigraph was used to collect subject rest-activity data, which were used to calculate sleep-related, wake-related and circadian rhythm-related parameters. These parameters included least active 5 hours (L5), relative amplitude of the rest-activity rhythm (RA) and mean duration of sleep bouts (MDSB) during the daytime. The MMSE and the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) were used to assess for changes in cognitive function. RESULTS: Sixty-two subjects were randomized and provided data for circadian, daytime and nighttime parameters (placebo, n = 12; lemborexant 2.5 mg [LEM2.5], n = 12; lemborexant 5 mg [LEM5], n = 13, lemborexant 10 mg [LEM10], n = 13 and lemborexant 15 mg [LEM15], n = 12). Mean L5 showed a decrease from baseline to week 4 for LEM2.5, LEM5 and LEM15 that was significantly greater than with placebo (all p < 0.05), suggesting a reduction in restlessness. For RA, LS mean change from baseline to week 4 versus placebo indicated greater distinction between night and day with all dose levels of lemborexant, with significant improvements seen with LEM5 and LEM15 compared with placebo (both p < 0.05). The median percentage change from baseline to week 4 in MDSB during the daytime indicated a numerical decrease in duration for LEM5, LEM10 and LEM15, which was significantly different from placebo for LEM5 and LEM15 (p < 0.01 and p = 0.002, respectively). There were no serious treatment-emergent adverse events or worsening of cognitive function, as assessed by the MMSE and ADAS-Cog. Lemborexant was well tolerated. No subjects discontinued treatment. CONCLUSIONS: This study provides preliminary evidence of the potential utility of lemborexant as a treatment to address both nighttime and daytime symptoms in patients with ISWRD and AD-D.

[Experience of using reamberin for detoxification therapy at the stage of deworming in children with chronic opisthorchiasis].

The study presents data on the reversible aggregation of erythrocytes in 50 children with chronic opisthorchiasis and 45 children with inflammatory diseases of the upper digestive tract without opisthorchiasis (chronic gastroduodenitis, duodenal ulcers), all patients aged from 7 to 17 years. The results of using reamberin for detoxification therapy at the stage of deworming in children with chronic opisthorchiasis are assessed.

[Changes in erythrocyte superoxide dismutase and catalase activity in premature newborns with intraventricular haemorrhages].

Superoxide dismutase and catalase activities have been studied in peripherical blood erythrocytes of 49 premature newborns at 28-37 weeks gestation. Superoxide dismutase and catalase activities were lower in patients with bacterial infection of meninges. The standard therapy did not restore superoxide dismutase and catalase activities by the end of the neonatal period.

[Experience with non-drug correction of autonomic disorders in adolescents]. / Opyt nemedikamentoznoi korrektsii begetativnykh rasstroistv u podrostkov.

The efficiency of recovery of autonomic imbalance by auricular electric neurostimulation (AENS) was studied. Thirty-nine children aged 11 to 15 years who had been diagnosed as having vegetative dystonia were divided into 2 groups: Group 1 (n = 18) received therapy with AENS; Group 2 (a control group) (n = 21) had the standard drug therapy. The study has indicated that AENS is more effectively than the standard therapy. In Group 1, clinical symptoms began ameliorating more early than in Group 2. According to instrumental data, positive changes were recorded in all the children in Group 1 and only in 57.2% in Group 2. It is concluded that it is expedient to use AENS to correct autonomic imbalance.

[The activity of superoxide dismutase and glutathione peroxidase and the level of malonic dialdehyde in prematures with hypoxic disorders of the central nervous system]. / Aktivnost'superoksiddismutazy,glutationperoksidazy i uroven; malonovogo dial'degida u nedonoshennykh novorozhdennykh s gipoksicheskim porazheniem tsentral'noi nervnoi sistemy.

The activity of superoxide dismutase and glutathione peroxidase and the level of malonic dialdehyde were studied 53 prematures with hypoxia of the central nervous system. A low activity of superoxide dismutase and glutathione peroxidase, which depended on a prematurity degree and on a content of malonic dialdehyde in the erythrocyte cell membranes, was found. A higher level of malonic dialdehyde in erythrocyte membranes was shown to be an unfavorable prognostication factor for the development of intraventricular hemorrhages in prematures.

[Ontogenetic peculiarities of hemostasis in newborn children]. / Ontogeneticheskie osobennosti gemostaza u novorozhdennykh detei.

A total of 25 newborns (15 full-term and 10 preterm babies) were examined. The coagulative and summary lytic blood activity with regard for the aggregategram and hemocoagulagram findings was studied. The following was established: the neonatal period of healthy babies is characterized by changing stages in the hemostasis system, i.e. hypocoagulation is followed by the normalized coagulation fibrinolytic activity. Preterm babies have more pronounced changes and become normal later.

Cytokines decrease sGC in pulmonary artery smooth muscle cells via NO-dependent and NO-independent mechanisms.

Exposure of rat pulmonary artery smooth muscle cells (rPASMC) to cytokines leads to nitric oxide (NO) production by NO synthase 2 (NOS2). NO stimulates cGMP synthesis by soluble guanylate cyclase (sGC), a heterodimer composed of alpha(1)- and beta(1)-subunits. Prolonged exposure of rPASMC to NO decreases sGC subunit mRNA and protein levels. The objective of this study was to determine whether levels of NO produced endogenously by NOS2 are sufficient to decrease sGC expression in rPASMC. Interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) increased NOS2 mRNA levels and decreased sGC subunit mRNA levels. Exposure of rPASMC to IL-1beta and TNF-alpha for 24 h decreased sGC subunit protein levels and NO-stimulated sGC enzyme activity. L-N(6)-(1-iminoethyl)lysine (NOS2 inhibitor) or 1H-[1,2,4]oxadiazolo-[4,3-a]quinoxalin-1-one (sGC inhibitor) partially prevented the cytokine-mediated decrease in sGC subunit mRNA levels. However, cytokines also decreased sGC subunit mRNA levels in PASMC derived from NOS2-deficient mice. These results demonstrate that levels of NO and cGMP produced in cytokine-exposed PASMC are sufficient to decrease sGC subunit mRNA levels. In addition, cytokines can decrease sGC subunit mRNA levels via NO-independent mechanisms.

[Lipids of lymphocyte plasma membranes in patients with atherosclerosis and their children]. / Lipidy plazmaticheskikh membran limfotsitov u bol'nykh aterosklerozom i ikh detei.

Phospholipid composition and activity of 5'nucleotidase of lymphocyte plasmatic membranes were studied in patients with atherosclerosis (AS) and their children. The content of phosphatidylcholine, cholesterol/total phospholipid ratio, transmembrane asymmetry of lipids were increased, 5'nucleotidase activity decreased, and lymphocyte plasmatic membranes contained accumulations of lisophospholipids (LPL). This indicated increased hydrophobia and decreased functional activity and damage of lymphocyte plasmatic membranes. Increased transmembrane lipid asymmetry and LPL accumulations were detected in the lymphocyte plasmatic membranes of children with aggravated heredity for AS. Presumably these disorders anticipate the changes in the structure of plasmatic membranes, observed in adult patients with AS, and progress in case of exposure to unfavorable factors.

Maturational changes in ovine pulmonary vascular responses to inhaled nitric oxide.

Developmental changes in modulation of pulmonary vasomotor tone by endothelium-derived nitric oxide (EDNO) may reflect maturational differences in endothelial synthesis of and/or vascular smooth muscle response to nitric oxide. This study sought to determine whether pulmonary vascular sensitivity and responsiveness to nitric oxide change during newborn development, and whether this is related to changes in guanylate cyclase activity. Pulmonary artery dose-responses to inhaled nitric oxide (iNO, 0.25-100 parts per million) were measured in hypoxic, indomethacin-treated, isolated lungs from 1-day (1-d)- and 1-month (1-m)-old lambs. The lungs of 1-m-old lambs were ventilated with 4% (oxygen) O2, and lungs of 1-d-old lambs were ventilated with either 4% or 7% O2 in order to achieve similar stimuli or vasomotor tone. Cyclic guanosine monophosphate (cGMP) concentrations in the perfusate were measured at iNO concentrations of 0, 5, and 100 parts per million (ppm). Basal and stimulated pulmonary guanylate cyclase activity was also measured in lung extracts in vitro. The effects of iNO were similar in both 1-d groups, even though baseline hypoxic tone was significantly higher in 1-d lungs ventilated with 4% O2 than with 7% O2. Furthermore, both the 1-d 7% O2 and 1-d 4% O2 lungs exhibited greater responsiveness and sensitivity to iNO than 1-m lungs. Perfusate cGMP concentrations and soluble guanylate cyclase activity were higher under stimulated than basal conditions, but neither differed statistically between 1 d and 1 m. These data suggest that pulmonary vascular responsiveness and sensitivity to nitric oxide decrease with age, but the mechanisms underlying these maturational changes require further investigation.

Adenovirus-mediated gene transfer of cGMP-dependent protein kinase increases the sensitivity of cultured vascular smooth muscle cells to the antiproliferative and pro-apoptotic effects of nitric oxide/cGMP.

Studies in vitro have underestimated the importance of cGMP-dependent protein kinase (PKG) in the modulation of vascular smooth muscle cell (SMC) proliferation and apoptosis in vivo. This is attributable, in part, to a rapid decline in PKG levels as vascular SMC are passaged in culture. We used a recombinant adenovirus encoding PKG (Ad.PKG) to augment kinase activity in cultured rat pulmonary artery SMC (RPaSMC). Incubation of Ad. PKG-infected RPaSMC (multiplicity of infection = 200) with 8-Br-cGMP decreased serum-stimulated DNA synthesis by 85% and cell proliferation at day 5 by 74%. The effect of 8-Br-cGMP on DNA synthesis in Ad.PKG-infected RPaSMC was blocked by KT5823 (PKG inhibitor), but not by KT5720 (cAMP-dependent protein kinase inhibitor). A nitric oxide (NO) donor compound, S-nitrosoglutathione, at concentrations as low as 100 nM, inhibited DNA synthesis in Ad. PKG-infected RPaSMC, but not in uninfected cells or in cells infected with a control adenovirus. In addition, 8-Br-cGMP and S-nitrosoglutathione induced apoptosis in serum-deprived RPaSMC infected with Ad.PKG, but not in uninfected cells or in cells infected with a control adenovirus. These results demonstrate that modulation of PKG levels in vascular SMC can alter the sensitivity of these cells to NO and cGMP. Moreover, these observations suggest an important role for PKG in the regulation of vascular SMC proliferation and apoptosis by NO and cGMP.

Cyclic-GMP-binding, cyclic-GMP-specific phosphodiesterase (PDE5) gene expression is regulated during rat pulmonary development.

Increased nitric oxide (NO) production plays a critical role in the mammalian pulmonary vascular adaptation to extrauterine life. NO activates soluble guanylate cyclase, increasing intracellular cGMP concentrations, thereby inducing relaxation of vascular smooth muscle. cGMP is inactivated by cyclic nucleotide phosphodiesterases (PDEs). One PDE isozyme, PDE5, specifically hydrolyzes cGMP, is abundant in lung tissues, and modifies the pulmonary vasodilatory response to exogenous NO. To investigate the regulation of PDE5 gene expression during pulmonary development, PDE5 mRNA levels, as well as cGMP-metabolizing PDE enzyme activity, were measured in the lungs of perinatal and adult rats. RNA blot hybridization revealed that PDE5 mRNA was detectable in fetal lung tissue as early as 18.5 d of the 22-d term gestation and reached maximal levels in neonatal lungs. mRNA levels in adult rat lungs were 3-4-fold less than the levels measured in lungs of 1- and 8-d-old rats. Pulmonary cGMP hydrolytic activity in 1-d-old animals was 30-fold greater than the cGMP hydrolytic activity of adult rat lungs. Zaprinast, a specific PDE5 antagonist, inhibited 52 and 56% of cGMP hydrolytic activity in lungs of 1- and 8-d-old rats, respectively, but only 18% of the activity in adult lungs. In situ hybridization revealed that PDE5 mRNA transcripts were present in the vascular smooth muscle cells of neonatal and adult lungs. PDE5 mRNA was also detected in the alveolar walls of neonatal rat lungs. These results demonstrate that the gene encoding PDE5 is abundantly expressed in the lungs of perinatal rats, and is available to participate in the mammalian pulmonary vascular transition to extrauterine life. Extravascular PDE5 gene expression in neonatal lungs suggests a potentially important nonvascular role for this enzyme during pulmonary development.

[Reversible red cell aggregation in children with insulin-dependent diabetes mellitus]. / Obratimaia agregatsiia eritrotsitov pri insulinzavisimom sakharnom diabete u detei.

Red cell aggregation has been studied by photometry in 47 children with insulin-dependent diabetes mellitus. The disease was associated with boosting of reversible red cell aggregation, which was most of all expressed during metabolic decompensation with ketoacidosis. When metabolic subcompensation was attained, this parameter did not completely normalize and still had to be corrected.

Nitric oxide decreases stability of mRNAs encoding soluble guanylate cyclase subunits in rat pulmonary artery smooth muscle cells.

Nitric oxide stimulates soluble guanylate cyclase (sGC) to convert GTP to the intracellular second messenger cGMP. In rat pulmonary artery smooth muscle cells, sGC is an obligate heterodimer composed of alpha1 and beta1 subunits. We investigated the effect of NO donor compounds on sGC subunit gene expression in rat pulmonary artery smooth muscle cells. Sodium nitroprusside and S-nitroso-glutathione decreased sGC subunit mRNA and protein levels, as well as sGC enzyme activity. 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one, an sGC inhibitor, blocked the effect of sodium nitroprusside on sGC subunit gene expression, whereas 8-bromo cGMP decreased subunit mRNA levels, demonstrating that NO-mediated decrease in sGC subunit mRNA levels is cGMP-dependent. sGC subunit mRNA levels decreased more rapidly in rat pulmonary artery smooth muscle cells exposed to NO than in cells exposed to actinomycin D, suggesting that NO decreases sGC subunit mRNA stability. Actinomycin D and cycloheximide blocked the ability of NO to decrease sGC subunit mRNA levels. These results demonstrate that NO decreases sGC subunit mRNA stability via a transcription- and translation-dependent mechanism.

Pulmonary soluble guanylate cyclase, a nitric oxide receptor, is increased during the perinatal period.

Nitric oxide (NO) has an important role in the pulmonary vasodilatation associated with the transition from fetal to neonatal life. NO activates pulmonary soluble guanylate cyclase (sGC), an obligate heterodimer composed of alpha1- and beta1-subunits, increasing synthesis of guanosine 3',5'-cyclic monophosphate (cGMP) and leading to vasodilation. In this study, regulation of sGC subunit expression during pulmonary development was examined. RNA blot hybridization revealed abundant alpha1- and beta1-subunit mRNA in lungs of late-gestation fetal and neonatal Sprague-Dawley rats, with markedly reduced levels detected in adult lungs. Pulmonary sGC enzyme activity in the presence of 1 mM sodium nitroprusside, a NO-donor compound, was approximately sevenfold greater in 1- and 8-day-old rats than in adult rats (P < 0.03). With the use of immunoblot techniques, pulmonary alpha1-subunit concentrations closely correlated with mRNA levels. With in situ hybridization, alpha1- and beta1-subunit mRNAs were readily detected in pulmonary vascular and bronchial smooth muscle cells as well as alveolar and serosal epithelial cells in lungs of 1-day-old rats. In adult lungs, sGC subunit mRNAs were present at low levels and were found nearly exclusively in bronchial and vascular smooth muscle cells. These results demonstrate that abundant pulmonary sGC is available to respond to the increased NO produced during the perinatal period. High-level expression of sGC subunit genes outside the vasculature of lungs of 1-day-old rats suggests an important role for NO-cGMP signal transduction in the perinatal regulation of pulmonary epithelial function and bronchial tone.

[Features of surface architectonics and ultrastructure of peripheral blood in children with insulin-dependent diabetes mellitus]. / Osobennosti poverkhnostnoi arkhitektoniki i ul'trastruktury perifericheskoi krovi u detei, bol'nykh insulinzavisimym sakharnym diabetom.

Electron microscopic study of the surface architectonics and ultrastructure of the peripheral blood erythrocytes in 25 children with insulin-dependent diabetes mellitus (IDDM) revealed that the decrease of the count of disk-shaped cells, increased count of transitional and degenerative forms, and alteration of their ultrastructure. Traditional therapy failed to completely normalized these characteristics over the entire follow-up.

Hyporesponsiveness to inhaled nitric oxide in isolated, perfused lungs from endotoxin-challenged rats.

Inhaled nitric oxide (iNO) causes selective pulmonary vasodilation and improves oxygenation in patients with the adult respiratory distress syndrome (ARDS). Approximately 30% of ARDS patients fail to respond to iNO. Because sepsis syndrome often accompanies a decreased response to iNO, we investigated NO responsiveness in isolated, perfused lungs from rats exposed to lipopolysaccharide (LPS). Eighteen hours after intraperitoneal injection of 0.5 mg/kg LPS, rat lungs were isolated, perfused, and preconstricted with U-46619. Ventilation with 0.4, 4, and 40 parts per million by volume NO vasodilated LPS-pretreated lungs 75, 47, and 42% less than control lungs (P < 0.01 value differs at each concentration). The diminished vasodilatory response to iNO was associated with decreased NO-stimulated guanosine 3',5'-cyclic monophosphate (cGMP) release into the perfusate. Soluble guanylate cyclase activity did not differ in lung extracts from LPS-pretreated and control rats. LPS increased pulmonary cGMP-phosphodiesterase (PDE) activity by 40%. The PDE-sensitive cGMP analogue 8-bromoguanosine 3',5'-cyclic monophosphate vasodilated lungs from LPS-pretreated rats less than lungs from control rats. In contrast, the PDE-insensitive 8-para-chlorophenylthioguanosine 3',5'-cyclic monophosphate vasodilated lungs equally from both groups. After LPS challenge, the rat pulmonary vasculature becomes hyporesponsive to iNO. Hyporesponsiveness to iNO appears partly attributable to increased pulmonary cGMP-PDE activity.

In vivo lipopolysaccharide pretreatment inhibits cGMP release from the isolated-perfused rat lung.

Administration of bacterial lipopolysaccharide (LPS) to rats stimulates synthesis of nitric oxide (NO), a free radical molecule that activates soluble guanylate cyclase, thereby increasing intracellular guanosine 3',5'-cyclic monophosphate (cGMP) concentration and inducing systemic vasodilatation. To investigate the effect of endotoxemia on the pulmonary NO/cGMP signal transduction system, we measured the release of cGMP by isolated-perfused lungs of rats that received an intraperitoneal injection of LPS (1 mg/kg) or saline 2 days earlier. Over 90 min, 1.4 +/- 0.78 and 0.079 +/- 0.016 nmol cGMP accumulated in pulmonary perfusates of saline- and LPS-treated rats, respectively (P < 0.05). Despite addition to the perfusate of Zaprinast, superoxide dismutase, or A23187, markedly less cGMP was released from the lungs of rats exposed to LPS than from the lungs of control rats. In contrast, after ventilation with 100 parts per million NO gas, cGMP accumulating in the perfusate of the lungs of both groups of rats was markedly increased, and the quantity of cGMP released from the lungs of LPS-treated rats was similar to that released by control rat lungs (2.8 +/- 0.57 vs. 3.3 +/- 0.88 nmol, P = NS). With the use of immunoblot techniques, equal concentrations of constitutive endothelial NO synthase were detected in the lungs of rats treated with saline or LPS. These results demonstrate that the NO/cGMP signal transduction system is abnormal in the lungs of rats exposed to LPS, at least in part, at the level of endothelial NO synthase activation.

Three members of the nitric oxide synthase II gene family (NOS2A, NOS2B, and NOS2C) colocalize to human chromosome 17.

Nitric oxide synthases (NOSs) are a family of enzymes responsible for the synthesis of nitric oxide from L-arginine and molecular oxygen. Three human NOS enzymes (I, II, and III) with differing cellular distribution and regulatory mechanisms have been identified. To determine whether additional NOSs are encoded in the human genome, a bovine NOS II-related cDNA was used to screen two human genomic libraries. Clones containing three independent genes were isolated. One clone encoded the previously identified NOS II gene (NOS2A). The two other genes specified amino acids homologous, but not identical, to human NOS II (NOS2B and NOS2C). Southern blot hybridization demonstrated that all three genes are present in the human genome. DNA from human-mouse somatic cell hybrids were used to determine the chromosomal location of the NOS II-related genes. All three NOS II-related genes colocalized to human chromosome 17 between bands p13.1 and q25. These observations suggest that there is more than one NOS II-related gene in the human genome. This finding may have important implications for the design of NOS isoform-specific inhibitors.