We have recently described the identification of a novel inherited bone marrow failure syndrome. The first set of patients was diagnosed through the exome analysis of cells from Japanese patients with hypoplastic anemia, which have been deposited to the JCRB cell bank for quite some time previously. Originally, these cases were diagnosed with a novel disorder based on increased levels of sister chromatid exchanges in lymphocytes; however, causative genes were clarified only after applying the recently developed next-generation sequencing technology. Aldehyde degradation deficiency syndrome (ADDS) is caused by combined defects in two genes, ADH5 and ALDH2, which are both critical for degrading endogenously generated formaldehyde. Formaldehyde is highly reactive and toxic to biological molecules including DNA, and its endogenous generation in the absence of the degradation system results in DNA damage that overwhelms the DNA repair capacity, leading to the development of BMF with loss of hematopoietic stem cells and progression to MDS/leukemia. In this short review, we would like to summarize what is known today about ADDS for a wide readership of hematology clinicians in Japan.

Evidence from our recent studies points to the notion that adult neurogenesis in the hippocampus may serve as a sensitive endpoint to detect developmental neurotoxicity. Adult neurogenesis is the postnatal process of continued generation of new neurons through the adult stage in the brain. Monitoring of granule cell lineages generated from the subgranular zone and γ-aminobutyric acid (GABA)-ergic interneurons in the hilus of the dentate gyrus as major players consisting of hippocampal neurogenesis is effective for detecting target cell populations of developmental neurotoxicants. Especially, reelin-expressing GABAergic interneurons are a useful marker to predict disruption of migration and correct positioning of newborn neurons following disruption of neurogenesis. Because axon terminal toxicants target granule cell lineage population showing neurite outgrowth, there may be common target mechanisms between the developmental and adult-type neurotoxicity. Because adult neurogenesis continues through the adult stage, developmental neurotoxicity could be detected in regular toxicity studies, such as in a 28-day repeated dose study. Alternatively, adult-type neurotoxicity could be detected by measuring the cellular responses in neurogenesis. Moreover, it should be stressed that there may be epigenetic toxicity mechanisms to affect the process of neurogenesis involving neuronal stem cells and interneuron subpopulations, showing continued disruption through the adult stage. These findings suggest that hippocampal neurogenesis is considered to be a critical target of neurotoxicity of both developmental and adult types.

Microglia originating from yolk sac exert various functions to maintain the homeostasis in the brain, and their functional breakdown appears to be involved in the pathophysiology of various neurological diseases. In this review article, loss of homeostatic microglia and new therapeutic approaches for rare neurological disorders are discussed. ASLP (adult-onset leukoencephalopathy with axonal spheroids and pigmented glia) known as a primary microgliopathy is an adult-onset leukoencephalopathy caused by CSF1R mutation. CSF1 receptor encoded by CSF1R plays an important role in the function of microglia. In brain of ALSP patients, homeostatic microglia are significantly reduced. The biallelic mutations for CSF1R cause childhood-onset severe phenotype and elimination of microglia from the brain parenchyma. Since microglia also almost disappear in CSF1R-deficient mice and rats, CSF1R deficiency and loss of microglia appear to be tightly associated across species. Based on the underlying mechanism of homeostatic microglia loss, novel approaches using cell transplantation of normal microglia-like cells have been attempted. Transplantation of wild-type bone marrow cells into Csf1r-/- mice results in replacement by donor-derived microglial-like cells in the recipient's brain. The concept of "microglial niche" may explain the rationale behind the microglial cell transplantation in disease condition(s). Hematopoietic stem cell transplantation (HSCT) has been attempted in 4 patients with ALSP. Beneficial effects by showing stabilization of the disease course have been observed. Although the effectiveness of HSCT for ALSP patients warrants further investigation, the approach of cell transplantation that replaces ruptured homeostatic microglia with normal microglia-like cells seems to be promising.

Schizophrenia is characterized by positive symptoms, negative symptoms and cognitive dysfunction. Although the abnormal neuronal development, impaired synaptic functions and impaired neural circuit functions are suggested to be the causes of psychiatric disorders, the molecular and cellular etiology of schizophrenia remains largely unclear. iPS-related technologies can be powerful for not only understanding the molecular and cellular etiology of schizophrenia but also drug discovery research. In 2011, the first iPS cells derived from patients with schizophrenia harboring a DISC1 mutation were generated. Subsequently, many iPS cells from patients with schizophrenia were established for understanding the molecular and cellular disease phenotypes of the differentiated neuronal cells. For replicating disease phenotypes with iPSC-derived neuronal cells, it is important to develop the differentiation strategies for generating cell-type specific cultures of various types of neurons, astrocytes and oligodendrocytes. Especially, scalable cultures of iPSC-derived neuronal cells are valuable platforms for drug discovery research. In this review, the focus has been made on the iPSC differentiation technology, pharmacological and drug discovery studies with iPSC-derived neurons from patients with schizophrenia. Continued advancement of the iPSC-related technologies and research will help the success in central nervous system drug discovery and development.

Although the cardiotoxicity of anti-cancer drugs is an important issue, the underlying mechanisms remain unknown. To develop a sensitive assay system for cardiotoxicity, we examined effects of anticancer drugs on contractile functions of human iPS cell-derived cardiomyocytes by using non-invasive motion field imaging analysis with extended drug exposure time. We succeeded in continuously measuring stable contractile function. The continued exposure revealed that the difference in cardiotoxicity between cardiotoxic doxorubicin and less toxic erlotinib was more evident after 8 days of treatment than with 3 days of treatment, suggesting that continued exposure improved the predictive power for cardiotoxicity of anti-cancer drugs.

Following the reports of paroxysmal nocturnal hemoglobinuria (PNH) due to PIGT and PIGB gene mutations, the definition of PNH was changed to a hematopoietic stem cell disease with complement-mediated intravascular hemolysis as a result of clonal expansion of hematopoietic stem cells with mutations in genes involved in glycosylphosphatidylinositol (GPI) anchor synthesis, including PIGA. Treatment with eculizumab (Soliris®), a humanized anti-C5 monoclonal antibody, significantly improved the quality of life in patients with PNH, remarkably reduced hemolysis, improved symptoms associated with hemolysis, and prevented thrombosis. Although the administration interval has been extended and convenience has been greatly improved using the technique of recycling antibodies (ravulizumab and crovalimab), extravascular hemolysis has become another issue. Although attempts have been made to overcome this issue with proximal complement (C3, factor D, and factor B) inhibitors, the optimal therapeutic agent is expected to be selected after evaluating for not only efficacy and safety but also convenience.

The introduction of autologous stem cell transplantation, proteasome inhibitors, and immunomodulatory drugs (IMiDs) has improved the treatment outcome for multiple myeloma (MM). However, many patients develop resistance to existing therapies, and novel treatment strategies for these patients must be established. Therapeutic antibodies including daratumumab targeting CD38 and elotuzumab targeting SLAMF7 have been introduced in the clinic as immunotherapies for MM. These antibodies exert cytotoxic effects on myeloma cells through the activation of effector cells such as natural killer cells and induction of phagocytosis by macrophages. Suppressed anti-tumor immunity may be related to acquisition of drug resistance by myeloma cells in patients with MM. It has been reported that IMiDs such as lenalidomide and pomalidomide enhance the effect of therapeutic antibodies through the stimulation of anti-tumor immunity. This stimulation of anti-tumor immunity is also observed in the effects of anti-CD38 antibodies, such as daratumumab and isatuximab. Therefore, it is expected that combination therapy with anti-CD38 antibodies and IMiDs may enhance anti-tumor immunity. Furthermore, chimeric antigen receptor (CAR) T cell therapy, antibody drug conjugates (ADC), and bispecific antibodies (BsAbs) are in the process of their introduction to the clinic as novel immunotherapies for MM.

Paroxysmal nocturnal hemoglobinuria (PNH) is a hematopoietic stem cell disease whose main symptom is complement-mediated intravascular hemolysis as a result of the clonal expansion of hematopoietic stem cells having mutations in genes involved in glycosylphosphatidylinositol (GPI) anchor synthesis including PIGA. With the advent of a humanized anti-C5 monoclonal antibody (eculizumab), the inhibitory effect on hemolysis, improvement in its various complicating symptoms, and preventive effect on thrombus formation were observed. In addition, the QOL in patients with PNH was significantly improved. Subsequently, the technology of recycling antibodies (ravulizumab and crovalimab) significantly extended the treatment interval and improved convenience, although the poor improvement of anemia due to extravascular hemolysis has been a major issue in some patients. Several clinical trials using proximal complement inhibitors (C3, factor D, factor B) are being conducted to overcome this critical task. Not only efficacy but also safety and convenience will be evaluated, and the best therapeutic agent will be selected in the near future.

The bone marrow microenvironment is low in oxygen, promoting a hypoxic response which causes myeloma cells to acquire stem cell properties and enhanced therapy resistance. We performed comprehensive gene and microRNA expression analyses of samples from myeloma patients and cell lines cultured under hypoxia. Through this, we identified the histone demethylase KDM3A, the glycolytic enzyme HK2, and microRNA-210 as factors playing important roles in the behavior of cells under hypoxic conditions. These genes were regulated by the hypoxia-inducible factor HIF. However, we also found that the expression of IRF4 and MYC, factors required for maintenance of differentiation and proliferation was suppressed by hypoxia. This suggests that the regulatory factors that induce drug resistance and the anti-apoptotic capacity of myeloma cells fluctuate with the partial pressure of oxygen in their environment. Based on this premise, a dual treatment strategy in which a dominant clone and a dormant clone adapted to the hypoxic microenvironment are treated simultaneously with orthogonal drugs is a potentially viable strategy to achieve a cure for multiple myeloma.

A 65-year-old woman received bone marrow transplantation from an HLA-DRB1 one locus mismatched donor for high-risk myelodysplastic syndrome. On day 237 after transplantation, she developed recurrent acute gastrointestinal graft-versus-host disease and adenoviral hemorrhagic cystitis. Hence, the methylprednisolone (mPSL) dose was increased to 2 mg/kg, and mesenchymal stem cells were administered. After the dose was tapered, she developed high fever, gross hematuria, and progressive pancytopenia. Then, the serum LDH, ferritin, and hepatobiliary enzyme levels of the patient increased, and hemophagocytosis was observed based on bone marrow examination. The adenovirus DNA level in the plasma was 6.3×106 copies/ml on day 278, and the volume of cerebrospinal fluid increased. Hence, the patient was diagnosed with meningitis and disseminated adenovirus infection. On day 288, cidofovir was administered at a dose of 1 mg/kg three times a week for 8 doses. The mPSL dose was again increased to 2 mg/kg for the treatment of hemophagocytic syndrome. Then, the patient's symptoms gradually improved, and the adenovirus viral load became negative on day 369. Based on the clinical course of our patient, cidofovir is useful for severe adenovirus infection.

Myelodysplastic syndrome (MDS) is a group of clonal hematopoietic disorders characterized by peripheral cytopenia and morphological abnormalities in hematopoietic cells, i.e., myelodysplasia. Aging-related somatic variants acquired in the hematopoietic cells are associated with MDS pathogenesis in adults. However, pediatric MDS often occurs because of germline predispositions. Myelodysplasia can be observed in not only MDS but also other hematopoietic and non-hematopoietic disorders, such as infections and primary immunodeficiencies. Therefore, careful differential diagnosis between MDS and other diseases is necessary. The bone marrow histopathology should be evaluated for accurate differentiation of MDS without excess blasts from aplastic anemia and MDS with excess blasts from acute myeloid leukemia. The treatment strategy for childhood MDS differs based on disease subtypes. The clinical courses of pediatric MDS without excess blasts are heterogeneous; therefore, it is crucial to assess the prognostic values of clinical and cytogenetic findings. In contrast, allogeneic hematopoietic cell transplantation should be considered as the only curative option for pediatric MDS with excess blasts.

Although the concept of a drug delivery system (DDS) is usually applied to conventional drug therapy, it is also important for cell-based therapy. The surface manipulation of living cells represents a powerful tool for controlling cell behaviors in the body, such as enhancement of cell-cell interactions, targeted delivery of cells, and protection from immunological rejection. Functional groups, including amines, thiols, and carbonyls, offer excellent opportunities for chemical modification through the formation of covalent bonds with exogenous molecules. Non-natural reactive groups introduced by metabolic labeling were recently utilized for targeted chemical modification. On the other hand, noncovalent strategies are also available; two major examples are electrostatic interaction with a negative charge on the cell surface and hydrophobic insertion or interaction with the cell membrane. In this study, we analyzed factors affecting cell surface modifications using PEG-lipid and succeeded in enhancing the efficacy of modification by cyclodextrin. Then, mesenchymal stem cells (MSCs), whose therapeutic effect has been demonstrated at the clinical stage and which have been clinically used as a drug, were decorated with PEG-lipid conjugates having a targeted ligand such as peptide or scFv, which are recognized by ICAM1. The peptide or scFv decoration enhanced the cell adhesion of MSCs on cytokine treated-endothelial cells. This technique will prompt the targeted delivery of MSCs to intended therapy sites, and underscores the promise of cell surface engineering as a tool for improving cell-based therapy.

Vigorous efforts are being made to manipulate cellular functions in a desirable manner for biomedical purposes. Recent advances in platform technologies have made cell editing achievable; this includes generation of induced pluripotent stem cells and chimeric antigen receptor T cells, as well as direct cell reprogramming. mRNA, as compared to DNA, is an excellent tool for potentiating cell editing technologies, owing to its distinct properties in gene introduction. Herein, hepatocytes were edited ex vivo and in vivo, by introducing pro-survival mRNA, to be resistant to cell death. DNA-based introduction of pro-survival gene poses safety concerns due to its genomic integration, as prolonged and uncontrolled expression of pro-survival proteins after the integration may promote cancer. In contrast, mRNA lacks such a risk. Moreover, mRNA-based introduction of Bcl-2, a pro-survival factor, was more effective in preventing the death of cultured hepatocytes than Bcl-2 plasmid DNA (pDNA) introduction. Mechanistically, mRNA induced protein expression in a larger percentage of the hepatocytes compared to pDNA, presumably because the process of pDNA nuclear entry in transfection is challenging. In hepatocyte transplantation to mouse liver, ex vivo introduction of Bcl-2 mRNA significantly improved the engraftment efficiency of the hepatocytes, leading to successful functional support of the liver in a mouse model of chronic hepatitis. Furthermore, in vivo administration of Bcl-2 mRNA exhibited an anti-apoptotic effect on the hepatocytes of a mouse model of fulminant hepatitis. These results demonstrate the potential advantages of mRNA introduction over DNA introduction in cell editing.

Bacillus cereus bacteremia is an infectious disease that may sometimes be fatal with a rapid clinical course. We performed a retrospective analysis on 12 patients with Bacillus cereus bacteremia recruited from January 2010 to March 2015. The primary diseases were acute leukemia (n=5), myelodysplastic syndromes (n=3), malignant lymphoma (n=3), and hemophagocytic syndrome (n=1). Neutrophil count at the onset of this bacteremia was less than 500 cells/µl in 9 patients. At the onset of bacteremia, we observed neurological symptoms (n=7), gastrointestinal symptoms (n=6), and findings suspected of infection at the venous catheter insertion site (n=6). Vancomycin was administered to all the patients; 10 patients showed improvement whereas 2 died early after allogeneic hematopoietic stem cell transplantation owing to bacteremia. Three patients had sequelae of central nervous system disorders. Neurological and gastrointestinal symptoms with fever may be predictors for this bacteremia, and early administration of appropriate antibacterial drugs may improve the prognosis. Future research should be aimed toward the identification of the clinical features of poor prognosis and establishment of remedies for Bacillus cereus bacteremia.

Predicting drug-induced side effects in central nervous system is important because they can lead to the discontinuation of new drugs/candidates or the withdrawal of marketed drugs. Although many efforts are made, evaluation system using animals have not been highly predictive in humans. In addition, animal experiments are time-consuming and costly. To address these issues, in vitro evaluation methods, such as the use of New Approach Methodologies (NAM) have been explored. Human iPS cell technology has already been applied to assess drug-induced cardiotoxicity. In addition, the use of human iPS cell technology and in silico has been promoted for neurotoxicity assessment during the developmental neurotoxicity in terms of chemical safety issues. Organization for Economic Cooperation and Development (OECD) guidance regarding developmental neurotoxicity is under preparation. In this review, we will review the current trends in safety assessment methods for the central nervous system in light of these international trends.

Microglia are immune cells resident in the central nervous system (CNS). It has been gradually clarified that microglia play various roles at the developmental stage of the CNS. From embryonic to early postnatal age, microglia remove apoptotic cells by phagocytosis and refine the neural circuits by synaptic pruning. In addition, microglia promote the proliferation and differentiation of neural stem cells by releasing physiologically active substances. Our group has focused on the physiological actions of microglia via cytokines and chemokines at the early postnatal developmental stage. We found that a large number of activated microglia accumulate in the early postnatal subventricular zone (SVZ). We demonstrated that the these SVZ microglia facilitate neurogenesis and oligodendrogenesis via inflammatory cytokines including IL-1β, TNFα, IL-6, IFNγ. We have also found that microglia regulate the functional maturation of the blood brain barrier (BBB) and identified the cytokines and chemokines involved in the effects of microglia. These findings indicate that microglia are physiologically more important than ever thought to reveal robust brain functions. Furthermore, the new mode of microglial action may lead to the discovery of drug targets of the incurable CNS diseases.

We have been investigating the physiological and pathological roles of stem cells and progenitor cells in the central nervous system using multimodal imaging methods, including positron emission tomography (PET), in vivo optical imaging, and light as well as electron microscopy. Furthermore, we generated transgenic rats for selective ablation of these cells. Imaging studies have demonstrated the proliferation and dynamics of neural stem cells in neurogenic regions and glial progenitor cells expressing a chondroitin sulfate proteoglycan (neuron-glial antigen 2; NG2) in the brain of adult rodents. Glial progenitor cells change their direction of differentiation into mature oligodendrocytes or astrocytes by neural activity following their proliferation. This phenomenon was thought to control the local tissue structure for maintenance of moderate neural activity. Furthermore, selective ablation of glial progenitor cells in the brain induced defects of neurons via neuroinflammation with microglial activation and proinflammatory cytokine production in the region. Thus, we have proposed a novel concept that glial progenitor cells regulate the neuro-immune system in the central nervous system, in addition to their role as germinal cells, giving rise to mature glial cells. Neuroinflammation is associated with the onset and progression of depression, chronic fatigue syndrome, and neurodegenerative diseases, including Alzheimer's disease. Anti-inflammatory effects of glial progenitor cells might bring about the possibility of these cells as the new therapeutic targets for such neurological disorders.

Blood vessels including arteries, veins, and capillaries, are densely spread throughout the body. One round of systemic blood circulation through these blood vessels occurs approximately every minute, and blood sent by the heart transports oxygen, nutrients, and fluid to cells throughout the body. This nourishes cells, tissues, and organs and maintains homeostasis. The relatively simple structure of blood vessels consists of endothelial cells surrounded by a basal lamina and pericytes covering the outer layer. However, blood vessels patterning markedly varies among tissues. The diversity and plasticity of vascular networks are considered vital for this system to facilitate distinct functions for each tissue. Recent studies revealed that blood vessels create a tissue-specific niche, thus attracting attention as biologically active sites for tissue development. This vascular niche establishes specialized microenvironments through both direct physical contact and secreted-soluble factors. Here, we review advances in our understanding of how the vascular niche is utilized by neural stem and progenitor cells during neocortical development, and describe future perspectives regarding new treatment strategies for neural diseases utilizing this vascular niche.

Although classic Hodgkin's lymphoma (CHL) sometimes develops after treatment for multiple myeloma (MM), simultaneous diagnosis of both malignancies is extremely rare without previous treatment history. Here we describe a case of a 54-year-old female who complained of left cervical lymphadenopathy. Biopsy specimen from the left cervical lymph node revealed mixed-cellularity CHL. Bone marrow aspirate comprised 10.3% plasma cells. She was diagnosed with MM due to involved: uninvolved serum free light chain ratio of >100. She achieved complete response for CHL after 4 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy along with 30 Gy of involved-field radiotherapy. Three years later, bortezomib, lenalidomide, and dexamethasone (VRd-lite) therapy was initiated for MM. Severe neutropenia during her 1st cycle prompted a dosage reduction of lenalidomide and bortezomib. Partial response was achieved after 4 cycles of VRd-lite followed by high-dose melphalan/autologous stem cell transplantation. No severe adverse events were recorded. This was followed by 4 cycles of carfilzomib, lenalidomide, and dexamethasone therapy, which resulted in complete remission. As the number of elderly people increases, multiple myeloma patients with previous history of other malignancies would increase. Our case has shown that VRd-lite therapy may be suitable for those patients.