Could there be an Alternative to Marriage? -Evolution of same-sex unions in comparative perspective-

departmental bulletin pape

論説: 婚姻に代わる制度は考えられるか -同性婚を巡る各国法制の展開-

departmental bulletin pape

Changes in anemia management and hemoglobin levels following revision of a bundling policy to incorporate recombinant human erythropoietin

In April 2006, Japan's health insurance system instituted a bundling policy that included recombinant human erythropoietin (rHuEPO) in outpatient hemodialysis therapy. To evaluate outcomes of this, we analyzed a prospective cohort of hemodialysis patients in the Japan Dialysis Outcomes and Practice Patterns Study, in 53 facilities using prevalent cross-sections of 1584 patients before and 1622 patients after the rHuEPO reimbursement change. Patient data included hemoglobin levels, iron management profiles, and anemia treatment with rHuEPO and intravenous iron. No significant differences were found in pre- or post-policy cross-sections for hemoglobin distributions or the percentage of patients prescribed rHuEPO. Among patients receiving rHuEPO, the mean dose significantly decreased by 11.8 percent. The percentage of patients prescribed intravenous iron over 4months significantly increased; however, the mean dose of iron did not significantly change. Thus, this bundling policy was associated with reduced rHuEPO doses, increased intravenous iron use, and stable hemoglobin levels in Japanese patients receiving hemodialysis

Expression and Function of Inducible Costimulator on Peripheral Blood CD4 ؉ T Cells in Behçet's Patients with Uveitis: A New Activity Marker?

PURPOSE. Inducible costimulator (ICOS) is an important costimulatory molecule involved in T-cell activation. In this study, the role of ICOS in the pathogenesis of uveitis in Behçet's disease (BD) was investigated. METHODS. Peripheral blood mononuclear cells (PBMCs) were obtained from BD patients with uveitis in the active or remission phase and in healthy subjects. Total RNA was isolated from PMBCs, and mRNA expression was analyzed on an oligonucleotide microarray. ICOS expression on CD4 ϩ T cells was determined by flow cytometry, and the functional costimulatory effect of ICOS/B7RP-1 interaction was assessed on stimulation with concanavalin A (conA) or IRBP in the presence or absence of anti-ICOS mAb. RESULTS. As the result of microarray analysis, ICOS in PBMCs showed the greatest difference in expression in BD patients with uveitis compared with healthy control subjects. ICOS expression on CD4 ϩ T cells in BD patients with uveitis was significantly higher than that in healthy individuals, both before and after conA stimulation. Among the BD patients, ICOS expression on CD4 ϩ T cells was significantly higher in those with active uveitis than in those with remitted uveitis. Blockade of ICOS/B7-related protein-1 (B7RP-1) interaction by anti-ICOS mAb significantly decreased IFN-␥, IL-17, and TNF-␣ production by PBMCs when stimulated with conA or IRBP in BD with active uveitis. CONCLUSIONS. High ICOS expression in BD patients with uveitis contributed to the upregulation of IFN-␥, IL-17, and TNF-␣ production, suggesting that abnormal ICOS costimulation may play an immunopathologic role in the pathogenesis of uveitis in BD. (Invest Ophthalmol Vis Sci. 2010;51:5099 -5104) DOI: 10.1167/iovs.10-5286 E ndogenous uveitis such as Behçet's disease (BD), VogtKoyanagi-Harada syndrome, sympathetic ophthalmia, birdshot retinochoroidopathy, and sarcoidosis is a potentially blinding disease in humans and is responsible for 10% to 15% of the acquired blindness in Japan. 1 Although endogenous uveitis covers a spectrum of clinical entities, all forms are believed to share immunohistologic similarities characterized by the infiltration of mainly T cells. Behçet's disease (BD) is a systemic inflammatory disease characterized by oral and genital ulcers as well as ocular, cutaneous, arthritic, vascular, and neurologic lesions. 3-5 An increasing number of reports indicate that aberrant cellular immunity, such as pathogenic CD4 ϩ T-cell[b]-mediated autoimmunity via the Th1/Th17 pathway, plays a key role in the pathophysiological process in BD with uveitis, 6 -10 although the mechanisms of ocular inflammation in BD remain largely unknown. During recent years, the understanding of immunologic mechanisms involved in uveitis has advanced greatly through investigations of experimental autoimmune uveoretinitis (EAU), an animal model of human uveitis that can be induced by immunization of susceptible animals with interphotoreceptor retinoid-binding protein (IRBP) or with an eye-specific retinal antigen or by adoptive transfer of CD4 ϩ T cells specific for retinal antigens. 11 EAU resembles certain human uveitic conditions in various aspects 14,15 Although CD28 regulation has substantial effects on immunity, its function appears to reside predominantly in the control of primary, but not secondary, immune responses in various autoimmune diseases. 16 -18 The CD28 homolog inducible costimulator (ICOS) has recently been identified as a novel member of the CD28 costimulator family and is expressed by activated T cells in both humans and mice. To identify new genes that may cause or contribute to the disease process of ocular BD, we used cDNA microarrays that provide the expression profile of more than 54,000 genes, some of which are immune-related, whereas others are involved in the cell cycle, cell growth, intracellular signaling, cellular adhesion, and transport, and we compared the expression profiles of healthy individuals and patients. One of the genes found to be upregulated in patients with ocular BD is ICOS, an activation marker expressed on activated T cells that binds B7RP-1-expressing monocytes. The engagement of ICOS with B7RP-1 along with an appropriate antigen provide a positive signal that promotes T-cell differentiation, cytokine secretion, and effector function in the absence of CD28. ϩ T cells and B7RP-1 expressed on infiltrating APCs are upregulated directly after disease onset. 30 Therefore, we speculated that in active BD, pathogenic CD4 ϩ T cells that infiltrate the eye express ICOS in the inflamed eye and would be an appropriate target for the treatment of human ocular BD. Moreover, we have demonstrated that blockade of the ICOS/ B7RP-1 costimulatory pathway inhibits ocular inflammation in the effector phase of murine EAU. 30 Therefore, to investigate the role of ICOS in the pathogenesis of ocular BD, we assessed its expression on peripheral blood CD4 ϩ T cells and functional roles in patients with ocular BD. The results suggest that upregulation of ICOS is associated with the pathogenesis of uveitis in BD. MATERIALS AND METHODS PBMC Samples Thirty-five patients with BD (27 men and 8 women, mean age; 37.8 Ϯ 11.1 years) were enrolled in the study Heparinized blood samples were obtained from patients and healthy individuals, and PBMCs were isolated within 2 hours by density gradient centrifugation. The PBMCs were washed twice and resuspended at 1 ϫ 10 6 cells/mL in complete medium (RPMI 1640 supplemented with 10% fetal calf serum, 1 mM L-glutamine, 100 U/mL penicillin, and 100 g /mL streptomycin). Cell suspension was dispensed in 24-well plates (Falcon; BD Biosciences, Mountain View, CA) at 1 mL/well and incubated with or without concanavalin A (ConA; 10 g/mL) for 12 hours. Analysis of Gene Expression with cDNA Array Gene expression profile of human PBMCs was analyzed by microarray, as described previously. 37 Briefly, total RNA was isolated from pooled PBMCs obtained from seven patients with BD and active uveitis by an extraction method (Isogen Nippon Gene, Tokyo, Japan), and portions (2 g) of the preparation were subjected to amplification of mRNA with T7 RNA polymerase. Biotin-labeled cRNA (10 g) synthesized from the amplified RNA was subjected to hybridization with the Human Whole Genome Bioarray chip (Amersham Biosciences, Piscataway, NJ) that contains oligonucleotides corresponding to a total of approximately 55,585 human genes. Detection and digitization of hybridization signals were performed (G2565; Agilent Technologies, San Diego, CA) and analyzed (CodeLink Expression Analysis software version 4.0; Amersham Biosciences). The microarray data of various costimulatory molecules are summarized in Reagents FITC-conjugated anti-human CD4 (L3T4) was purchased from eBioscience (San Diego, CA), and anti-human ICOS (DX29) from BD PharMingen (San Diego, CA). ConA was obtained from Vector Laboratories (Burlingame, CA). Preparation of IRBP Fresh swine IRBP was purified according to the method described by Fukai et al. Immunofluorescence and Flow Cytometry The results of ICOS gene expression obtained from microarray were confirmed by flow cytometry. PMBCs were isolated by density gradient centrifugation of heparinized blood samples obtained from patients and healthy individuals. Each PBMC sample was divided into two aliquots: one for direct flow cytometry analysis of ICOS expression and the other for flow cytometry analysis after activation with conA at 10 g/mL for 12 hours. ICOS analysis was performed by using the following procedures: A cocktail of FITC-conjugated anti-CD4 and PE-conjugated anti-ICOS was added to the PBMCs. After the cells were washed with PBS, the stained cells (live-gated based on forward-and sidescatter profiles and propidium iodide exclusion) were passed through a flow cytometer (FACSCalibur; BD Biosciences, San Jose, CA) and the results analyzed (CellQuest program; BD Biosciences). ICOS expression on human CD4 ϩ T cells was calculated by gating for the CD4 ϩ T cell population, and 10,000 cells were analyzed in each experiment. Cytokine Assay Purified PBMCs (5 ϫ 10 5 /well) from BD patients with active uveitis were cultured in 96-well microtiter plates, with or without stimulation with conA (3 g/mL) or IRBP (10 g/mL) plus anti-ICOS mAb (10 g/mL) or control IgG at 37°C for 48 hours. The unstimulated PBMCs served as negative control samples. After stimulation, cell-free supernatants were collected at 48 hours and assayed for IFN-␥, TNF-␣, IL-2, and IL-6 by cytometric bead array (CBA) kits (BD PharMingen) and IL-17 by ELISA (Human IL-17 Quantikine ELISA kit; R&D Systems, Minneapolis, MN), according to the manufacturers' instructions. The minimum levels detected by CBA kits in either the culture supernatant or serum/plasma were 2.6 pg/mL for IL-2, 3.0 pg/mL for IL-6, 7.1 pg/mL for IFN-␥, and 2.8 pg/mL for TNF-␣; the minimum level in the IL-17 ELISA was 7.8 pg/mL. In a preliminary study, serial concentrations of conA (1, 3, 5, and 10 g/mL) or IRBP (1, 5, and 10 g/mL) were used in the assays. The results showed that optimal concentrations of cytokines were obtained at a concentration of 3 g/mL for conA and 10 g/mL for IRBP, as previously described. Statistical Analysis Data were analyzed (JMP 5; SAS Institute, Inc., Cary, NC) and the results expressed as the mean Ϯ SD. Statistical analysis was performed by using a paired or unpaired t-test. P Ͻ 0.05 was considered significant. RESULTS Analysis of Microarray Results in BD Patients with Active Uveitis To identify the genes involved in the pathogenesis of ocular BD, we compared phosphorescent images of the arrays hybridized with cDNA probes generated from RNA preparations from BD patients with active uveitis and healthy individuals. The array membrane that we used contained 360 positive bacterial controls and 384 negative controls. All positive controls were detected on the microarray. No signals were observed for the negative spots, indicating that the hybridization was highly specific. The DNA screening can evaluate more than 54,000 genes for a single sample. Among these genes, we focused on the immune-related ones, especially those of costimulatory molecules. Among the seven genes of costimulatory molecules, ICOS showed the greatest difference in expression in BD patients with active uveitis compared with that in healthy control subjects ICOS Expression on CD4 ؉ T Cells of BD Patients with Uveitis Flow cytometry was performed to confirm the results of gene array analysis. ICOS expression (median fluorescence intensity [MFI] of ICOS on CD4 ϩ T cells; Comparison of ICOS Expression on CD4 ؉ T Cells in BD Patients with Active or Inactive Uveitis Next, we compared ICOS expression on CD4 ϩ T cells in BD patients with active or inactive uveitis. ICOS expression (MFI of ICOS on CD4 ϩ T cells, Cytokine Production Stimulated with ConA and Uveitogenic Antigen To determine whether ICOS has functional costimulatory activity, we first measured the amounts of pathogenic Th1 and Th17 cytokines (IFN-␥, IL-17, TNF-␣, IL-6, and IL-2) produced by nonspecific stimulation (conA) of PBMCs obtained from BD patients with active uveitis. When ICOS costimulation was blocked with anti-ICOS mAb, the amounts of IFN-␥, IL-17, and TNF-␣ (Figs. 3A-C) produced by PBMCs were both significantly reduced. Since PBMCs from BD patients are known to be sensitized to the two most uveitogenic retina-specific antigens, S-antigen and IRBP, 1 we then examined the amounts of pathogenic Th1 and Th17 cytokines produced by stimulation with swine IRBP protein as the specific antigen. DISCUSSION The precise pathogenesis of uveitis associated with BD is unknown. Accumulated data obtained from animal models such as EAU suggest that Th1 and Th17 cells have major roles IOVS, October 2010, Vol. 51, No. 10 New Activity Marker for Ocular Behçet's Disease 5101 Downloaded from iovs.arvojournals.org on 06/30/2019 in its pathogenesis. We have previously shown that blockade of the ICOS ϩ costimulatory pathway has an ameliorating effect during the effector phase of EAU, by suppressing the expansion and effector function of pathogenic Th1 cells. In conclusion, our data provide additional evidence of the potential utility of ICOS expression on CD4 ϩ T cells as a marker of disease activity and as a promising therapeutic target for ocular BD via its inhibition of Th1 and Th17 cytokines. As the population studied was small and heterogeneous, further studies are needed to confirm the findings

Thyroid Ultrasound Findings in Children from Three Japanese Prefectures: Aomori, Yamanashi and Nagasaki

Due to the likelihood of physical and mental health impacts following the unprecedented accident at the Fukushima Daiichi Nuclear Power Plant, the Fukushima prefectural government decided to conduct the Fukushima Health Management Survey to assist in the long-term health management of residents. This included thyroid ultrasound examination for all children in Fukushima. For appropriate evaluation of ultrasound screening of the thyroid, it is important to understand its reference data of thyroid findings in children in general. In order to analyze the frequencies of specific thyroid findings, we conducted ultrasound screening of the thyroid by the same procedures as used in Fukushima in 4,365 children, aged 3 to 18 years, from three Japanese prefectures. Overall, thyroid cysts were identified in 56.88% and thyroid nodules in 1.65% of the participants. Thyroid cysts and nodules with a maximum diameter of more than 5 mm were identified in 4.58% and 1.01%, respectively, and age-adjusted prevalences were 3.82% and 0.99%, respectively. Although the prevalence of cysts and nodules varied among the examination areas, no significant differences were observed among the three examination areas in the prevalence of cysts and nodules with a maximum diameter of more than 5 mm. Also, the prevalence of thyroid cysts and nodules, especially those with a maximum diameter of more than 5 mm, significantly increased with age, and showed a female predominance. We also identified ectopic thymus (1.95%), diffuse goiter (1.40%), ultimobranchial body (0.73%), lymph node swelling (0.21%) and thyroid agenesis (0.05%). This is the first ultrasound description of the age-adjusted prevalence of thyroid cysts and nodules, or of the prevalence of abnormalities other than cysts and nodules, such as ectopic thymus, in relation to age, in the general Japanese child population. We contend that this can provide relevant information for the Fukushima Health Management Survey and future population studies