Glutathione concentration during maturation and after fertilization in pig oocytes: relevance to the ability of oocytes to form male pronucleus

The present study examined the kinetics of glutathione (GSH) concentration during maturation and after fertilization in pig oocytes and its relevance to the ability of pig oocytes to form a male pronucleus after in vitro fertilization. The GSH concentration was significantly higher in pig oocytes matured in Waymouth medium than in pig oocytes matured in either modified (m) TCM-199 or mTLP media. The addition of 0.04-0.57 mM cysteine (CySH) to mTLP significantly increased both the GSH concentrations in oocytes matured in vitro and the rate of male pronucleus formation as compared to those in oocytes cultured in mTLP alone. When pig oocytes were cultured 12, 24, or 36 h in mTLP plus 0.14 mM CySH, their GSH concentrations were significantly higher than in uncultured oocytes. After fertilization, the GSH concentration in pig oocytes declined significantly. GSH concentrations in oocytes matured in vivo did not differ from those in oocytes matured in mTLP plus 0.14 or 0.57 mM CySH. The results indicate that 1) the composition of maturation medium affects the GSH concentration in pig oocytes; 2) the addition of CySH to maturation medium permits GSH synthesis by the pig oocytes; 3) GSH levels in pig oocytes change during maturation and after fertilization; and 4) GSH synthesis during oocyte maturation is an important factor for promoting their ability to form a male pronucleus after fertilization.

Effect of maturation media on male pronucleus formation in pig oocytes matured in vitro

The present study was carried out to examine the effect of maturation media on male pronucleus formation of pig oocyte matured and fertilized in vitro. Follicular oocytes collected from prepubertal gilts at a local slaughter house were cultured (36 h) in three different media (mTCM-199, Waymouth MB 752/l, and mTLP-PVA), fertilized in vitro, and assessed for nuclear maturation and male pronucleus formation. The addition of 10% (v/v) pig follicular fluid (pFF) to maturation media significantly increased the rate of nuclear maturation of pig oocytes (P less than 0.01), whereas the rate of nuclear maturation of pig oocytes among three different media did not differ. However, the rate of male pronucleus formation of pig oocytes was significantly higher in pig oocytes matured in Waymouth MB 752/l with or without pFF than in oocytes matured in the other two media (P less than 0.01). In experiment 2, the addition of cysteine (the same concentration as in Waymouth medium, 0.57 mM), to mTLP-PVA significantly increased the rate of male pronucleus formation of pig oocytes compared with the control (P less than 0.01). The results indicate that the composition of maturation medium affects the ability of pig oocytes to form male pronuclei following sperm penetration; media containing a high concentration of cysteine (possibly as a substrate of glutathione), such as Waymouth MB 752/l, can remarkably promote this ability.

Tie-2 and angiopoietin-1 expression in human thyroid tumors

Tie-2 is an endothelial cell-specific receptor tyrosine kinase involved in vascular maturation and remodeling. Although its expression is considered to be restricted to vascular endothelial cells and hematopoietic progenitors, our immunohistochemical and in situ hybridization studies showed that Tie-2 and its ligand, angiopoietin (Ang)-l were expressed not only in benign and malignant human thyroid tumor cells but also in hyperplastic regions of adenomatous goiter. To confirm the expression in these tissues further, we used a laser capture microdissection system to isolate epithelial tumor cells from tissue specimens selectively, and demonstrated the expression of Tie-2 and Ang-1 mRNAs in tumor cells by RT-PCR analysis. Furthermore, Tie-2 and Ang-1 mRNAs and proteins were also detected in rat thyroid cell lines, FRTL-5 and PCCL-3. Our results suggest that Ang-1/Tie-2 signaling may be involved in the proliferation of thyroid epithelial cells.

Effects of arsenic on younger generations

Health risks caused by the chronic exposure to arsenic-contaminated groundwater has been recognized in many Asian and Latin American countries. While the health effects among adults have been well documented, those among the younger generations including children, infants, babies, and fetus have been scarcely reported. In this minireview, possible effects of chronic arsenic exposure on the younger generations are discussed in terms of skin manifestations among the children, exposure among newborns and infants especially from the breast milk, child growth and development, reproductive performance. For each of the topics, our preliminary results obtained in an arsenic-contaminated area in Bangladesh will be described, followed by a brief overview on the recent publications dealing with the topic. Although there exist some human data that suggest possible effects on some of the above-mentioned endpoints, the data as a whole is too premature to conclude whether the arsenic poses serious threat to younger generations or not. Considering the public health importance of toxic effects imposed during the early life stages, it is clear that much more scientific efforts should be made to elucidate the possible effects of arsenic on the younger generations.

Profile of HIV type 1 infection and genotypic resistance mutations to antiretroviral drugs in treatment-naive HIV type 1-infected individuals in Hai Phong, Viet Nam

We evaluated the prevalence and profile of antiretroviral treatment (ART)-associated resistance mutations among HIV-1 strains in northern Vietnam by genotypically analyzing strains isolated from ART-naive individuals in Hai Phong, a city in which HIV-1 is highly prevalent. Plasma samples were collected from injecting drug users (IDU, n = 760), female sex workers (FSW, n = 91), seafarers (n = 94), pregnant women (n = 200), and blood donors (n = 210), and screened for HIV-1 antibodies. Plasma viral RNA was extracted from HIV-1-positive samples, amplified by reverse transcriptase (RT)-PCR of protease and RT genes, and analyzed for genotypes and ART-associated resistance mutations. HIV-1 prevalence among IDU, FSW, seafarers, pregnant women, and blood donors was 35.9%, 23.1%, 0%, 0.5%, and 2.9%, respectively. Phylogenetic analyses revealed that the most prevalent HIV-1 subtype was CRF01_AE (98.3%), similar to strains prevalent in southern China. Four (1.4%) subtype B strains and one (0.3%) unique recombinant between subtypes B and C were also identified. We found protease inhibitor-associated major resistance mutations in one of the 294 cases analyzed (0.3%; mutation M46I). We found RT inhibitor-associated major resistance mutations in 7/273 cases (2.6%; one occurrence each of L74I, M184I, and K219E; three cases of K103N; and two cases of G190E). One CRF01_AE strain harboring a protease codon 35 insertion was first identified in Vietnam. Thus, monitoring of drug-resistant HIV-1 and establishment of a database are required for the proper selection of ART in Vietnam.

Video-assisted subtotal or near-total thyroidectomy for Graves' disease

BACKGROUND

Surgery remains the treatment of choice for patients with Graves' disease. The purpose of the present study was to assess the usefulness and efficacy of video-assisted subtotal or near-total thyroidectomy in patients with Graves' disease.

METHODS

Between March 2000 and December 2004, 63 patients with Graves' disease underwent video-assisted subtotal, near-total or total thyroidectomy. Fifty-three patients (84 per cent) were considered for surgery after failure of antithyroid drug and radioiodine therapy, whereas the other ten patients were initially selected for surgical treatment based on their own preference. Treatment outcome was evaluated, including surgical complications, thyroid function, quality of life and patient satisfaction with the surgical result.

RESULTS

All patients were operated on using a video-assisted technique, with some modifications depending on time and experience. There were no conversions to open surgery. Three patients (5 per cent) had temporary recurrent laryngeal nerve palsy that recovered spontaneously. Most patients were satisfied with the surgical results, particularly regarding the placement of the surgical scars.

CONCLUSION

Video-assisted subtotal or near-total thyroidectomy is a safe and effective procedure for treatment of Graves' disease.

Intraoperative identification of canine hepatocellular carcinoma with indocyanine green fluorescent imaging

OBJECTIVES

To evaluate the feasibility of high-sensitivity near-infrared fluorescence imaging with indocyanine green for intraoperative identification of hepatocellular carcinoma in dogs.

METHODS

Twelve hepatic nodules were surgically resected from six dogs. In each dog, 0 · 5 mg/kg indocyanine green was intravenously injected for 12 to 18 hours preoperatively. The hepatic nodules were investigated under laparotomy using a near-infrared fluorescence imaging light camera system prior to resection. Resected nodules were histopathologically diagnosed and their fluorescence images were evaluated.

RESULTS

Of the 12 hepatic nodules, 6 were diagnosed as hepatocellular carcinoma and 6 as nodular hyperplasia. Indocyanine green-fluorescence was observed in four large hepatocellular carcinoma nodules and one case of nodular hyperplasia, whereas it was absent in the remaining nodules. The sensitivity and positive predictive values of indocyanine green fluorescent imaging for hepatocellular carcinoma was 71 · 4 and 80 · 0%, respectively. Complete resection of the hepatic masses was achieved in all dogs.

CLINICAL SIGNIFICANCE

Near-infrared fluorescence imaging may be feasible for intraoperative mapping of hepatocellular carcinomas in hepatic lobes and may help increase the chance of complete resection of hepatocellular carcinoma in dogs.

Urinary iodine levels and thyroid diseases in children; comparison between Nagasaki and Chernobyl

We evaluated the incidence of childhood thyroid diseases and urinary iodine levels in Nagasaki, Japan and in Gomel, Belarus, which was greatly radio-contaminated by the Chernobyl accident, in order to obtain the comparative data of thyroid diseases between iodine-rich (Japan) and -deficient (Belarus) areas. In Nagasaki, the median level of urinary iodine, measured by ammonium persulfate digestion in microplate method, was 362.9 microg/L. In order to evaluate the geographical differences in Japan, other samples were collected in Hamamatsu and in South Kayabe, Hokkaido, where the median levels were 208.4 microg/L and 1015.5 microg/L, respectively. Furthermore, thyroid screening by ultrasound (US) in Nagasaki revealed only four cases that showed goiter (1.6%) and two cases (0.8%) that had cystic degeneration and single thyroid cyst. There was no evidence of thyroid nodule detected by US examination. In contrast, the median of urinary iodine level was 41.3 microg/L in Gomel. The incidences of goiter (13.6%) and echogenic abnormality (1.74%) in Gomel were much higher than in Nagasaki, suggesting the critical involvement of iodine deficiency in increased childhood thyroid abnormality around Chernobyl. Radioactive iodine released just after the Chernobyl accident may have influenced predominantly children residing in iodine-deficient areas. Our results suggest that management of thyroid screening for schoolchildren at ordinary times may be beneficial for monitoring the adverse effects of radioactive iodine from the standpoint of future prospective study.

Impact of CRF01_AE-specific polymorphic mutations G335D and A371V in the connection subdomain of human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT) on susceptibility to nucleoside RT inhibitors

Certain mutations in the connection subdomain and RNase H domain of reverse transcriptase (RT) of subtype B HIV-1 contribute to resistance to nucleoside reverse transcriptase inhibitors (NRTIs). However, the impact of non-B subtype polymorphisms in this region on drug resistance remains unclear. In this study, we determined the frequencies of drug resistance mutations of the entire RT in patients with treatment failure from a cohort of Circulating recombinant form (CRF) 01_AE HIV-1-infected patients in Hanoi, Viet Nam. Subsequently, we assessed the impact of CRF01_AE polymorphisms G335D and A371V with or without thymidine analogue mutations (TAMs) on susceptibility to NRTI with recombinant viruses. In 49 patients with treatment failure, resistance mutations to NRTIs in the N-terminal half of RT were observed in 89.8%. In the C-terminal half, G335D (100%), N348I (36.8%), A371V (100%), A376S (5.3%) and A400T (97.4%) were detected, although G335D, A371V and A400T were considered polymorphisms of CRF01_AE. Drug susceptibility showed G335D, A371V, or both did not confer resistance by themselves but conferred significant resistance to NRTIs with TAMs, especially in mutants containing G335D, A371V and TAM type 2. Our results suggest the important role of CRF01_AE polymorphisms in the C-terminal half of RT in drug resistance.

Shape of the haemoglobin-oxygen equilibrium curve and oxygen transport efficiency

The sigmoid shape of the oxygen equilibrium curve (OEC) of haemoglobin permits large changes in oxygen saturation (S) upon narrow variations of the partial pressure of oxygen (P). The slope of the Hill plot (n) calculated from the Adair constants for human adult haemoglobin is usually maximised at S values greater than 0.5, implying that co-operative interactions of haemoglobin subunits are maximised above half-saturation. Our analysis of OECs based on the Adair equation shows that the slope of the OEC, S', which is proportional to the capacitance coefficient beta (Piiper et al., Respir. Physiol. 13: 292-304, 1971) and is a direct measure for oxygen-transport efficiency of haemoglobin, is maximised at S values smaller than 0.5, usually at S = 0.38. The analysis also gives the relations: Pdmax < P50 < Pnmax and Sdmax < 0.5 < Snmax where Pdmax, P50 and Pnmax are P at which S' is maximised, P at half-saturation and P at which n is maximised, respectively, and Sdmax and Snmax are S at Pdmax and S at Pnmax, respectively. Thus the most efficient point of OEC does not coincide with the point of maximal cooperativity nor with the oxygen saturation level of mixed venous blood in resting conditions (S approximately = 0.75). The steep portion of the OEC around S = 0.38 is exploited for large oxygen demands under conditions of exercise. The most efficient oxygen unloading region around S = 0.38 could be revealed by the Adair analysis but not by analysis using the conventional Hill equation.

Assessment study on the high-performance liquid chromatography-type hydroxyapatite chromatography in the presence of sodium dodecyl sulfate

The HPLC-type hydroxyapatite chromatography in the presence of sodium dodecyl sulfate (SDS) was assessed with special attention to the behavior of the surfactant. A significant amount of SDS was found to be adsorbed to the hydroxyapatite packed in the column from the starting buffer, 50 mM sodium phosphate buffer, pH 7.0, only when the buffer contained SDS in a concentration at or above its critical micelle concentration. When the phosphate buffer concentration was increased while the SDS concentration was kept at 1 mg/ml, the adsorbed surfactant was desorbed in advance of the release of proteins. Polypeptides derived from proteins could be successfully separated only when the column had been thoroughly equilibrated with the above-mentioned starting buffer solution. When a protein polypeptide complexed with SDS, which had been similarly equilibrated, was applied to the column, an amount of SDS corresponding to 75-90% (w/w) of the surfactant originally bound to the polypeptide was released upon its binding to the hydroxyapatite. On the other hand, porin, an Escherichia coli outer membrane protein, retaining its trimeric native structure in the presence of SDS, released a significantly smaller amount of SDS. When the membrane protein was denatured to give a single polypeptide, it behaved in a manner similar to that of the other protein polypeptides. The mechanism of binding of the protein polypeptides was discussed on the basis of these results. The native and denatured entities of porin could be efficiently separated as the result of the difference in their mode of interaction with the hydroxyapatite.

Appropriate method of administration of propofol, fentanyl, and ketamine for patient-controlled sedation and analgesia during extracorporeal shock-wave lithotripsy

PURPOSE

The aim of this study was to identify the appropriate method for administering propofol, fentanyl, and ketamine (PFK) for patient-controlled sedation and analgesia (PCSA) during extracorporeal shock-wave lithotripsy (ESWL).

METHODS

Twenty-one unpremedicated patients were randomly assigned to three groups that received different drug administration regimens. (group 1: low loading dose and high demand bolus, group 2: high loading dose and demand bolus, group 3: high loading dose and low demand bolus).

RESULTS

The patients in all groups were hemodynamically stable during ESWL. Oxygen desaturation was recognized in all groups, but was avoided by 2 l.min(-1) of oxygen supply via a nasal prong. The total administration dose of the drugs was significantly higher ( P < 0.05) in group 2 than in groups 1 and 3. The median level of sedation was the same, but the episodes of oversedation were not recognized in group 3 ( P < 0.05). A significant difference in the frequency of episodes of oversedation was found between groups 2 and 3 ( P < 0.05). The results were good or excellent for almost all patients, and were assessed as fair by only one patient in group 2.

CONCLUSION

We concluded that the method used for group 3 is the most appropriate for administering PFK for PCSA during ESWL.

Paediatric HIV and elimination of mother-to-child transmission of HIV in the ASEAN region: a call to action

Recent achievements in scaling up paediatric antiretroviral therapy (ART) have changed the life of children living with HIV, who now stay healthy and live longer lives. However, as it becomes more of a chronic infection, a range of new problems have begun to arise. These include the disclosure of HIV serostatus to children, adherence to ART, long-term toxicities of antiretroviral drugs and their sexual and reproductive health, which are posing significant challenges to the existing health systems caring for children with HIV with limited resources, experiences and capacities. While intensified efforts and actions to improve care and treatment for these children are needed, it is crucial to accelerate the prevention of mother-to-child transmission (PMTCT) of HIV, which is the main cause of paediatric HIV in the ASEAN region so as to eliminate the fundamental cause of the problem. This report argues that given over 70% of women have access to at least one antenatal care visit in the region and acceptance of HIV testing after receiving counselling on PMTCT could be as high as 90%, there is an opportunity to strengthen PMTCT services and eventually eliminate new paediatric HIV infections in the ASEAN countries.

A comparison between low-flow leak test and oxygen flush leak test

PURPOSE

The clinical efficacy of two methods of preanesthetic leak test,namely the oxygen flush leak test (OFLT) and the low-flow leak test (LFLT), was compared regarding their ability to detect leakage in the anesthesia circuit and their accuracy.

METHODS

Examinees comprised 16 staff anesthesiologists and 7 physicians undergoing anesthesia training at our institution. They performed the two leak tests on anesthesia machines with some intentional leaks (0.1-1.0 l.min(-1)). The leakage detection rates (LDR) were analyzed by the chi(2)-test. The ability to detect leaks was measured by recording how many leaks were detected by 50% (LDR(50)) and 95% (LDR(95)) of the examinees.

RESULTS

The LDRs in the two tests were significantly different (chi(2)- analysis, P < 0.0001). Both LDR(50) and LDR(95) for the LFLT (0.23 and 0.41 l.min(-1), respectively) were smaller than the values for the OFLT (0.37 and 0.82 l.min(-1), respectively). The sensitivity and specificity of the LFLT (0.97 and 0.84, respectively) were higher than those of the OFLT (0.78 and 0.80, respectively).

CONCLUSION

The LFLT was found to be superior to the OFLT regarding leak detection and reliability. We therefore recommend the LFLT for preanesthetic leak testing.

Sigmoid shape of the oxygen equilibrium curve and the P50 of human hemoglobin

The fractional saturation of hemoglobin with oxygen was plotted against P/P50 and the slope of the abscissa at 1 was calculated for 38 OEC data sets of human Hb A. There was a linear correlation between the slope and the Hill coefficient (nmax), and the slope was about one-fourth that of nmax. This implies that the slope of the abscissa at 1 of Y vs P/P50 plot can provide information about the magnitude of cooperativity in hemoglobin oxygen binding.

Analysis of Gaze Information Patterns of Nurses Gathering Patient Information Using Electronic Health Records

The objective of this study was to clarify gaze information patterns of nurses gathering patient information using electronic health records. We recorded the electronic health record screen on which nurses' gazes were presented using an eye tracker and analyzed the recorded images. The analysis revealed two types of gaze information patterns of nurses engaged in patient information gathering. However, no regularity was observed in the gaze information patterns of the nurses viewing the electronic health record sections after selecting a patient.

Development of two-stage multi-anvil apparatus for low-temperature measurements

The two-stage 6-8 multi-anvil (MA8) apparatus is an important large-volume, high-pressure technique that has been widely used in the high pressure mineralogy and material synthesis, mainly at room temperature or above. Recently, we have successfully developed a two-stage MA8 apparatus for low-temperature physical property measurements. The first-stage anvils at top and bottom sides are fabricated as a single piece in order to reduce the total size of the cylindrical module, which is put in a top-loading high pressure cryostat and compressed by a 1000 ton hydraulic press. A castable, split octahedral gasket with integrated fin was specifically designed in order to introduce the electrical leads from the inside sample container filled with a liquid pressure transmitting medium. By using tungsten carbide (WC) second-stage cubes with a truncated edge length of 3 mm and an octahedral gasket with an edge length of 6 mm, we have successfully generated pressure over 20 GPa at room temperature. Since the high pressure limit can be pushed to nearly 100 GPa by using the sintered diamond second-stage cubes, our MA8 apparatus has a great potential to expand the current pressure capacity for precise low-temperature measurements with a large sample volume. Edited by: A. Goñi, A. Cantarero, J. S. Reparaz

OP0110 CELL-TYPE-SPECIFIC TRANSCRIPTOME ARCHITECTURE UNDERLYING THE ESTABLISHMENT AND EXACERBATION OF SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with unknown etiology involving multiple immune cells and has diverse clinical phenotypes. This heterogeneous nature has hampered a better understanding of SLE pathogenesis and the development of effective therapeutic agents. While recent single-cell RNA sequencing studies of SLE identified several important cell subpopulations, they were limited by sparse expression information at single-cell level and small sample sizes.

Objectives

This study aimed to elucidate the dysregulated gene expression pattern linked to multiple clinical statuses of SLE with a fine cellular resolution and higher sensitivity. We also attempted to resolve a complex interaction between risk variants and the transcriptome dysregulation seen in SLE patients.

Methods

We conducted a large-scale bulk transcriptome study of 6,386 RNA-sequencing data including 27 purified immune cell types in peripheral blood from 136 SLE and 89 healthy donors in the Immune Cell Gene Expression Atlas from the University of Tokyo (ImmuNexUT) cohort1. At enrollment, SLE patients had diverse clinical manifestations (disease activity, organ involvement and treatment profiles) and 22 patients were re-evaluated after belimumab treatment.

Results

We first profiled two distinct cell-type-specific transcriptomic signatures: disease-state and disease-activity signatures, reflecting disease establishment and exacerbation, respectively.

After confirming the high replicability of both signatures in independent cohorts, we identified candidates of biological processes unique to each signature: e.g., upregulated E2F transcriptional activity in Th1, CD8+ memory T-lineage and NK cells, and dynamic increase of IL21 and CXCL13 in Th1 cells in an active phase of SLE. Pathway analysis highlighted the importance of immunometabolic process for SLE (e.g., oxidative phosphorylation) in cell-type-specific resolution.

Moreover, we demonstrated cell-type-specific contributions to diverse organ involvement, e.g., Th1 for mucocutaneous, monocyte-lineage cells for musculoskeletal, neutrophil-lineage cells for renal activity, respectively.

We also observed the strong associations of disease-activity signatures with treatment effect: (i) belimumab suppressed activity signatures from B-lineage cells, especially in good responders and (ii) mycophenolate mofetil substantially suppressed activity signatures from plasmablast, Th1, and central memory CD8 cells.

However, through stratified LD score regression using large-scale SLE-GWASs, we revealed that disease-activity signatures were less enriched around SLE risk variants than disease-state signatures. Consistent with this result, the directions of SLE risk alleles’ expression quantitative trait locus (eQTL) effects were significantly concordant with the directions of disease-state signatures, but not with those of activity signatures. These findings suggested that the current genetic case-control studies may not well capture clinically vital biology linked to drug target discovery for SLE. Meanwhile, we also detected some examples of activity signatures that might contribute to the disease risk by modulating risk allele’s eQTL effects.

Figure 1.

Conclusion

We identified comprehensive gene signatures reflecting the establishment and exacerbation of SLE, which provide essential foundations for future genomic, genetic, and clinical studies.

References

[1]Ota, M. et al. Dynamic landscape of immune cell-specific gene regulation in immune-mediated diseases. Cell 2021;184:3006-21.e17.

Acknowledgements

This study was supported by Chugai Pharmaceutical Co., Ltd., Tokyo, Japan; the Ministry of Education, Culture, Sports; and the Japan Agency for Medical Research and Development (AMED) (JP21tm0424221 and JP21zf0127004).

Disclosure of Interests

Masahiro Nakano: None declared, Mineto Ota Grant/research support from: Mineto Ota belongs to the Social Cooperation Program, Department of functional genomics and immunological diseases, supported by Chugai Pharmaceutical., Yusuke Takeshima Grant/research support from: Yusuke Takeshima belonged to the Social Cooperation Program, Department of functional genomics and immunological diseases, supported by Chugai Pharmaceutical., Yukiko Iwasaki: None declared, Hiroaki Hatano: None declared, Yasuo Nagafuchi Grant/research support from: Yasuo Nagafuchi belongs to the Social Cooperation Program, Department of functional genomics and immunological diseases, supported by Chugai Pharmaceutical., Kwangwoo Kim: None declared, So-Young Bang: None declared, Hye Soon Lee: None declared, Hirofumi Shoda: None declared, Xuejun Zhang: None declared, Sang-Cheol Bae: None declared, Chikashi Terao: None declared, Kazuhiko Yamamoto: None declared, Tomohisa Okamura Grant/research support from: Tomohisa Okamura belongs to the Social Cooperation Program, Department of functional genomics and immunological diseases, supported by Chugai Pharmaceutical., Kazuyoshi Ishigaki: None declared, Keishi Fujio Speakers bureau: Keishi Fujio receives speaker fees from Chugai Pharmaceutical., Consultant of: Keishi Fujio receives consulting honoraria from Chugai Pharmaceutical., Grant/research support from: Keishi Fujio receives research support from Chugai Pharmaceutical.