The relationship among sleep, resilience, and stress response in Japanese female university students during the COVID-19 pandemic.

We examined the effect of sleep and resilience on stress responses in female Japanese university students during the COVID-19 pandemic. Sleep was measured using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J), stress response was evaluated using the Stress Response Scale-18 (SRS-18), and resilience using the Resilience Scale for Students (RS-S). Multiple regression analysis showed that approximately 40% of the SRS-18 score could be explained by PSQI-J score and RS-S score. Subjective sleep quality, daytime dysfunction, and global score of PSQI-J had direct influences on SRS-18.

Association between Physical Frailty and Sleep Disturbances among Patients on Hemodialysis: A Cross-Sectional Study.

INTRODUCTION: Among patients on hemodialysis (HD), physical frailty and sleep disturbances are not only common but also associated with adverse outcomes. The aim of this study was to evaluate the association between physical frailty and sleep disturbances in patients on HD. METHODS: This cross-sectional study was conducted from June 2017 to March 2021, with outpatients receiving HD 3 times a week at two dialysis facilities in Japan. Sleep disturbances were identified with the Athens Insomnia Scale (AIS). Physical frailty was defined using the Fried Frailty Phenotype. Patients were classified as "non-frailty (number of frailty components: 0-2)" or "frailty (3-5)." We examined the association of sleep disturbances with physical frailty and its components by performing a logistic regression analysis. RESULTS: We analyzed 360 patients (mean age 65.6 years; 62% men). Eighty-one patients (23%) were classified into the group with frailty, and the mean AIS score was 5.2 ± 4.2 points. After adjusting for clinical characteristics, increasing the AIS score per 1 point was associated with higher odds of physical frailty (odds ratio, 1.12; 95% confidence interval, 1.05-1.20; p < 0.01). As for the frailty components, exhaustion, low physical activity, and weak grip strength showed an association with sleep disturbances (all p < 0.05). CONCLUSIONS: Sleep disturbances were independently associated with physical frailty in patients on HD. Future studies are warranted to investigate the causality between physical frailty and sleep disturbances in this population.

Perceived difficulty in activities of daily living and survival in patients receiving maintenance hemodialysis.

PURPOSE: Most patients receiving hemodialysis have perceived difficulty in mobility tasks, such as basic activities of daily living (ADL), ambulation, and walking up or down stairs, even if they can ambulate independently. Perceived difficulty in performing ADL (ADL difficulty) is reportedly a useful predictor of mortality in older community-dwelling people. However, very few studies have examined the association of ADL difficulty with clinical outcomes in patients receiving hemodialysis. This study aimed to identify the association between ADL difficulty related to mobility tasks of lower limbs and all-cause mortality in patients receiving hemodialysis who are able to ambulate independently. METHODS: This retrospective study analyzed 300 clinically stable outpatients (median age, 65.0 years) receiving hemodialysis. ADL difficulty was evaluated at baseline with a novel questionnaire developed for patients receiving hemodialysis. Lower scores indicated lower ADL, i.e., greater ADL difficulty. The patients were divided into two groups by the median ADL score: a higher ADL group and a lower ADL group. The association between ADL difficulty and all-cause mortality was estimated by Cox regression analyses. RESULTS: Median follow-up duration was 58 months. The incident rates were 0.02 per person-year in the higher ADL group and 0.06 per person-year in the lower ADL group (P < 0.001). After adjusting for the effects of clinical characteristics, the hazard ratio for all-cause mortality in the lower ADL group was 2.70 (95% confidence interval 1.57-4.64) compared with that in the higher ADL group. CONCLUSIONS: Perceived difficulty in mobility tasks was independently associated with all-cause mortality among ambulatory patients receiving hemodialysis.

Trajectory of Lean Body Mass Assessed Using the Modified Creatinine Index and Mortality in Hemodialysis Patients.

RATIONALE & OBJECTIVE: Although a declining body mass index (BMI) is associated with higher mortality in patients on hemodialysis, BMI cannot distinguish lean body mass from fat mass. It remains unclear whether changes over time in lean body mass are associated with mortality. We examined the prognostic significance of changes in the modified creatinine index, a proxy for lean body mass. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Outpatients (n=349; mean age, 67.4 years; 60% men) undergoing maintenance hemodialysis 3 times a week at a treatment center. PREDICTOR: Modified creatinine index and BMI trajectories over a 1-year period. OUTCOMES: All-cause mortality. ANALYTICAL APPROACH: We calculated the percentage of change in modified creatinine index and BMI over a 1-year period. Patients were categorized according to change in modified creatinine index/BMI: no decline (≥0%) or decline (<0%). Kaplan-Meier and Cox proportional hazard analyses were performed to examine whether modified creatinine index and BMI trajectories were associated with mortality. RESULTS: During follow-up (median, 1,157 days), 79 patients died. Decreasing modified creatinine index (HR, 1.31; 95% CI, 1.11-1.54) and BMI (HR, 1.25; 95% CI, 1.01-1.54) over time, measured as continuous variables and expressed per 1-standard deviation decrease, were independently associated with higher risk for all-cause mortality. The decline in modified creatinine index/no decline in BMI group (HR, 2.14; 95% CI, 1.04-4.45) and the decline in modified creatinine index/decline in BMI group (HR, 3.05; 95% CI, 1.58-5.90) had higher rates of mortality compared to the no decline in modified creatinine index/decline in BMI group. LIMITATIONS: The absence of a direct measure of lean body and fat mass and limited generalizability to non-Japanese hemodialysis populations. CONCLUSIONS: The modified creatinine index trajectory is independently associated with mortality and provides additional prognostic information to the BMI trajectory in patients on hemodialysis.

Evaluating depression in cognitively healthy elderly people by using Mini-Mental State Examination.

AIM: We examined a method for evaluating depression with the Mini-Mental State Examination in cognitively healthy elderly people and employed the projective perspective. METHODS: In MMSE three groups-normal, depressed tendency, and depressed-completed the Mini-Mental State Examination (MMSE) and a Japanese version of the 15-item Geriatric Depression Scale. The Mini-Mental State Examination evaluated individuals' writing based on a sentence, the number of written words, and sentence content; it also assessed their copying of drawn figures. RESULTS: In the depressed group, the proportion corresponding to the characteristics of (i) to (iii) was higher than in the other two groups: (i) the calculation score was 0 or 1; (ii) subjects scored above the median in sentence writing relative to similar subjects with the same language and clinical setting; and (iii) subjects expressed feelings in their writing. One point was given for each characteristic, and we calculated the sum. Depressed subjects had a score ≥2. CONCLUSIONS: This evaluation method can differentiate depressed subjects with high accuracy (sensitivity: 77.8%, specificity: 76.4%) without placing an extra burden on the subjects.

Effects of electrical muscle stimulation in frail elderly patients during haemodialysis (DIAL): rationale and protocol for a crossover randomised controlled trial.

INTRODUCTION: The phenomenon of population ageing is accompanied by increases in the number of elderly haemodialysis patients worldwide. The incidence of frailty is high in the haemodialysis population and is associated with poor clinical outcome. Although several interventions have been developed for use in general haemodialysis patients, the efficacy of such rehabilitation programmes in frail elderly patients on haemodialysis has not been elucidated. Here, we examined whether electrical muscle stimulation (EMS) would show beneficial effects in frail elderly patients on haemodialysis. METHODS AND ANALYSIS: This is a randomised, two-period, controlled crossover trial, which will enrol 20 patients. Haemodialysis patients aged ≥65 years and defined as frail (ie, Short Physical Performance Battery score 4-9), will be randomly assigned to either group 1 (EMS intervention beginning in treatment period I, followed by reallocation as controls in treatment period II after a 5-week washout period) or group 2 (opposite schedule) in a 1:1 ratio. The two intervention periods will last 5 weeks each with an intervening washout period of 5 weeks. In the EMS intervention group, the treatment will be applied to the skeletal muscle of the entire lower extremity for 5 weeks, three times/week for 30-40 min during haemodialysis. The primary outcome of this study is the change in quadriceps isometric strength after the interventions. The secondary outcomes are the changes in physical function, physical activity, difficulty in activities of daily living, body composition, cognitive function, depressive symptoms, quality of life, blood test results and the clinical safety and feasibility of EMS therapy. ETHICS AND DISSEMINATION: This study has been approved by the institutional review board/ethics committee of Kitasato University Allied Health Sciences. This study will be reported in peer reviewed publications and at conference presentations. TRIAL REGISTRATION NUMBER: UMIN000032501.

Association between frailty and bone loss in patients undergoing maintenance hemodialysis.

Frailty is significantly associated with bone loss in the general population. However, it is unclear whether this association also exists in patients undergoing hemodialysis who have chronic kidney disease-mineral and bone disorder (CKD-MBD). This study aimed to assess the association between frailty and bone loss in patients undergoing hemodialysis. This cross-sectional study included 214 (90 women, 124 men) Japanese outpatients undergoing maintenance hemodialysis three times per week, with a mean age of 67.1 years (women) and 66.8 years (men). Frailty was defined based on criteria set forth by the Cardiovascular Health Study (CHS)-19 (21.1%) women and 47 (37.9%) men were robust, 41 (45.6%) women and 43 (34.7%) men were pre-frail, and 30 (33.3%) women and 34 (27.4%) men were frail. For bone mass, quantitative ultrasound (QUS) parameters (speed of sound, broadband ultrasound attenuation, stiffness index) of the calcaneus were measured. The association between frailty and QUS parameters was determined separately for women and men using multivariate analysis of covariance (ANCOVA), with adjustments for clinical characteristics including age, body mass index, hemodialysis vintage, diabetes, current smoking, serum albumin, phosphate, corrected calcium, intact parathyroid hormone, and medication for CKD-MBD (vitamin D receptor activator, calcimimetics). ANCOVA revealed that all QUS parameters declined significantly with increasing levels of frailty in both sexes (P < 0.05). In conclusion, frailty (as defined by CHS criteria) should be considered a risk factor for bone loss in patients undergoing hemodialysis.

Characteristics of dementia patients who described or did not describe the relationship between two people on the COGNISTAT speech sample.

Speech sample of Cognitive Status Examination (COGNISTAT) is a task in which examinees freely talk about what is happening in a presented picture. We investigated whether there are differences in the characteristics between patients who described or did not describe the relationship between two people in the speech sample based on age, gender, cognitive dysfunction, and type of dementia (Alzheimer's disease and dementia with Lewy bodies). The participants were 60-year-old or older patients diagnosed with Alzheimer's disease or dementia with Lewy bodies who undertook the Mini-Mental State Examination (MMSE) and COGNISTAT at a general hospital specialized in care for the elderly. MMSE and COGNISTAT were performed by a female clinical psychologist in all patients. In a stepwise logistic regression analysis using the two groups (description and no description groups) as a response variable, and the age, gender, diagnosis, MMSE score, and score of each COGNISTAT subtest as explanatory variables, the MMSE score (OR = 1.09; 95% CI [1.03, 1.15]) and gender (OR = 1.79; 95% CI [1.09, 2.93]) factors were extracted. These results indicated that patients with severer overall cognitive dysfunction and male patients were unlikely to describe the relationship between two people in a speech sample.

Utility of Regular Management of Physical Activity and Physical Function in Hemodialysis Patients.

BACKGROUND/AIMS: Several clinical practice guidelines recommend regular assessment of physical activity and physical function as part of routine care in hemodialysis patients. However, there is no clear evidence to support these recommendations. We investigated whether the proportion of attendance at a regular program for management of physical activity and physical function can predict all-cause mortality and cardiovascular events in hemodialysis patients. METHODS: This retrospective cohort study consisted of 266 hemodialysis patients participating in the management program at least once. Participants were tracked for 3 years after their first attendance at the management program to determine their attendance proportion. The main study outcomes included all-cause mortality and a composite of fatal and nonfatal cardiovascular events. RESULTS: Median patient age was 64.5 (interquartile range, 56.8 - 72.0) years, 45% were women, and the median time on hemodialysis was 35.5 (interquartile range, 12.0 - 114.3) months at baseline. Sixty-five patients died over a median follow-up of 79 months. The incidence of cardiovascular events was 60 over a median follow-up of 68 months. Even after adjusting for any of the prognostic models, participants who attended ≤ 75% of sessions (n = 140) had higher risks of mortality (hazard ratio (HR), 1.79; 95% confidence interval (CI): 1.00 - 3.36; P = 0.049) and cardiovascular events (HR, 1.84; 95% CI: 1.07 - 3.48; P = 0.03) than those attending > 75% of sessions (n = 126). CONCLUSION: Hemodialysis patients in whom physical activity and physical function could be assessed more regularly had better prognosis than those with only intermittent assessment.

Effects of zolpidem/triazolam on cognitive performance 12 hours after acute administration.

OBJECTIVE: Most previous studies have concluded that decreased cognitive function and performance due to ultra-short acting hypnotics do not persist after 6-9 h post-administration. This study examined the effects of ultra-short acting hypnotics on cognitive function and performance 12 h after administration, ie, a time considered sufficient for the effects of hypnotics to disappear. METHODS: Thirteen healthy young male volunteers (mean age, 23.4 ± 3.2 years) participated in this study. Participants attended three sessions of polysomnography (PSG) recording preceded by oral administration of placebo for the first session, and 5 mg zolpidem or 0.25 mg triazolam for the second and third sessions, in a double-blinded, randomized manner at intervals of at least five days. A cognitive test battery was administered following each session, consisting of a psychomotor vigilance task (PVT), which reflects alertness and sleepiness, digit symbol substitution test (DSST), which reflects attention and working memory function, and assessment of subjective sleepiness and mental condition using a visual analog scale (VAS). RESULTS AND CONCLUSIONS: The administration of hypnotics significantly increased total sleep time, sleep efficiency, and sleep stages 2 and 4, and significantly decreased wake after sleep onset and sleep stage 1. PVT parameters were not affected by the administration of hypnotics, but DSST score was significantly lower, and "subjective alertness," "vigor," and "sadness" significantly deteriorated, after administration. In conclusion, while objective sleepiness disappeared 12 h after the administration of ultra-short acting hypnotics, their effects to decrease cognitive function persisted even after 12 h post-administration.

Exposure of drugs for hypertension, diabetes, and autoimmune disease during pregnancy and perinatal outcomes: an investigation of the regulator in Japan.

Assessment of perinatal effects of drug exposure during pregnancy after approval is an important issue for regulatory agencies. The study aimed to explore associations between perinatal outcomes and maternal exposure to drugs for chronic diseases, including hypertension, diabetes, and autoimmune disease.We reviewed 521 cases of adverse reactions due to drug exposure during pregnancy who were reported to the Pharmaceuticals and Medical Devices Agency, a regulatory authority in Japan. The primary outcomes were fetal and neonatal death and malformation of infants. Associations between perinatal outcomes and exposure to each drug category for hypertension, diabetes, and autoimmune disease were evaluated using logistic regression analysis.Of the 521 cases (maternal age: 15-47 years; mean 32.3 ±â€Š5.5), fetal and neonatal deaths were reported in 159 cases (130 miscarriage; 12 stillbirth; 4, neonatal death; and 13 abortion due to medical reasons), and malformations of infants were observed in 124 cases. In contrast to the trend of association between diabetes with or without medication and fetal and neonatal death (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.17-1.36), exposure to oral antidiabetics tended to be associated with fetal and neonatal death (OR, 4.86; 95% CI, 0.81-29.2). Malformation tended to be correlated with exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (OR, 2.98; 95% CI, 0.76-11.7). This association showed trends opposite to that of the association with hypertension itself (OR, 0.42; 95% CI, 0.18-1.02) or overall antihypertensives (OR, 0.42; 95% CI, 0.15-1.13). Occurrence of multiple malformations was associated with exposure to biologics (OR, 8.46; 95% CI, 1.40-51.1), whereas there was no significant association between multiple malformations and autoimmune disease with or without medication (OR 1.07; 95% CI, 0.37-3.06).These findings suggest that drugs of different categories may have undesirable effects when used during pregnancy. However, the regulatory database was not originally designed to evaluate the causal associations between drug exposure and adverse drug reactions. The limitations of spontaneous reporting systems should be carefully taken into account. Further studies are needed to elucidate the effects of individual drugs in each category on perinatal outcomes.

Application of iPS cell-derived macrophages to cancer therapy.

We established a method to produce a large quantity of myeloid cells from human inducible pluripotent stem cells (iPSCs). When injected intraperitoneally into mice carrying established peritoneal tumors, iPSC-derived myeloid cells (iPS-MCs) efficiently accumulated within neoplastic lesions. The intraperitoneal injection of iPS-MCs expressing interferon ß significantly inhibited the growth of human gastric and pancreatic cancers implanted in the peritoneal cavity of immunocompromised mice.

Therapeutic effect of human iPS-cell-derived myeloid cells expressing IFN-ß against peritoneally disseminated cancer in xenograft models.

We recently developed a method to generate myeloid cells with proliferation capacity from human iPS cells. iPS-ML (iPS-cell-derived myeloid/macrophage line), generated by introducing proliferation and anti-senescence factors into iPS-cell-derived myeloid cells, grew continuously in an M-CSF-dependent manner. A large number of cells exhibiting macrophage-like properties can be readily obtained by using this technology. In the current study, we evaluated the possible application of iPS-ML in anti-cancer therapy. We established a model of peritoneally disseminated gastric cancer by intraperitoneally injecting NUGC-4 human gastric cancer cells into SCID mice. When iPS-ML were injected intraperitoneally into the mice with pre-established peritoneal NUGC-4 tumors, iPS-ML massively accumulated and infiltrated into the tumor tissues. iPS-ML expressing IFN-ß (iPS-ML/IFN-ß) significantly inhibited the intra-peritoneal growth of NUGC-4 cancer. Furthermore, iPS-ML/IFN-ß also inhibited the growth of human pancreatic cancer MIAPaCa-2 in a similar model. iPS-ML are therefore a promising treatment agent for peritoneally disseminated cancers, for which no standard treatment is currently available.

Immunotherapy with pluripotent stem cell-derived dendritic cells.

In vivo transfer of dendritic cells (DC) has proven efficient in the priming of T cells and is regarded as a powerful means of providing anti-cancer immunotherapy. Clinical trials of anti-cancer therapy with DC pulsed with peptide antigens have been carried out in many institutions, although dramatic therapeutic effect has not been observed in most of the trials. Negative regulation of the immune response by DC might be applicable to treatment of autoimmune diseases and transplantation medicine. Currently, the DC used for anti-cancer vaccine therapy are generated from the peripheral blood monocytes of the patients. However, there is a limitation in the number of available monocytes and the potential of monocytes to differentiate into DC varies depending on the individual blood donors. To resolve the issue of the cell source for DC therapy, several groups have developed methods to generate DC from pluripotent stem cells. This review introduces methods to generate functional DC from pluripotent stem cells of mouse and human.

Dual effects of TRAIL in suppression of autoimmunity: the inhibition of Th1 cells and the promotion of regulatory T cells.

TRAIL is known to play a pivotal role in the inhibition of autoimmune disease. We previously demonstrated that administration of dendritic cells engineered to express TRAIL and myelin-oligodendrocyte glycoprotein reduced the severity of experimental autoimmune encephalomyelitis and suggested that CD4(+)CD25(+) regulatory T cells (Tregs) were involved in mediating this preventive effect. In the current study, we investigated the effect of TRAIL on Tregs, as well as conventional T cells, using TRAIL-deficient mice. Upon induction of experimental autoimmune encephalomyelitis, TRAIL-deficient mice showed more severe clinical symptoms, a greater frequency of IFN-γ-producing CD4(+) T (Th1) cells, and a lower frequency of CD4(+)Foxp3(+) Tregs than did wild-type mice. In vitro, conventional T cells stimulated by bone marrow-derived dendritic cells (BM-DCs) from TRAIL-deficient mice showed a greater magnitude of proliferation than did those stimulated by BM-DCs from wild-type mice. In contrast, TRAIL expressed on the stimulator BM-DCs enhanced the proliferative response of CD4(+)CD25(+) Tregs in the culture. The functional TRAILR, mouse death receptor 5 (mDR5), was expressed in conventional T cells and Tregs upon stimulation. In contrast, the decoy receptor, mDc-TRAILR1, was slightly expressed only on CD4(+)CD25(+) Tregs. Therefore, the distinct effects of TRAIL may be due to differences in the mDc-TRAILR1 expression or the signaling pathways downstream of mouse death receptor 5 between the two T cell subsets. Our data suggest that TRAIL suppresses autoimmunity by two mechanisms: the inhibition of Th1 cells and the promotion of Tregs.

Pluripotent stem cell-derived dendritic cells for immunotherapy.

Dendritic cell (DC) is regarded as a powerful means for anti-cancer immunotherapy. Clinical trials of cancer therapy with DC loaded with cancer antigens, such as tumor cell-lysates or HLA class I-binding antigenic peptides, have been conducted. Antigen-specific negative manipulation of the immune response by DC is a potential treatment for autoimmune diseases and also for control of allo-reactive immune responses in transplantation medicine. Currently, DC for clinical use are generated from peripheral blood monocytes of the patients. However, the number of monocytes obtained from the patients is limited and the potential of monocytes to differentiate into DC varies depending on the blood donor. Thus, the issue of limited cells is a serious obstacle for DC therapy. ES cells and iPS cells have pluripotency and unlimited propagation capacity and may be an ideal cell source for DC-therapy. Several groups, including us, have developed methods to generate DC from ES cells or iPS cells. This review introduces the studies on generation, characterization, and genetic modification of DC derived from ES cells or iPS cells.

Pluripotent stem cells as source of dendritic cells for immune therapy.

Dendritic cells (DC) are the most potent antigen-presenting cells. In vivo transfer of antigen-bearing DC has proven efficient in priming T cell responses specific to the antigen. DC-based cellular vaccination is now regarded as a powerful means for immunotherapy, especially for anti-cancer immunotherapy. Clinical trials of therapy with DC pulsed with peptide antigens or genetically modified to present antigens are currently carried out in many institutions. In addition, antigen-specific negative regulation of immune response by DC is considered to be a promising approach for treatments of autoimmune diseases and also for regulation of allo-reactive immune response causing graft rejection and GVHD in transplantation medicine. DC for transfer therapy are now generated by in vitro differentiation of peripheral blood monocytes of the patients. However, there is a limitation in the number of available monocytes, and the DC-differentiation potential of monocytes varies depending on the blood donor. Embryonic stem (ES) cells possess both pluripotency and infinite propagation capacity. We consider ES cells to be an ideal source for DC to be used in immunotherapy. Several groups, including us, have developed methods to generate DC from ES cells. This review introduces the studies on generation, characterization, and genetic modification of DC derived from ES cells or induced pluripotent stem (iPS) cells. The issues to be resolved before clinical application of pluripotent stem cell-derived DC will also be discussed.

Characterization of dendritic cells and macrophages generated by directed differentiation from mouse induced pluripotent stem cells.

Methods have been established to generate dendritic cells (DCs) from mouse and human embryonic stem (ES) cells. We designated them as ES-DCs and mouse models have demonstrated the induction of anti-cancer immunity and prevention of autoimmune disease by in vivo administration of genetically engineered ES-DCs. For the future clinical application of ES-DCs, the histoincompatibility between patients to be treated and available human ES cells and the ethical concerns associated with human ES cells may be serious obstacles. However, recently developed induced pluripotent stem (iPS) cell technology is expected to resolve these issues. This report describes the generation and characterization of DCs derived from mouse iPS cells. The iPS cell-derived DCs (iPS-DCs) possessed the characteristics of DCs including the capacity of T-cell-stimulation, antigen-processing and presentation and cytokine production. DNA microarray analyses revealed the upregulation of genes related to antigen-presenting functions during differentiation into iPS-DCs and similarity in gene expression profile in iPS-DCs and bone marrow cell-derived DCs. Genetically modified iPS-DCs expressing antigenic protein primed T-cells specific to the antigen in vivo and elicited efficient antigen-specific anti-tumor immunity. In addition, macrophages were generated from iPS cells (iPS-MP). iPS-MP were comparable with bone marrow cell-derived macrophages in the cell surface phenotype, functions, and gene expression profiles.

Multiple antigen-targeted immunotherapy with alpha-galactosylceramide-loaded and genetically engineered dendritic cells derived from embryonic stem cells.

Numerous tumor-associated antigens (TAA) have been identified and their use in immunotherapy is considered to be promising. For TAA-based immunotherapy to be broadly applied as standard anticancer medicine, methods for active immunization should be improved. In the present study, we demonstrated the efficacy of multiple TAA-targeted dendritic cell (DC) vaccines and also the additive effects of loading alpha-galactosylceramide to DC using mouse melanoma models. On the basis of previously established methods to generate DC from mouse embryonic stem cells (ES-DC), 4 kinds of genetically modified ES-DC, which expressed the melanoma-associated antigens, glypican-3, secreted protein acidic and rich in cysteine, tyrosinase-related protein-2, or gp100 were generated. Anticancer effects elicited by immunization with the ES-DC were assessed in preventive and also therapeutic settings in the models of peritoneal dissemination and spontaneous metastasis to lymph node and lung. The in vivo transfer of a mixture of 3 kinds of TAA-expressing ES-DC protected the recipient mice from melanoma cells more effectively than the transfer of ES-DC expressing single TAA, thus demonstrating the advantage of multiple as compared with single TAA-targeted immunotherapy. Loading ES-DC with alpha-galactosylceramide further enhanced the anticancer effects, suggesting that excellent synergic effects of TAA-specific cytotoxic T lymphocytes and natural killer T cells against metastatic melanoma can be achieved by using genetically modified ES-DC. With the aid of advancing technologies related to pluripotent stem cells, induced pluripotent stem cells, and ES cells, clinical application of DC highly potent in eliciting anticancer immunity will be realized in the near future.