长波紫外线对小鼠朗格汉斯细胞生物学活性的影响

目的　研究体外长波紫外线 (UVA)对小鼠表皮朗格汉斯细胞 (LC)生物学活性的影响。方法　观察不同剂量的UVA对BALB/c小鼠表皮LC存活率、膜相关抗原 (Ia、B7 1、B7 2、CD40 )的表达及其抗原提呈功能的影响。结果　生理剂量的UVA (<80kJ/m2 )照射 ,对LC的存活率影响不明显 ,却能增加LC膜抗原的表达 ,促进其抗原提呈功能。超生理剂量的UVA则反之。结论　生理与非生理剂量的UVA对LC会产生不同的生物学效应 ,这可能是UVA调节机体免疫功能的分子基础。     

Effects of ultraviolet irradiation on surface marker expression by epidermal immunocompetent cells and contact sensitization to dinitrofluorobenzene in mice

We studied the effects of ultraviolet (UV) irradiation on murine epidermal Ia-positive Langerhans cells (Ia + LC) and Thy-I-positive dendritic epidermal cells (Thy-I + dEC). We also studied contact hypersensitivity to dinitrofluorobenzene (DNFB) introduced through UV-treated epidermis. C3H/HeN mice were exposed to UVB or 8-methoxypsoralen plus UVA (PUVA). UVB and PUVA treatment led to a dramatic reduction in surface marker expression of both Ia + LC and Thy-I + dEC. High-dose UVB irradiation (360 J/m2) interfered with contact hypersensitivity to DNFB; the density of Ia + LC may thus be related to the sensitizing potential. In contrast, low-dose UVB (120 J/m2) and PUVA treatment had little effect on contact hypersensitivity despite a marked reduction in Ia + LC. The density of Thy-I + dEC appeared not to be associated with contact hypersensitivity. These results suggest that there may be a Langerhans cell density-independent mechanism for the induction of contact hypersensitivity.     

Modulation of expression of epidermal Langerhans cell properties following in situ exposure to glucocorticosteroids

Langerhans cells (LC) have been implicated as antigen-presenting and target cells in contact allergic, cell-mediated reactions. We have examined the effects in guinea pigs, rats, and humans of in situ (epicutaneous) exposure to glucocorticosteroids (GCS) on the expression of epidermal LC markers. Reductions in the number of Fc-rosetting, C3b-rosetting, and immune-associated (Ia) antigen-bearing LC occurred in a dose-related fashion, with the degree of such reductions dependent upon the specific GCS employed. These reductions were determined to be reversible following cessation of exposure to GCS. T6 antigenicity, another cell surface marker of human LC, was little affected by GCS exposure. Simultaneous immunofluorescent staining for T6 and Ia antigenicity within human epidermis of amcinonide treated skin detected reduced numbers of T6+/Ia+ cells with a concomitant increase in T6+/Ia- cells. The data presented suggest a selective reduction in the expression of immunologically important receptors and antigens by LC which may be involved in steroid-responsive contact allergic reactions.     

Immunostimulatory capabilities of highly enriched Langerhans cells in vitro

Langerhans cells (LC) are epidermal antigen-presenting cells capable of inducing allogenic, antigen-specific, and cytotoxic T cell proliferation. Previous studies have examined the dynamics of LC maintained in vitro in crude epidermal cell (EC) suspensions in which the major cell type is the keratinocyte (KC). To avoid the confounding effects of KC and other immunoregulatory cells on LC dynamics in vitro, highly enriched murine LC (85%) were studied, through 72 h of incubation in vitro, for their ability to present alloantigen (in a primary allogenic proliferation assay) and foreign antigen (in a secondary autologous proliferation assay). The results were compared to similar studies using crude EC suspensions. Freshly prepared LC are very poor stimulators of a primary allogenic proliferation response, with a 12- to 16-fold increase in stimulatory capacity by 72 h using panned-enriched and crude EC suspensions, respectively. Similarly, freshly prepared LC are weak stimulators of a secondary autologous proliferation response, with a 2.5- to 6-fold increase in immunostimulatory capability by 72 h. The overall increased stimulatory effect observed with the crude EC suspensions compared to highly enriched LC is most likely attributed to the effect of KC on T cell proliferation, rather than to a maturation effect of KC on LC during the 72 h of in vitro incubation. Using back-scattered electron imaging, the surface density of MHC-class II molecules (Ia) increased three- to fourfold through culture, which parallels the increase in functional ability. This study demonstrates that LC in either a crude or highly enriched cell suspension mature into potent immunostimulatory cells after incubation in vitro with an increased surface expression of Ia molecules. Keratinocytes are not necessary for LC maturation in vitro, but seem to exert some stimulatory effect by enhancing lymphocyte proliferation in the functional assay system.     

Epidermal Langerhans cells--a cycling cell population

The limited number of Langerhans cells (LC) in human epidermis and the resultant technical difficulties have left open the question of LC kinetics. In the present study using flow cytometry (FCM) we have applied 3 methods to estimate LC-DNA distribution: (1) FCM-DNA measurement on highly enriched LC suspensions, (2) FCM-correlated analysis of DNA and OKT-6(+) cells in total epidermal cell suspensions, (3) LC-enriched suspensions (70-90%) were FACS (fluorescence-activated cell sorter) sorted on microscopic slides, and stained with the Feulgen technique, and DNA was measured densitometrically. In the latter method, contaminating keratinocytes were counterlabeled with antikeratin serum to eliminate them from LC-DNA estimation. All 3 in vitro analyses clearly showed that human LC are a cycling cell population in the epidermis. The number of LC in S (1.3-3.3%) and G2/M (1.0-2.5%) phase compares with those found for keratinocytes. Assuming that this percentage of keratinocytes in S and G2/M phases is sufficient to maintain the structural integrity of the epidermis, it was suggested that LC may represent a stable, self-reproducing cell population in normal epidermis.     

Ultrastructural and phenotypic changes in Langerhans cells induced in vitro by contact allergens

Ultrastructural changes of murine Langerhans cells (LC) were examined following exposure of crude epidermal cell suspensions to the contact allergens dinitrochlorobenzene, nickel sulphate and lead nitrate at various concentrations and for various incubation times. An immunogold labelling technique was employed to study changes in surface expression of MHC Class II (Ia) molecules. In all cases, activation of LC was evident after as little as 15 min exposure and was characterized by a marked increase in surface expression of Ia molecules, prominent rough endoplasmic reticulum and numerous ribosomes and lysosomes. Degenerative changes in LC were apparent to varying degrees depending on the allergen, its concentration and the time of incubation. Degenerative changes included swollen mitochondria, membrane disruption or rupture, loss of density of the cytoplasm (cytolysis), loss of dendritic processes and decreased expression of Ia molecules. In the case of dinitrochlorobenzene, degenerative changes were present and usually severe at concentrations greater than 10 micrograms/ml, while exposure to nickel sulphate and lead nitrate was associated with only mild degenerative changes. These observations indicate that contact allergens have a variety of direct effects on LC, including activation and degeneration, which are dose- and time-dependent. Since these alterations of LC were observed in the absence of other immunologically active cells, peripolesis cannot be involved in these events.     

The functional maturation of Langerhans cells in CTL induction during tissue culture

In the previous report, we investigated the effects of tissue culture on the APC function of murine epidermal Langerhans cells (LC) in the induction of allo-CTL in vitro, and found that (1) cultured ear LC expressed increased amounts of Ia antigens on their cell surface, and (2) they induced extremely enhanced levels of CTL over those produced by freshly prepared ear LC and also (3) cultured tail LC were proved to be able to induce CTL for the first time. It seemed that tissue culture decreased the functional heterogeneity among the murine ear LC and tail LC in addition to that among Ia+ APC in spleen and in epidermis. In this study, we investigated the culture conditions that increase the APC function of LC. Our data indicate that LC cultured with dermal components exhibited more enhanced APC function than LC cultured in single cell suspension with only epidermal cells. Recent studies indicate that IL-1 and GM-CSF, which keratinocytes release, are essential for freshly prepared LC to mature into highly efficient APC that resemble splenic dendritic cells. We found dermal factors are more important than epidermal ones for LC to mature in tissue culture.     

Effect of glucocorticoids and gamma radiation on epidermal Langerhans cells

The effect of 750 rads of gamma radiation on the rate of return of epidermal Langerhans cells (LC) following suppressive doses of topical glucorticoids was studied in guinea pigs. Gamma radiation alone had no effect on the LC as assessed by staining for cell membrane ATPase activity and Ia antigen. It did, however, delay the expected return of Ia but not ATPase surface markers on the LC after perturbation with glucocorticoids. The delayed return of surface Ia antigen is possibly related to a radiation-induced defect in the production of a required lymphokine and/or in intracellular Ia transport. Although our data do not rule out a cytolytic effect of steroids on the LC, they do strongly suggest that, at least in part, glucocorticoids act on the LC by altering cell surface characteristics.     

Langerhans cells, antigen presentation, and the diversity of responses to chemical allergens.

Respiratory and contact chemical allergens provoke differential immune responses in mice, stimulating preferentially T helper-2 (TH2) and TH1 cells, respectively. In an attempt to discover whether such differences are effected at the level of antigen handling and presentation we have examined the effect of topical exposure to trimellitic anhydride (TMA), a respiratory allergen, and 2,4-dinitrochlorobenzene (DNCB), a contact allergen, on Langerhans cell (LC) MHC class II (Ia) expression. Neither chemical caused a significant change in LC size. As measured by analytical flow cytometry, exposure to DNCB resulted in a time-dependent increase in LC Ia expression that exceeded 160% of control values within 24 h. Exposure to concentrations of TMA that caused an equivalent activation of draining lymph nodes failed to affect Ia expression by LC. Application of sodium lauryl sulfate at concentrations that caused edema also failed to influence LC Ia. These data demonstrate that TMA and DNCB exert differential effects on epidermal LC, possibly indicative of differences in antigen handling.     

Recombinant gamma interferon induces HLA-DR expression on cultured human keratinocytes

In normal human epidermis, expression of HLA-DR antigen is restricted to Langerhans cells (LC) and acrosyringial epithelium. However, in diseases such as lichen planus and graft-vs.-host, HLA-DR antigen appears to be expressed by keratinocytes, although the exact source of the HLA-DR is unclear. Two possibilities are that (1) the HLA-DR is shed by neighboring immunocompetent cells, or (2) that the keratinocytes are synthesizing the antigen themselves. Recently, gamma interferon has been shown to induce HLA-DR biosynthesis and expression on human malignant melanoma cells lines and on normal vascular endothelium. We report here that pure recombinant human gamma interferon (100 units/ml) induces HLA-DR expression on 60-70% of cultured human adult keratinocytes depleted of LC within 2-4 days of culture as determined by fluorescence-activated cell sorter (FACS) analysis using monoclonal antibodies. No residual LC or lymphocytes could be detected in these cultures. This is the first demonstration of HLA-DR expression by cultured human keratinocytes. This expression may be of functional significance in antigen presentation and cell-mediated cytotoxicity involving the epidermis.     

Thy-1 antigen-bearing dendritic cells populate murine epidermis

Two distinct cell populations, melanocytes and Langerhans cells (LC), have been recognized previously to possess dendritic configuration in normal mammalian epidermis. Employing immunofluorescence microscopy with monoclonal antibodies against Thy-1.2 antigen to identify cells in whole mounts of murine epidermis, we have identified a third dendritic cell population which differs from both LC and melanocytes. Thy-1 antigen-bearing (Thy-1+) epidermal cells are primarily dendritic, although round and angular forms may be found. They are distributed relatively evenly across skin surfaces, although densities vary greatly from site to site and from strain to strain. Densities were highest in ear epidermis from the pigmented strain B10.A (580 cells/mm2), a value approaching that of epidermal LC, and were lowest in ear epidermis from the albino strain BALB/c (5 cells/mm2). Thy-1+ epidermal cells possess neither Ia antigens nor substantial amounts of melanin, and their surface distributions are disparate from those of both LC and mature melanocytes. We propose that at least some of these cells are T lymphocytes whose malignant counterparts account for cutaneous T-cell lymphomas.     

Rapid induction of Thy-1 antigenic markers on keratinocytes and epidermal immune cells in the skin of mice following topical treatment with common preservatives used in topical medications and in foods

Earlier experiments from our laboratory revealed that the medication most commonly used for depigmenting patients with vitiligo, monobenzyl ether of hydroquinone (MBEH), when applied to the skin of DBA/2 mice caused an increase in the population density (cells/mm2) of identifiable Ia+ and ATPase+ Langerhans cells. Further, this increase in Langerhans cell density could be correlated with an increase of contact hypersensitivity (CHS) reactivity to dinitrofluorobenzene (DNFB). The current experiments demonstrated that other compounds chemically similar to MBEH, such as butylated hydroxytoluene (BHT) and butylated hydroxyanisole (BHA), which are used as preservatives/antioxidants in many topical medications, cosmetics, food, and rubber products, can in five days significantly increase the population density of Thy-1+ dendritic epidermal cells. These compounds had no effects on Ia+ cells. This observation suggests that the Thy-1+ DEC cells may be more mobile and/or their surface markers may be readily expressed and are not a slowly mobile (trafficking) population of cells as suggested by the results of previous work. In addition, these parasubstituted phenolic compounds behaved like pertussis toxin and induced Thy-1 and Ia expression on keratinocytes. These changes in Thy-1 immune markers were not accompanied by functional alterations in the immune response to contact allergens as measured by the ear swelling technique.     

Solar-simulating irradiation of the skin of human subjects in vivo produces Langerhans cell responses distinct from irradiation ex vivo and in vitro

It has been postulated that Langerhans cells (LC) provide tolerogenic signals in the local impairment of cutaneous immune functions and antigen-specific tolerance induced by UV radiation. Studies in vitro and ex vivo have indicated that UV radiation may down-regulate the expression of costimulatory molecules on LC, leading to reduced antigen-presenting function. In contrast, we recently observed an up-regulatory stage in the number of human epidermal LC with induced expression of B7 costimulatory molecules 12-24 h after solar-simulating UV radiation (SSR) in vivo. To examine the apparent discrepancy between the observed human LC responses in vitro, ex vivo and in vivo, we compared the three protocols in a parallel fashion. The intact skin as well as skin explants and epidermal cell suspensions from the same individuals were irradiated with a single erythematogenic dose of SSR. The expression of cell surface markers in the epidermal cells was analysed with flow cytometry 24 h later. The number of CD1a+/HLA-DR+ LC increased post-SSR in vivo by a factor of 2.8+/-0.4, whereas in irradiated skin explants ex vivo or in cell suspensions in vitro, reduced numbers were seen. HLA-DR expression intensities were found to have increased on DR+ and CD1a+/DR+ cells in vivo. Similarly, SSR induced B7-2 (CD86) expression in CD1a+ cells significantly in vivo (P=0.031) but reduced the expression ex vivo or in vitro. We conclude that the early up-regulatory stage of human LC number and membrane markers, recorded at 24 h after a single exposure to SSR, is exclusively an in vivo phenomenon.     

Immunosuppressive effects of transforming growth factor beta: inhibition of the induction of Ia antigen on Langerhans cells by cytokines and of the contact hypersensitivity response

Recent reports show that transforming growth factor (TGF)-beta exerts a variety of immunosuppressive activities. The present study focuses on the effects of TGF-beta 1 on expression of Ia antigen by Langerhans cells. Although TGF-beta 1, in concentrations from 0.001 to 100 micrograms/ml, has no effect on constitutive expression of Ia antigen on these cells, the in vitro up-regulation of Ia antigen on the surface of LC by interleukin (IL)-1, tumor necrosis factor-alpha, interferon-gamma, IL-3, and granulocyte/macrophage-colony stimulating factor is inhibited by the concomitant addition of 1 microgram/ml TGF-beta 1. In contrast, TGF-beta 1 has no effect on the up-regulation induced by IL-2 or IL-6. In this report, the activity of TGF-beta closely resembles that of Cyclosporine A (CsA). Similar results are seen in vivo when either TGF-beta 1 (5 micrograms, intraperitoneally [ip], daily on days 0-3) or CsA (1 mg, subcutaneously [sc], twice daily on days 0-3) are given together with IL-2 (500 U, intraperitoneally [ip], twice daily on days 1-3) or interferon-gamma (4,000 U, ip, twice daily on days 1-3). Given the important role of Ia expression in cell-mediated immune reactions, the effect of TGF-beta on contact sensitivity was next investigated. In doses of 5 micrograms, ip, daily on days 6-8, TGF-beta inhibits the expression of contact reactivity in animals sensitized on day 0 and challenged on day 7. In contrast, no effect is observed on the induction of contact sensitivity in mice given TGF-beta 1 on days--1 to 2, sensitized on day 0, and challenged on day 7. The possible importance of antagonism between TGF-beta and other cytokines, especially IFN-gamma, involved in the elicitation of contact hypersensitivity reactions is discussed.     

Immunologic aspects of acute cutaneous graft-versus-host disease: decreased density and antigen-presenting function of Ia+ Langerhans cells and absent antigen-presenting capacity of Ia+ keratinocytes

Cutaneous graft-versus-host disease (GVHD) provides a unique model for studying the pathogenesis of several important lymphocyte-mediated skin diseases. Morphologic studies have suggested that Ia antigen (Ia)-bearing epidermal Langerhans cells (LC) may be specific targets for destruction in these conditions. Keratinocytes synthesize and express Ia in GVHD and some other lymphocyte-mediated skin disorders; Ia+ keratinocytes, constitutively able to secrete epidermal cell-derived thymocyte activating factor (ETAF)/interleukin 1, may possess antigen-presenting capacity, thus leading to enhanced cutaneous immune responses and disease chronicity. We therefore investigated the fate of Ia+ LC, and the potential antigen-presenting capacity of Ia+ keratinocytes, in a murine model of GVHD. Lethally irradiated C3H/He (H-2k) mice developed acute cutaneous GVHD, and expressed keratinocyte Iak, 8 days after injection of BALB/c (H-2d) bone marrow and spleen cells. Immunofluorescence studies showed a progressive decrease in the density of Ia+ epidermal LC during the evolution of GVHD. This decrease was paralleled by a progressive reduction in the allostimulatory capacity of GVHD epidermal cells (EC) in the allogeneic EC-lymphocyte reaction (ELR). The fall in the density of Ia+ LC, and in EC allostimulatory capacity in both primary and secondary ELRs, was consistently greater in GVHD mice than in mice treated only with x-irradiation. The allostimulatory capacity of GVHD and x-irradiated EC could not be restored by addition of indomethacin or exogenous ETAF to ELR cultures. The decreased allostimulatory capacity was not the result of inhibition of the ELR, since EC from GVHD and x-irradiated mice did not cause suppression when added to control ELR cultures. The capacity of EC to present ovalbumin, purified protein derivative of tuberculin, 2,4,6-trinitrobenzenesulfonic acid coupled to EC, and native cytochrome c (CYTc) to antigen-specific T-cell lines, clones, or hybridomas was reduced in x-irradiated mice and markedly decreased in GVHD mice. The capacity of EC from x-irradiated and GVHD mice to present CYTc fragment 81-104, which does not require further processing or catabolism by accessory cells, was similarly decreased. Taken together, the results indicate that: the function of LC is markedly and progressively impaired in acute GVHD; LC function is also decreased, but to a lesser extent, following x-irradiation alone; and Ia+ keratinocytes from lethally irradiated mice undergoing GVHD do not exhibit antigen-presenting capacity.     

Cutaneous dermal Ia+ cells are capable of initiating delayed type hypersensitivity responses

The presence of Langerhans cells (LC) within the epidermis has been shown to be critical for inducing T-cell-mediated immune responses in the skin. The purpose of this study was to assess whether cells in the dermis can initiate T-cell-mediated delayed-type hypersensitivity responses in vivo. Initially, back skins from C3H mice were trypsinized to remove the epidermis. The dermis was enzymatically dispersed and filtered to obtain a cell suspension. However, dermal cells exposed to trypsin were contaminated with numerous disaggregated hair follicles. These hair follicles contained Ia+ cells (presumably LC), and upon haptenation in vitro with trinitrophenyl, initiated contact hypersensitivity reactions in vivo. We therefore used dispase in place of trypsin to prevent follicular disaggregation and to allow preparation of dermal cell suspensions free of hair follicles. These hair follicle-free dermal cells were haptenated with trinitrophenyl and injected intradermally. Elicitation of contact hypersensitivity by epicutaneous painting 6 d later revealed the mean +/- SEM incremental ear-swelling response to be 53 +/- 8 mm X 10(-3). In contrast, mice sensitized by injection with dermal cells depleted of Ia+ cells demonstrated only 10 +/- 1 mm X 10(-3) of ear swelling. Thus, like dendritic LC of the epidermis, perivascular dendritic Ia+ cells of the dermis are capable of initiating T-cell-mediated contact hypersensitivity in vivo and may be highly relevant for presentation of antigen to T cells trafficking through the dermis.     

Quantitation of surface antigens on cultured murine epidermal Langerhans cells: rapid and selective increase in the level of surface MHC products

It was recently discovered that murine epidermal Langerhans cells (LC) changed significantly in function and phenotype when maintained in culture. Notably, accessory cell function for primary immune responses increased while cytologic markers like ATPase, nonspecific esterase, and Birbeck granules were lost. To further analyze LC differentiation, we used flow cytometry and a panel of 22 monoclonal antibodies to quantitate changes in surface antigens at the single-cell level. A striking change was a fivefold increase in the amount of Ia antigens (which are expressed on class II MHC products) during the first day of culture. The increase was evident within 3 h and reached a plateau at 15-24 h. Both I-A and I-E products behaved similarly. The increase in Ia was blocked by 1 microgram/ml cycloheximide. Expression of other surface antigens was then monitored on Ia+ LC by two-color flow cytometry. Low levels of class I (H-2D and H-2K) MHC products were detected on freshly isolated LC, and these antigens also increased severalfold during the first day of culture. Fc receptors (identified with the 2.4G2 mAb) and the F4/80 macrophage antigen decreased, as reported previously. Three antigens that were detected in fresh suspensions were expressed at constant levels in culture. These were the C3bi receptor and the pan leukocyte and interdigitating cell antigens. Several leukocyte antigens that were not found initially on LCs did not appear, including B220 anti-B cell, 33D1 anti-dendritic cell, and CD4, CD5, CD8 T-cell specificities. We conclude that the surface of cultured LCs undergoes selective changes in culture. As a result, the cells are rich in Ia and H-2 and have detectable C3bi receptors, but have little or no LFA-1, Ti, CD4, 5, and 8, 33D1, 2.4G2, F4/80, and B220 antigens.     

Ontogeny of Ia-positive and Thy-1-positive leukocytes of murine epidermis

Murine epidermis harbors 2 populations of dendritic leukocytes: Langerhans cells (LC) and Thy-1-positive dendritic epidermal cells (Thy-1 +DEC). In the adult mouse these cell types are morphologically distinct and display highly characteristic phenotypes. LC bear Ia-antigens and a group of markers typical for mononuclear phagocytes: Fc- and C3bi-receptors, macrophage-specific antigen F4/80, and membrane ATPase. Thy-1 +DEC, in contrast, lack these markers but express high levels of Thy-1 and asialo-GM1 (asGM1) antigen. Since LC and Thy-1 +DEC share a common origin from the bone marrow we expected to gain insight into their relationship by studying their ontogenetic development. Epidermal sheets from fetal and newborn C3H/He and C57B1/6 mice obtained at defined ages from day 17 of gestation up to day 30 of postnatal life were monitored for the emergence of the above-mentioned markers for LC and Thy-1 +DEC. In double-labeling experiments LC markers were first detected by visualizing the monoclonal antibodies by a sensitive triple-layer rhodamine-immunofluorescence technique; in a second step, after appropriate blocking procedures, Thy-1 and asGM1 antigens were demonstrated by direct and indirect immunofluorescence. We found that in fetal epidermis, only few cells expressed either Thy-1 or Ia (4 and 1 cells/mm2, respectively, on day 18 of gestation). The bulk of Thy-1 +DEC and Ia +EC appeared only after birth. Adult proportions of Thy-1 +DEC and Ia +EC were reached at around 1 month of postnatal life. In contrast, all the other LC markers were expressed on a substantial number of fetal dendritic cells (280 cells/mm2 on day 18 of gestation), indicating the presence of phenotypically immature Ia-negative LC in fetal epidermis. By day 4 of postnatal life all F4/80 +EC and ATPase +EC (i.e., LC) had acquired Ia-antigens. Surprisingly, LC also bore asGM1 antigens, which in the adult epidermis are strictly confined to Thy-1 +DEC, up to day 5 of postnatal life. Thus, LC in fetal and early newborn epidermis are not yet fully differentiated. As they differentiate, they acquire Ia antigens and lose asGM1 antigens. In contrast, a phenotypically immature Thy-1 +DEC population could not be traced with the markers used. Thy-1 +DEC appear to be characterized by a stable phenotype (Thy-1+/asGM1+) throughout their lifetime.