Apoptosis and suppression of tumor growth by artepillin C extracted from Brazilian propolis

Herbal therapeutics that block the oncogenic kinase PAK1: a practical approach towards PAK1-dependent diseases and longevity

Over 35 years research on PAKs, RAC/CDC42(p21)-activated kinases, comes of age, and in particular PAK1 has been well known to be responsible for a variety of diseases such as cancer (mainly solid tumors), Alzheimer's disease, acquired immune deficiency syndrome and other viral/bacterial infections, inflammatory diseases (asthma and arthritis), diabetes (type 2), neurofibromatosis, tuberous sclerosis, epilepsy, depression, schizophrenia, learning disability, autism, etc. Although several distinct synthetic PAK1-blockers have been recently developed, no FDA-approved PAK1 blockers are available on the market as yet. Thus, patients suffering from these PAK1-dependent diseases have to rely on solely a variety of herbal therapeutics such as propolis and curcumin that block PAK1 without affecting normal cell growth. Furthermore, several recent studies revealed that some of these herbal therapeutics significantly extend the lifespan of nematodes (C. elegans) and fruit flies (Drosophila), and PAK1-deficient worm lives longer than the wild type. Here, I outline mainly pathological phenotypes of hyper-activated PAK1 and a list of herbal therapeutics that block PAK1, but cause no side (harmful) effect on healthy people or animals.

Evaluation of genotoxicity and antigenotoxicity of artepillin C in V79 cells by the comet and micronucleus assays

Artepillin C (3,5-diprenyl-p-coumaric acid) is one of the major phenolic compounds found in Brazilian green propolis, as well as in its botanical source, Baccharis dracunculifolia DC (Asteraceae). The present study evaluated the possible genotoxic and protective activities of artepillin C, in vitro, using methyl methanesulfonate (MMS) as a positive control, by comet and micronucleus assays. The cultures of Chinese hamster lung fibroblasts (V79 cells) were treated with different concentrations of artepillin C (2.5, 5.0, 10.0, and 20 μM). In antigenotoxicity assessment, the 3 concentrations of artepillin C (2.5, 5.0, and 10.0 μM) were associated with MMS (200 μM-comet assay and 400 μM-micronucleus assay). A statistically significant increase in the DNA damage and micronucleus frequencies was observed in the culture treated with the highest concentration of the artepillin C in comparison to the control group. All concentrations of artepillin C showed protective activity in relation to MMS-induced genotoxicity, which may be due to its antioxidant properties.

Identification of the cell targets important for propolis-induced cell death in Candida albicans

Candida albicans is the most common fungal pathogen of humans, forming both commensal and opportunistic pathogenic interactions, causing a variety of skin and soft tissue infections in healthy people. In immunocompromised patients C. albicans can result in invasive, systemic infections that are associated with a high incidence of mortality. Propolis is a complex mixture of several resinous substances which are collected from plants by bees. Here, we demonstrated the fungicidal activity of propolis against all three morphogenetic types of C. albicans and that propolis-induced cell death was mediated via metacaspase and Ras signaling. To identify genes that were involved in propolis tolerance, we screened ~800 C. albicans homozygous deletion mutants for decreased tolerance to propolis. Fifty-one mutant strains were identified as being hypersensitive to propolis including seventeen genes involved in cell adhesion, biofilm formation, filamentous growth, phenotypic switching and pathogenesis (HST7, GIN4, VPS34, HOG1, ISW2, SUV3, MDS3, HDA2, KAR3, YHB1, NUP85, CDC10, MNN9, ACE2, FKH2, and SNF5). We validated these results by showing that propolis inhibited the transition from yeast-like to hyphal growth. Propolis was shown to contain compounds that conferred fluorescent properties to C. albicans cells. Moreover, we have shown that a topical pharmaceutical preparation, based upon propolis, was able to control C. albicans infections in a mouse model for vulvovaginal candidiasis. Our results strongly indicate that propolis could be used as a strategy for controlling candidiasis.

Anti-inflammatory and antimicrobial evaluation of neovestitol and vestitol isolated from Brazilian red propolis

The objective of this study was to evaluate anti-inflammatory and antimicrobial activities of neovestitol and vestitol isolated from Brazilian red propolis (BRP). BRP ethanolic extract (EEP), neovestitol, and vestitol were evaluated by anti-inflammatory properties using a neutrophil migration assay. The antimicrobial activity was evaluated by minimal inhibitory and bactericidal concentrations (MIC and MBC) against Streptococcus mutans , Streptococcus sobrinus , Staphylococcus aureus , and Actinomyces naeslundii . Neovestitol, vestitol, and EEP inhibited neutrophil migration at a dose of 10 mg/kg. Regarding antimicrobial activity, neovestitol showed MICs ranging from <6.25 to 25-50 μg/mL and MBCs ranging from 25-50 to 50-100 μg/mL, while vestitol showed MICs ranging from 25-50 to 50-100 μg/mL and MBCs ranging from 25-50 to 50-100 μg/mL. Both isoflavonoids neovestitol and vestitol are consistent bioactive compounds displaying anti-inflammatory and antimicrobial activities that can strongly act in a low dose and concentration and have a promising potential to be applied in the pharmaceutical and food industries.

Recent progress of propolis for its biological and chemical compositions and its botanical origin

Propolis is the generic name given to the product obtained from resinous substances, which is gummy and balsamic and which is collected by bees from flowers, buds, and exudates of plants. It is a popular folk medicine possessing a broad spectrum of biological activities. These biological properties are related to its chemical composition and more specifically to the phenolic compounds that vary in their structure and concentration depending on the region of production, availability of sources to collect plant resins, genetic variability of the queen bee, the technique used for production, and the season in which propolis is produced. Many scientific articles are published every year in different international journal, and several groups of researchers have focused their attention on the chemical compounds and biological activity of propolis. This paper presents a review on the publications on propolis and patents of applications and biological constituents of propolis.

Improvement of insulin resistance, blood pressure and interstitial pH in early developmental stage of insulin resistance in OLETF rats by intake of propolis extracts

Propolis, a resinous mixture collected from plants by the Apis mellifera bee, contains high level nutrient factors including vitamins, polyphenols, and amino acids that would be expected to improve insulin sensitivity. Insulin resistance would secondarily cause elevation of blood pressure and increase the risk of cardiovascular diseases. The purpose of this study is to investigate the effect of propolis extracts on blood glucose levels and blood pressures in an early developmental stage of insulin resistance in Otsuka Long-Evans Tokushima Fatty (OLETF) rats. OLETF rats (10 weeks old) were divided into three different groups: normal diet, 0.1% propolis diet, and 0.5% propolis diet. After 8 weeks, blood glucose levels, blood pressures, plasma metabolic factors and hormones, and interstitial fluid pH were measured. Casual blood glucose levels were decreased associated with a reduction of plasma insulin levels in both propolis diet groups compared with normal diet group. Propolis decreased systolic blood pressure with no significant changes in plasma aldosterone levels. We also found that interstitial fluid pH in ascites, liver, and skeletal muscle was higher in rats fed propolis diet than rats fed normal diet. These data suggests that dietary propolis improves insulin sensitivity and blood pressures in the early stage of the process in development of insulin resistance, which may be mediated by suppression of metabolic acidosis.

Artepillin C, a major ingredient of Brazilian propolis, induces a pungent taste by activating TRPA1 channels

Brazilian green propolis is a popular health supplement because of its various biological properties. The ethanol extract of Brazilian green propolis (EEBP) is characteristic for its herb-like smell and unique pungent taste. However, the ingredients responsible for its pungency have not yet been identified. This study provides the first evidence that artepillin C is the main pungent ingredient in EEBP and that it potently activates human transient receptor potential ankyrin 1 (TRPA1) channels. EEBP was fractionated using column chromatography with a step gradient elution of an ethanol-water solution, and the fractions having the pungent taste were determined by sensory tests. HPLC analysis revealed that the pungent fraction was composed primarily of artepillin C, a prenylated derivative of cinnamic acid. Artepillin C was also identified as the pungent compound of EEBP by organoleptic examiners. Furthermore, the effects of artepillin C and other cinnamic acids found in EEBP on TRPA1 channels were examined by calcium imaging and plate reader-based assays in human TRPA1-expressing cells to investigate the molecular mechanisms underlying their pungent tastes. Artepillin C and baccharin activated the TRPA1 channel strongly, whereas drupanin caused a slight activation and p-coumaric acid showed no activation. Because the EC₅₀ values of artepillin C, baccharin, and allyl isothiocyanate were 1.8 µM, 15.5 µM, and 6.2 µM, respectively, artepillin C was more potent than the typical TRPA1 agonist allyl isothiocyanate. These findings strongly indicate that artepillin C is the main pungent ingredient in EEBP and stimulates a pungent taste by activating TRPA1 channels.

Transcriptional profiling of Saccharomyces cerevisiae exposed to propolis

BACKGROUND

Propolis is a natural product of plant resins collected by honeybees (Apis mellifera) from various plant sources. Our previous studies indicated that propolis sensitivity is dependent on the mitochondrial function and that vacuolar acidification and autophagy are important for yeast cell death caused by propolis. Here, we extended our understanding of propolis-mediated cell death in the yeast Saccharomyces cerevisiae by applying systems biology tools to analyze the transcriptional profiling of cells exposed to propolis.

METHODS

We have used transcriptional profiling of S. cerevisiae exposed to propolis. We validated our findings by using real-time PCR of selected genes. Systems biology tools (physical protein-protein interaction [PPPI] network) were applied to analyse the propolis-induced transcriptional bevavior, aiming to identify which pathways are modulated by propolis in S. cerevisiae and potentially influencing cell death.

RESULTS

We were able to observe 1,339 genes modulated in at least one time point when compared to the reference time (propolis untreated samples) (t-test, p-value 0.01). Enrichment analysis performed by Gene Ontology (GO) Term finder tool showed enrichment for several biological categories among the genes up-regulated in the microarray hybridization such as transport and transmembrane transport and response to stress. Real-time RT-PCR analysis of selected genes showed by our microarray hybridization approach was capable of providing information about S. cerevisiae gene expression modulation with a considerably high level of confidence. Finally, a physical protein-protein (PPPI) network design and global topological analysis stressed the importance of these pathways in response of S. cerevisiae to propolis and were correlated with the transcriptional data obtained thorough the microarray analysis.

CONCLUSIONS

In summary, our data indicate that propolis is largely affecting several pathways in the eukaryotic cell. However, the most prominent pathways are related to oxidative stress, mitochondrial electron transport chain, vacuolar acidification, regulation of macroautophagy associated with protein target to vacuole, cellular response to starvation, and negative regulation of transcription from RNA polymerase II promoter. Our work emphasizes again the importance of S. cerevisiae as a model system to understand at molecular level the mechanism whereby propolis causes cell death in this organism at the concentration herein tested. Our study is the first one that investigates systematically by using functional genomics how propolis influences and modulates the mRNA abundance of an organism and may stimulate further work on the propolis-mediated cell death mechanisms in fungi.

Chemical composition and botanical origin of red propolis, a new type of brazilian propolis

Red propolis is a new type of Brazilian propolis. This material, as well as the secretions of 20 plant species that are often mentioned as its probable botanical source, have been investigated by RP-HPTLC. Phytochemical evidence based on UV-VIS spectra, RP-HPLC and GC-MS, showed Dalbergia ecastophyllum (L.) Taub. to be the main source of red propolis in Alagoas state. The propolis and plant resin showed high relative percentages of the isoflavonoids 3-Hydroxy-8,9-dimethoxypterocarpan and medicarpin. To our knowledge this is the first report of the secretion of a leguminous species being the source of propolis.

Artepillin C (3,5-diprenyl-4-hydroxycinnamic acid) sensitizes LNCaP prostate cancer cells to TRAIL-induced apoptosis

Naturally occurring phenolic compounds have been shown to sensitize prostate cancer cells to tumour necrosis factor-related apoptosis-inducing ligand (TRAIL)-induced apoptosis. TRAIL is a potent stimulator of apoptosis in cancer cells and an important immune effector molecule in the surveillance and elimination of developing tumours. However, many cancer cells are resistant to TRAIL-mediated death. In this study, we aimed to determine the mechanisms by which TRAIL resistance can be overcome in prostate cancer cells by 3,5-diprenyl-4-hydroxycinnamic acid (artepillin C). Artepillin C is a bioactive component of Brazilian green propolis that possesses antitumour and chemopreventive activities. TRAIL-resistant LNCaP prostate cancer cells were treated with TRAIL and artepillin C. Cytotoxicity was measured by MTT and lactate dehydrogenase (LDH) assays. Apoptosis was detected using Annexin V-FITC staining by flow cytometry and fluorescence microscopy. Death receptor (DR) (TRAIL-R1/DR4 and TRAIL-R2/DR5) expression was analyzed using flow cytometry. Mitochondrial membrane potential (ΔΨm) was evaluated using DePsipher staining by fluorescence micro scopy. The inhibition of NF-κB (p65) activation was confirmed with the ELISA-based TransAM NF-κB kit. Caspase-8 and caspase-3 activities were determined by colorimetric protease assays. The results showed that artepillin C sensitized the TRAIL-resistant LNCaP cells by engaging the extrinsic (receptor-mediated) and intrinsic (mitochondrial) apoptotic pathways. Artepillin C increased the expression of TRAIL-R2 and decreased the activity of NF-κB. Co-treatment with TRAIL and artepillin C induced the significant activation of caspase-8 and caspase-3, as well as the disruption of ΔΨm. These findings show that prostate cancer cells can be sensitized to TRAIL-mediated immunoprevention by artepillin C and confirm the role of phenolic compounds in prostate cancer immunochemoprevention.

Immunostimulant effect of Egyptian propolis in rabbits

The present experiment was conducted to study the effect of ethanolic extract of Egyptian propolis given alone or in combination with inactivated Pasteurella multocida vaccine on rabbits challenged with a virulent strain of Pasteurella multocida. Fifty-six New-Zealand rabbits, 6–8 weeks old and non-vaccinated against pasteurellosis, were randomly divided into eight equal groups. The first group was kept as a control for the experiment. The other groups received different treatments with propolis extract, inactivated vaccine, or both. The experiment continued for seven weeks during which clinical signs, body weight, and mortality rate were monitored, and blood samples were collected weekly for evaluating the leukogram, serum biochemistry, and immune response in all groups of animals. At the end of the seventh week, the animals were subjected to challenge with a virulent strain of Pasteurella multocida. Two weeks later, tissue specimens were collected from different organs for histopathological examination. Results showed that rabbits of the groups treated with both propolis and the vaccine by different routes appeared healthy after challenge. It has been concluded that alcoholic extract of propolis administrated in combination with inactivated Pasteurella multocida vaccine has no adverse effects on the general health conditions and enhances immune response in rabbits.

Selective inhibition of human type-5 17β-hydroxysteroid dehydrogenase (AKR1C3) by baccharin, a component of Brazilian propolis

The human aldo-keto reductase (AKR) 1C3, also known as type-5 17β-hydroxysteroid dehydrogenase and prostaglandin F synthase, has been suggested as a therapeutic target in the treatment of prostate and breast cancers. In this study, AKR1C3 inhibition was examined by Brazilian propolis-derived cinnamic acid derivatives that show potential antitumor activity, and it was found that baccharin (1) is a potent competitive inhibitor (K(i) 56 nM) with high selectivity, showing no significant inhibition toward other AKR1C isoforms (AKR1C1, AKR1C2, and AKR1C4). Molecular docking and site-directed mutagenesis studies suggested that the nonconserved residues Ser118, Met120, and Phe311 in AKR1C3 are important for determining the inhibitory potency and selectivity of 1. The AKR1C3-mediated metabolism of 17-ketosteroid and farnesal in cancer cells was inhibited by 1, which was effective from 0.2 μM with an IC(50) value of about 30 μM. Additionally, 1 suppressed the proliferation of PC3 prostatic cancer cells stimulated by AKR1C3 overexpression. This study is the first demonstration that 1 is a highly selective inhibitor of AKR1C3.

Anti-Tumor Effects of Water-Soluble Propolis on a Mouse Sarcoma Cell Line In Vivo and In Vitro

The honeybee product propolis and its extracts are known to have biological effects such as antibiotic, anti-viral, anti-inflammatory and anti-tumor activities. This study was designed to investigate whether water-soluble propolis (WSP) inhibits tumor growth. The tumor cell line used was mouse sarcoma 180 (S-180), and its growth was determined in vitro and in vivo with exposure to different concentrations of WSP.

The effects of WSP on tumor cells in vitro were evaluated by measuring the intracellular uptake of 3 H -thymidine. 3 H -thymidine uptake was inhibited in accordance with the concentration of WSP. The minimum concentration of WSP necessary for 3 H -thymidine uptake inhibition was 1.0 μg/ml and uptake was suppressed to 88% of the level in non-treated cells at this concentration.

In an experiment using tumor-bearing mice, oral administration of WSP was begun 24 hours after transplantation of S-180 cells. WSP was administered to the mice 5 times, every other day for 10 days. The doses were 320 mg/kg (10 mg/mouse) or 960 mg/kg (30 mg/mouse) of body weight. All mice were sacrificed 10 days after transplantation, and tumor growth was evaluated. The orally administered WSP significantly inhibited the growth of transplanted tumors ( p < 0.05). Furthermore, histological findings revealed a significant reduction in mitotic cells and tumor invasion of the muscular tissue at both dose-levels of WSP.

Comparative Studies of the (Anti) Mutagenicity of Baccharis dracunculifolia and Artepillin C by the Bacterial Reverse Mutation Test

Baccharis dracunculifolia is a plant native from Brazil, commonly known as ‘Alecrim-do-campo’ and ‘Vassoura’ and used in alternative medicine for the treatment of inflammation, hepatic disorders and stomach ulcers. Previous studies reported that artepillin C (ArtC, 3-{4-hydroxy-3,5-di(3-methyl-2-butenyl)phenyl}-2(E)-propenoic acid), is the main compound of interest in the leaves. This study was undertaken to assess the mutagenic effect of the ethyl acetate extract of B. dracunculifolia leaves (Bd-EAE: 11.4–182.8 µg/plate) and ArtC (0.69–10.99 µg/plate) by the Ames test using Salmonella typhimurium strains TA98, TA97a, TA100 and TA102, and to compare the protective effects of Bd-EAE and ArtC against the mutagenicity of a variety of direct and indirect acting mutagens such as 4-nitro-O-phenylenediamine, sodium azide, mitomycin C, benzo[a]pyrene, aflatoxin B1, 2-aminoanthracene and 2-aminofluorene.The mutagenicity test showed that Bd-EAE and ArtC did not induce an increase in the number of revertant colonies indicating absence of mutagenic activity. ArtC showed a similar antimutagenic effect to that of Bd-EAE in some strains of S. typhimurium, demonstrating that the antimutagenic activity of Bd-EAE can be partially attributed to ArtC. The present results showed that the protective effect of whole plant extracts is due to the combined and synergistic effects of a complex mixture of phytochemicals, the total activity of which may result in health benefits.

Preventive and protective effects of Turkish propolis on H₂O₂-induced DNA damage in foreskin fibroblast cell lines

The aim of the present study was to evaluate the potential of Turkish propolis extracts if they prevent or protect foreskin fibroblast cells against hydrogen peroxide (H₂O₂)-induced oxidative DNA damage. Hydrogen peroxide (40 μM) was used as an inducer of oxidative DNA damage. The damage of DNA was evaluated by using the alkaline single cell gel electrophoresis (comet) assay. Turkish propolis extracts at concentrations of 25, 50, 75 and 100 μg/ml were prepared by ethanol. Anti-genotoxicity was assessed before, simultaneously, and after treatment of propolis extract (50 μg/ml) with H₂O₂. The results showed a significant decrease in H₂O₂-induced DNA damage in cultures treated with propolis extract. The antioxidant activity of phenolic components found in propolis may contribute to reduce the DNA damage induced by H₂O₂. Our findings confirmed the chemopreventive activity of propolis and showed that this effect may occur under different mechanisms.

The antimicrobial effects of propolis collected in different regions in the Basque Country (Northern Spain)

The antimicrobial activity of 19 propolis extracts prepared in different solvents (ethanol and propylene glycol) (EEP/PEP), was evaluated against some bacterial and fungal isolates using the agar-well diffusion method. It was verified that all the samples tested showed antimicrobial activity, although results varied considerably between samples. Results revealed that both types of propolis extracts showed highly sensitive antimicrobial action against Gram-positive bacteria and fungi at a concentration of 20% (Staphylococcus aureus, Streptococcus mutans, Candida albicans and Saccharomyces cerevisae) with a minimal inhibitory concentration (MIC) ranging from 0.5 to 1.5 mg/ml, with a moderate effect against Streptococcus pyogenes (MIC from 17 to 26 mg/ml). To our knowledge, this is the first study showing elevated antimicrobial activity against Gram-negative bacteria [Salmonella enterica (MIC from 0.6 to 1.4 mg/ml)] and lesser activity against Helicobacter pylori (MIC from 6 to 14 mg/ml), while Escherichia coli was resistant. This concluded that the Basque propolis had a strong and dose-dependent activity against most of the microbial strains tested, while database comparison revealed that phenolic substances were responsible for this inhibition, regardless of their geographical origin and the solvent employed for extraction. Statistical analysis showed no significant differences (P ≤ 0.05) between EEP and PEP extracts.

Molecular characterization of propolis-induced cell death in Saccharomyces cerevisiae

Propolis, a natural product of plant resins, is used by the bees to seal holes in their honeycombs and protect the hive entrance. However, propolis has also been used in folk medicine for centuries. Here, we apply the power of Saccharomyces cerevisiae as a model organism for studies of genetics, cell biology, and genomics to determine how propolis affects fungi at the cellular level. Propolis is able to induce an apoptosis cell death response. However, increased exposure to propolis provides a corresponding increase in the necrosis response. We showed that cytochrome c but not endonuclease G (Nuc1p) is involved in propolis-mediated cell death in S. cerevisiae. We also observed that the metacaspase YCA1 gene is important for propolis-mediated cell death. To elucidate the gene functions that may be required for propolis sensitivity in eukaryotes, the full collection of about 4,800 haploid S. cerevisiae deletion strains was screened for propolis sensitivity. We were able to identify 138 deletion strains that have different degrees of propolis sensitivity compared to the corresponding wild-type strains. Systems biology revealed enrichment for genes involved in the mitochondrial electron transport chain, vacuolar acidification, negative regulation of transcription from RNA polymerase II promoter, regulation of macroautophagy associated with protein targeting to vacuoles, and cellular response to starvation. Validation studies indicated that propolis sensitivity is dependent on the mitochondrial function and that vacuolar acidification and autophagy are important for yeast cell death caused by propolis.

MK615, a prospective anti-proliferative agent, enhances CD4/CD8 ratio after exposure to irradiation

PURPOSE

Recently, it was found that MK615 possessed an anti-proliferative ability on treated cancer cells as a consequence of triterpenoid compounds. It is well known that radiation affects cellular-mediated immunity in cancer patients who are treated with radiotherapy. Similarly, the ability of triterpenoid compounds to enhance the cellular-mediated immunity has been observed. Therefore, in the present study, we attempted to investigate the effect of MK615 on both cancer cells and cellular-mediated immunity after irradiation.

MATERIALS AND METHODS

After mice were inoculated with mouse mammary carcinoma (FM3A) cells, they were categorised as follows: Non-treated, irradiated with 5 Gy, treated with 660 μg/day MK615 (MK615, an extract from the Japanese apricot) and lastly exposed to both irradiation and MK615. Afterward, mice were sacrificed and spleens were utilised to measure the cluster of differentiation 4 and 8 (CD4 and CD8) using flowcytometry. Simultaneously, in vitro study, human alveolar basal epithelial carcinomic (A549), mouse lymphoma (EL4) and FM3A cell lines were examined. Growth inhibition was assessed via colony, cell viability and apoptotic assays.

RESULTS

The median survival was in favour of the MK615-treated group (26.1 ± 1.9 days) compared with non-treated group (22.3 ± 2.3 days) (p < 0.05). Approximately 50% reduction of the CD4/CD8 ratio was observed following the exposure to irradiation alone. However, this ratio was comparable between the non-treated and both MK615-treated groups. Additionally, only the dual treatment was associated with tumour volume reduction. In contrast, in vitro study showed that MK615 had no significant (p ≥ 0.1) effect on the selected cell lines with or without irradiation.

CONCLUSION

MK615 has a potential to reduce tumour volume and may normalise cellular-mediated immunity level following the exposure to irradiation.

Influence of honey bee products on transplantable murine tumours

The effect of propolis [it is a water-soluble derivative (WSDP)] and related polyphenolic compounds of propolis (caffeic acid, caffeic acid phenethyl ester and quercetin), honey, royal jelly and bee venom on tumour growth, metastasizing ability and induction of apoptosis and necrosis in murine tumour models (mammary carcinoma and colon carcinoma) was investigated. WSDP and related polyphenolic compounds showed significant anti-metastatic effect (P < 0.01 and P < 0.001) given either before or after tumour-cell inoculation. Oral or systemic application of WSDP or caffeic acid significantly reduced subcutaneous tumour growth and prolonged the survival of mice. Honey also exerted pronounced anti-metastatic effect (P < 0.05) when applied before tumour-cell inoculation (peroral 2 g kg(-1) for mice or 1 g kg(-1) for rats, once a day for 10 consecutive days). Royal jelly did not affect metastasis formation when given intraperitoneally or subcutaneously. However, intravenous administration of royal jelly before tumour-cell inoculation significantly (P < 0.05) inhibited metastasis formation. When mice were given 10(5) tumour cells intravenously immediately after bee venom injection, the number of tumour nodules in the lung was significantly lower (P < 0.001) than in untreated mice or mice treated with bee venom subcutaneously. Local presence of bee venom in the tissue caused significant delay in subcutaneous tumour formation. These findings clearly demonstrate that anti-tumour and anti-metastatic effects of bee venom are highly dependent on the route of injection and on close contact between components of the bee venom and tumour cells. These data show that honey bee products given orally or systemically may have an important role in the control of tumour growth and tumour metastasizing ability.

Inhibition of corneal neovascularization with propolis extract

Neovascularization of the normally avascular cornea is seen in many pathological conditions including trauma, corneal transplantation, inflammation and eye diseases. Various growth factors and proteinases are involved in corneal neovascularization. Data supporting a causal role for vascular endothelial growth factor (VEGF) and matrix metalloproteinases (MMPs) are extensive. Inhibition of angiogenesis is a main strategy for treating corneal neovascularization. Several findings have shown that corneal neovascularization can be reduced by using anti-VEGF and anti-MMPs agents. Efficacy of a propolis extract has been demonstrated for reducing angiogenesis in vitro and in vivo. Propolis extracts containing artepillin C and caffeic acid phenyl ester significantly reduced the number of newly formed vessels and expression of MMPs and VEGF production from various cells. So far, propolis extract is a potential candidate as an anti-angiogenic agent and can inhibit cell proliferation, migration and capillary tube formation. We hypothesize that topical application of propolis is potentially useful for inhibiting corneal neovascularization and restoration of corneal clarity.

Brazilian red propolis--chemical composition and botanical origin

Propolis contains resinous substances collected by honey bees from various plant sources and has been used as a traditional folk medicine since ca 300 BC. Nowadays, the use of evidence-based complementary and alternative medicine (CAM) is increasing rapidly and so is the use of propolis in order to treat or support the treatment of various diseases. Much attention has been focused on propolis from Populus sp. (Salicaceae) and Baccharis dracunculifolia (Asteracea), but scientific information about the numerous other types of propolis is still sparse. We gathered six samples of red propolis in five states of Northeastern Brazil. The beehives were located near woody perennial shrubs along the sea and river shores. The bees were observed to collect red resinous exudates on Dalbergia ecastophyllum (L) Taub. (Leguminosae) to make propolis. The flavonoids of propolis and red resinous exudates were investigated using reversed-phase high-performance liquid chromatography and reversed-phase high-performance thin-layer chromatography. We conclude that the botanical origin of the reddish propolis is D. ecastophyllum. In areas where this source (D. ecastophyllum) was scarce or missing, bees were collecting resinous material from other plants. Propolis, which contained the chemical constituents from the main botanical origin, showed higher antimicrobial activity.

Ultrastructural view of colon anastomosis under propolis effect by transmission electron microscopy

AIM: To evaluate the effect of propolis administration on the healing of colon anastomosis with light and transmission electron microscopes.

METHODS: Forty-eight Wistar-Albino female rats were divided into two groups and had colon resection and anastomosis. In group I, rats were fed with standard rat chow pre- and postoperatively. The rats in group II were fed with standard rat chow and began receiving oral supplementation of propolis 100 mg/kg per day beginning 7 d before the operation and continued until they were sacrificed. Rats were sacrificed 1, 3, 7 and 14 d after operation, and anastomotic bursting pressures measured. After the resection of anastomotic segments, histopathological examination was performed with light and transmission electron microscopes by two blinded histologists and photographed.

RESULTS: The colonic bursting pressures of the propolis group were statistically significantly better than the control group. Ultrastructural histopathological analysis of the colon anastomosis revealed that propolis accelerated the phases of the healing process and stimulated mature granulation tissue formation and collagen synthesis of fibroblasts.

CONCLUSION: Bursting pressure measurements and ultra structural histopathological evaluation showed that administration of propolis accelerated the healing of colon anastomosis following surgical excision.

Validated method for the quantification of artepillin-C in Brazilian propolis

Brazilian propolis contains several phenolic compounds among which 5 diprenyl-4-hydroxycinnamic acid (artepillin-C) is commonly found in areas where flora is rich in Baccharis species. The quantification of artepillin-C has become an important factor as an indicator of Brazilian propolis quality and the compound may be used as a chemical marker for quality control in exportating green propolis. This work was to validate the method and evaluate the content of artepillin-C from 33 samples collected in different Brazilian regions. The method used was HPLC with UV-vis detection and a reversed-phase C(18) column. The validation parameters studied were: linearity, accuracy, precision, quantification and detection limits. The results obtained were: detection limit = 0.0036 microg/mL, quantification limit = 0.012 microg/mL, accuracy = 0.0064 and 0.078, recovery 98-102%. Artepillin-C content varied from 0 to 11% depending on the geographical origin. Propolis from the southeast region presented the highest level of artepillin-C (5.0-11.0%). Whist that from the northeast region did not show any artepillin-C.

Propolis and the immune system: a review

Propolis has been used empirically for centuries and it was always mentioned as an immunomodulatory agent. In recent years, in vitro and in vivo assays provided new information concerning its mechanisms of action, thus a review dealing with propolis and the immune system became imperative. This review compiles data from our laboratory as well as from other researchers, focusing on its chemical composition and botanical sources, the seasonal effect on its composition and biological properties, its immunomodulatory and antitumor properties, considering its effects on antibody production and on different cells of the immune system, involving the innate and adaptive immune response. In vitro and in vivo assays demonstrated the modulatory action of propolis on murine peritoneal macrophages, increasing their microbicidal activity. Its stimulant action on the lytic activity of natural killer cells against tumor cells, and on antibody production was demonstrated. Propolis inhibitory effects on lymphoproliferation may be associated to its anti-inflammatory property. In immunological assays, the best results were observed when propolis was administered over a short-term to animals. Propolis antitumor property and its anticarcinogenic and antimutagenic potential are discussed. Since humans have used propolis for different purposes and propolis-containing products have been marketed, the knowledge of its properties with scientific basis is not only of academic interest but also of those who use propolis as well. This review opens a new perspective on the investigation of propolis biological properties, mainly with respect to the immune system.

Suppression of tumor-induced angiogenesis by Brazilian propolis: Major component artepillin C inhibits in vitro tube formation and endothelial cell proliferation

Propolis, a resinous substance collected by honeybees from various plant sources, possesses various physiological activities such as antitumor effects. We have previously shown that propolis of Brazilian origin was composed mainly of artepillin C and that its constituents were quite different from those of propolis of European origin. In this report, we examined an antiangiogenic effects of Brazilian propolis and investigated whether artepillin C was responsible for such effects. In an in vivo angiogenesis assay using ICR mice, we found that the ethanol extract of Brazilian propolis (EEBP) significantly reduced the number of newly formed vessels. EEBP also showed antiangiogenic effects in an in vitro tube formation assay. When compared with other constituents of EEBP, only artepillin C was found to significantly inhibit the tube formation of HUVECs in a concentration-dependent manner (3.13-50microg/ml). In addition, artepillin C significantly suppressed the proliferation of HUVECs in a concentration-dependent manner (3.13-50microg/ml). Furthermore, artepillin C significantly reduced the number of newly formed vessels in an in vivo angiogenesis assay. Judging from its antiangiogenic activity in vitro and in vivo, we concluded that artepillin C at least in part is responsible for the antiangiogenic activity of EEBP in vivo. Artepillin C may prove useful in the development of agents and foods with therapeutic or preventive activity against tumor angiogenesis.

Analysis of propolis from Baccharis dracunculifolia DC. (Compositae) and its effects on mouse fibroblasts

This paper confirms Baccharis dracunculifolia DC. (Compositae) as the main botanical source of the propolis from southeastern Brazil (state of São Paulo) investigated to ascertain specific biological activity in relation to mouse NIH-3T3 fibroblasts, skin cells directly involved in the cicatrization processes. Flavonoid and total phenolic compounds were determined by spectrophotometry, and chemical composition by HPLC; the chromatographic profile, characterized largely by flavonoids and aromatic acids, was found to be qualitatively similar to that of Baccharis dracunculifolia DC. The adsorption of phenolic compounds in the propolis to skin powder was also investigated, and 68% of these compounds adsorbed to the skin powder. At concentrations from 0.12 to 7.81 microg/ml, the propolis revealed no statistical significant differences from its control solutions; however, at concentrations of 31.25 microg/ml or more, the propolis was toxic to NIH-3T3 cells. Thus, the propolis from Baccharis dracunculifolia DC. (Compositae) presents an in vitro concentration-dependent toxicity on mouse NIH-3T3 fibroblasts.

Adjuvant effect of green propolis on humoral immune response of bovines immunized with bovine herpesvirus type 5

Despite recent technological advances in vaccine production, most vaccines depend on the association with adjuvant substances. In this study, propolis, which has been attracting the attention of researchers due to its bioactive properties, was evaluated as an immunological adjuvant. The association of 40mg/dose of an ethanolic extract of green propolis with an inactivated oil vaccine against bovine herpesvirus type 5 (BoHV-5), resulted in a significant increase (P<0.01) in the neutralizing antibody levels, comparing to the bovines that received the same vaccine without propolis. Besides, propolis increased the percentage of animals with high antibody titers (above 32). Phenolic compounds such as artepillin C (3,5-diprenyl-4-hydroxycinnamic acid) and the derivatives of cinnamic acid besides other flavonoid substances were abundant in the propolis extract used, and they could be the main substances with adjuvant action. The effect of the green propolis extract on the humoral immune response can be exploited in the development of new vaccines.

Artepillin C isoprenomics: design and synthesis of artepillin C isoprene analogues as lipid peroxidation inhibitor having low mitochondrial toxicity

We designed and synthesized isoprene analogues of artepillin C, a major component of Brazilian propolis, and investigated the inhibitory activity on lipid peroxidation of rat liver mitochondria (RLM) and RLM toxicity based on isoprenomics. We succeeded in the synthesis of artepillin C isoprene analogues using regioselective prenylation within the range from 22% to 53% total yield. Reactivity of artepillin C and its isoprene analogues with ABTS (2,2'-Azinobis(3-ethylbenzothiazoline-6-sulfonate)) radical cations showed only a slight difference among the molecules. The isoprene side-chain elongation analogues of artepillin C showed almost the same inhibitory activity against RLM lipid peroxidation as artepillin C. Artepillin C and its isoprene analogues had very weak RLM uncoupling activity. Moreover, artepillin C and its isoprene analogues exhibited a lower inhibitory activity against adenosine 5'-triphosphate (ATP) synthesis by about two orders of magnitude than the effective inhibitory activity against RLM lipid peroxidation. From these results we conclude that artepillin C isoprene analogues could be potent lipid peroxidation inhibitors having low mitochondrial toxicity. We also conclude that elongation of the isoprene side chain of artepillin C to increase lipophilicity had little influence on the inhibitory activity toward RLM lipid peroxidation.

Effects of local administration of propolis and its polyphenolic compounds on tumor formation and growth

Many dietary constituents are chemopreventive in animal models, and experiments with cultured cells are revealing various potential mechanisms of action. Compounds classified as blocking agents can prevent, or greatly reduce, initiation of carcinogenesis, or suppressing agents can act on cell proliferation. Caffeic acid (CA) and caffeic acid phenethyl ester (CAPE), members of the polyphenolic compounds, are present in high concentrations in medicinal plants and propolis, a natural beehive product. A water-soluble extract of propolis (WSDP) and two components of propolis, CA and CAPE were investigated for direct antitumor activity in vivo and in vitro. The local presence of CA and CAPE in the tissue caused a significant delay in tumor formation and increased life span 29.30 to 51.73%, respectively. CA and CAPE, but not WSDP, significantly suppressed human HeLa cervical carcinoma cell proliferation in vitro. Based on these results, we postulate that the antitumor activity of polyphenolic compounds includes direct cytotoxic effects on tumor cells.

Water-soluble derivative of propolis and its polyphenolic compounds enhance tumoricidal activity of macrophages

Many plants and the plant-derived honeybee propolis have shown biological activities like immunomodulation and antitumor effect. The effect of two water-soluble propolis derivatives (WSDP) from Croatia and Brazil, caffeic acid, quercetin, chrysin and naringenin which are present in WSDP was assessed on the development of Ehrlich ascites tumor (EAT). The compounds (50 mgkg(-1)) were given by gastric intubations (po) 2 h prior to the intraperitoneal injection of EAT (2x10(6)) cells. It was observed that WSDP and its compounds effectively inhibited tumor growth and proliferation of EAT. The volume of ascitic fluid induced by EAT cells and total number of cells present in the peritoneal cavity was markedly reduced in EAT-bearing mice treated with test components. Treatment with test components increased the number of polymorphonuclear (PMN) cells and decreased the number of macrophages in the peritoneal cavity of treated animals. The macrophage spreading activity revealed that WSDP and all test compounds affected the functional state of macrophages increasing their tumoricidal activity. The effect of WSDP was most pronounced suggesting synergistic effect of components present in WSDP. It is likely that part of the antitumor efficacy of the assayed components against EAT cells was the results of increased macrophage activity.

Peroral Application of Water-soluble Derivative of Propolis (WSDP) and Its Related Polyphenolic Compounds and Their Influence on Immunological and Antitumour Activity

Polyphenolic compounds are widely distributed in the plant kingdom and display a variety of biological activities, including chemoprevention and growth inhibition of tumours. Propolis contains a conglomerate of polyphenolic compounds. We investigated the effect of propolis and polyphenolic compounds, components of propolis, on the growth and metastatic potential of a transplantable mammary carcinoma (MCa) of the mouse. Metastases in the lung were generated by 2 x 10(5) tumour cells injected intravenously (i.v.). A water-soluble derivative of propolis (WSDP) and the polyphenolic compounds (caffeic acid (CA) and caffeic acid phenethyl ester (CAPE)) were given to mice perorally before or after tumour cell inoculation. WSDP, CA and CAPE reduced the number of metastases in the lung. This implies that the antitumour activities of the compounds used in these studies are mostly related to the immunomodulatory properties of the compounds, their cytotoxicity to tumour cells, and their ability to induce apoptosis and/or necrosis.

Transepithelial transport of artepillin C in intestinal Caco-2 cell monolayers

The absorption characteristics of artepillin C (AC), an active ingredient of Brazilian propolis, were examined by measuring permeation across Caco-2 cell monolayers. The permeation rate in the basolateral-to-apical direction, J(bl-->ap), in the presence of proton gradient was 0.14 nmol/min/mg protein, whereas J(bl-->ap) in the absence of proton gradient was 1.14 nmol/min/mg protein. The latter value is nearly the same as the permeation rate in the apical-to-basolateral direction, J(ap-->bl), both in the presence and absence of proton gradient. In the presence of proton gradient, J(ap-->bl) was almost constant, irrespective of NaN(3) or benzoic acid. However, J(bl-->ap) dramatically increased upon the addition of NaN(3) or benzoic acid specifically to the apical side. In both the presence and absence of proton gradient, J(ap-->bl) also appeared to be constant irrespective of the paracellular permeability of Caco-2 cells. After AC was loaded apically in the presence of proton gradient, the intracellular AC increased with time. This accumulation was inhibited by apically loaded NaN(3). These indicate that AC transport occurs mainly via transcellular passive diffusion, although a considerable amount of AC was taken up intracellularly by monocarboxylic acid transporter (MCT) on the apical side and not transported out across the basolateral membrane, suggesting that different subtypes of MCT are involved.

PRÓPOLIS: UMA REVISÃO DOS RECENTES ESTUDOS DE SUAS PROPRIEDADES FARMACOLÓGICAS

RESUMO Própolis de Apis mellifera L. (Hymenoptera, Apidae) é um produto da colméia, elaborado a partir de exsudatos de resinas que as abelhas recolhem de determinadas plantas. A composição química da própolis é complexa e relacionada à diversidade vegetal encontrada em torno da colméia. Embora a própolis seja utilizada em medicina popular por milhares de anos, a falta de padrões que avaliem de maneira precisa suas atividades farmacológicas, dificulta a estandardização de produtos comerciais que garanta sua eficácia e segurança terapêutica para humanos e outros animais. Nesta revisão estão sumarizados alguns desenvolvimentos recentes da pesquisa farmacológica da própolis, enfocando-se as atividades antiinflamatórias, antimicrobianas, antineoplásica e antioxidante.

Immunomodulatory effect of caffeic acid phenethyl ester in Balb/c mice

Caffeic acid phenethyl ester (CAPE), an the active component of propolis, is known to have anticarcinogenic, antiviral and various biological activities; however, the effect of CAPE on the immunomodulatory activity in vivo remains unknown. We have investigated the effect of CAPE on the immune system in female Balb/c mice. CAPE (0, 5, 10, 20 mg/kg) was given to mice orally for 14 days. Immunomodulatory activity was evaluated by assessment of body and organ weight, lymphocyte blastogenesis, plaque-forming cell (PFC) assay, lymphocyte subpopulation by flow cytometry and cytokine production. Even though the change of body weight was not observed in CAPE-administered group, thymus weight and/or cellularity of thymus and spleen are decreased at the all dose groups of CAPE (5, 10, 20 mg/kg). On the other hand, CAPE had no effect on B lymphocyte proliferation induced by lipopolysaccharide (LPS) but increased T lymphocyte blastogenesis induced by concanavalin A (Con A) at the dose of 20 mg/kg. In the case of lymphocyte subpopulation, the population of T and B cells was not changed but CD4(+) T cell subsets are significantly increased in exposure to CAPE. The antibody responses to T lymphocyte dependent antigen, sheep red blood cell and keyhole limpet hemocyanin (KLH) were increased more than 10 mg/kg in CAPE-treated group. Likewise, the cytokine, IL-2, IL-4 and IFN-gamma were significantly increased at the dose of 20 mg/kg CAPE group. These results suggest that CAPE could have immunomodulatory effects in vivo.

Synergystic Antitumor Effect of Polyphenolic Components of Water Soluble Derivative of Propolis against Ehrlich Ascites Tumour

Effect of two preparation (Croatian and Brazilian) of water-soluble derivative of propolis (WSDP), caffeic acid, quercetin, chrysin, naringenin (components present in WSDP) on the development of Ehrlich ascites tumour (EAT) was evaluated. Test components (50 mg/kg) were given perorally or intraperitoneally 2 h prior the intraperitonel injection of EAT (2 x 10(6)) cells. It was observed that all test compounds effectively inhibited tumour growth and the proliferation of EAT. The volume of ascitic fluid induced by EAT cells and total number of cells present in the peritoneal cavity was markedly reduced in EAT-bearing mice treated with test components. In treated mice the number of polymorphonuclear (PMN) cells in the peritoneal cavity was increased while the number of macrophages was decreased. The macrophage spreading activity revealed that WSDP and all test compounds affected the functional state of macrophages increasing their tumorcidal activity; the effect of WSDP was most pronounced indicating synergistic effect of components present in WSDP. Antitumor activity of WSDP may be the result of different specific mechanism(s) of flavonoids present as compared to individual flavonoid given alone. It is likely that the part of antitumor efficacy of test components against EAT cells was the results of increased activity of macrophages.

Artepillin C in Brazilian propolis induces G0/G1 arrest via stimulation of Cip1/p21 expression in human colon cancer cells

Potential chemopreventive agents exist in foods. Artepillin C in Brazilian propolis was investigated for its effects on colon carcinogenesis. We had found that artepillin C was a bioavailable antioxidant, which could be incorporated into intestinal Caco-2 and hepatic HepG2 cells without any conjugation and inhibited the oxidation of intracellular DNA. Artepillin C was then added to human colon cancer WiDr cells. It dose-dependently inhibited cell growth, inducing G(0)/G(1) arrest. The events involved a decrease in the kinase activity of a complex of cyclin D/cyclin-dependent kinase 4 and in the levels of retinoblastoma protein phosphorylated at Ser 780 and 807/811. The inhibitors of the complex, Cip1/p21 and Kip1/p27, increased at the protein level. On the other hand, Northern blotting showed that artepillin C did not affect the expression of Kip1/p27 mRNA. According to the experiments using isogenic human colorectal carcinoma cell lines, artepillin C failed to induce G(0)/G(1) arrest in the Cip1/p21-deleted HCT116 cells, but not in the wild-type HCT116 cells. Artepillin C appears to prevent colon cancer through the induction of cell-cycle arrest by stimulating the expression of Cip1/p21 and to be a useful chemopreventing factor in colon carcinogenesis.

In vivo effects of propolis, a honeybee product, on gilthead seabream innate immune responses

The potential effect of the intraperitoneal or dietary administration of propolis, a honeybee product, on gilthead seabream (Sparus aurata L.) innate immune responses was evaluated. Fish were intraperitoneally injected with 5mg of water (WEP), ethanol (EEP) or both (WEP + EEP) extracts of propolis and sampled after 1, 3, 5 and 10 days. When administered in the diet, propolis was dissolved in ethanol and added to a pellet diet at a concentration of 0, 0.1 or 10 g kg(-1) diet, the fish being sampled after 1, 2, 4 and 6 weeks of feeding. Humoral (alternative complement activity and peroxidase content) and cellular (leucocyte peroxidase, phagocytosis, cytotoxicity and respiratory burst activity) immune responses were evaluated in both cases. The results suggest that propolis has limited immunostimulatory effects although intraperitoneal administration was more effective than dietary intake. The effects that were noted were at cellular level, namely, phagocytosis and cytotoxicity.

Modifying effect of propolis on dimethylhydrazine-induced DNA damage but not colonic aberrant crypt foci in rats

Propolis is a honeybee product with several biological and therapeutic properties, including antimutagenic and anticarcinogenic activities. The effects of an aqueous extract of propolis (AEP) were evaluated on the formation of 1,2-dimethylhydrazine (DMH)-induced aberrant crypt foci (ACF) and DNA damage in the colon of male Wistar rats by the ACF and Comet assays, respectively. AEP was administered orally at 0.01%, 0.03%, 0.1%, and 0.3% in the drinking water, which resulted in doses of approximately 12, 34, 108, and 336 mg/kg body weight/day. Animals were also given a single subcutaneous injection of 40 mg/kg DMH and sacrificed 4 hr later for evaluating DNA damage, or 4 doses of 40 mg/kg DMH, administered 2 doses/week for 2 weeks, and sacrificed 12 weeks after the last injection for evaluating ACF development in the distal colon. Administration of AEP either simultaneously with or after the DMH treatment resulted in no statistically significant reduction of ACF. In contrast, 0.01%, 0.03%, and 0.3% AEP, given simultaneously with DMH, reduced DNA damage induction in the mid and distal colon. However, 0.3% AEP alone increased DNA damage in the colon. In conclusion, AEP had no effect on the formation of DMH-induced ACF in rat colon, but it modulated DMH-induced DNA damage in colon cells. Further investigations are recommended in order to establish the conditions under which propolis produces either protective or deleterious effects.

Inhibitory effect of water-soluble derivative of propolis and its polyphenolic compounds on tumor growth and metastasizing ability: a possible mode of antitumor action

Polyphenolic compounds are widely distributed in the plant kingdom and display a variety of biological activities, including chemoprevention and tumor growth inhibition. Propolis is made up of a variety of polyphenolic compounds. We compared how the routes of administration of polyphenolic compounds deriving from propolis and of propolis itself affect the growth and metastatic potential of a transplantable mammary carcinoma (MCa) of the CBA mouse. The influence of tested compounds on local tumor growth was also studied. Metastases in the lung were generated by 2 x 10(5) tumor cells injected intravenously (IV). A water-soluble derivative of propolis (WSDP) and polyphenolic compounds (caffeic acid, CA, and CA phenethyl ester, CAPE) were given to mice per os (PO) or intraperitoneally (IP) before or after tumor cell inoculation. Tested compounds significantly decreased the number of lung colonies. When mice were inoculated with 10(5) MCa cells in the exact site of subcutaneous injection of different doses of WSDP, CA, or CAPE, tumor growth was inhibited, and survival of treated mice was prolonged. Antitumor activity, according to the results obtained, is mostly related to the immunomodulatory properties of the compounds and their capacity to induce apoptosis and necrosis. In conclusion, results presented here indicate that WSDP, CA, and CAPE could be potential useful tools in the control of tumor growth in experimental tumor models when administrated PO; because PO administration is the easiest way of introducing a compound used for prevention and/or cure of any disease, it is likely that this article has reached the goal of the investigation.