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Hou J, Feng Y, Yang Z, Ding Y, Cheng D, Shi Z, Li R, Xue L. Primary Sjögren's syndrome: new perspectives on salivary gland epithelial cells. Eur J Med Res 2024; 29:371. [PMID: 39014509 PMCID: PMC11253495 DOI: 10.1186/s40001-024-01967-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 07/09/2024] [Indexed: 07/18/2024] Open
Abstract
Primary Sjögren's syndrome (pSS) is a chronic autoimmune disease primarily affecting exocrine glands such as the salivary glands, leading to impaired secretion and sicca symptoms. As the mainstay of salivation, salivary gland epithelial cells (SGECs) have an important role in the pathology of pSS. Emerging evidence suggests that the interplay between immunological factors and SGECs may not be the initial trigger or the sole mechanism responsible for xerostomia in pSS, challenging conventional perceptions. To deepen our understanding, current research regarding SGECs in pSS was reviewed. Among the extensive aberrations in cellular architecture and function, this review highlighted certain alterations of SGECs that were identified to occur independently of or in absence of lymphocytic infiltration. In particular, some of these alterations may serve as upstream factors of immuno-inflammatory responses. These findings underscore the significance of introspecting the pathogenesis of pSS and developing interventions targeting SGECs in the early stages of the disease.
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Affiliation(s)
- Jiaqi Hou
- Rheumatology Department, Yueyang Hospital of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Yiyi Feng
- Rheumatology Department, Yueyang Hospital of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Zhixia Yang
- Rheumatology Department, Yueyang Hospital of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Yimei Ding
- Rheumatology Department, Yueyang Hospital of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Dandan Cheng
- Shanghai Skin Diseases Hospital, 200 Wuyi Road, Changning District, Shanghai, 200050, China
| | - Zhonghao Shi
- Rheumatology Department, Yueyang Hospital of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Rouxin Li
- Rheumatology Department, Yueyang Hospital of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Road, Hongkou District, Shanghai, 200437, China
| | - Luan Xue
- Rheumatology Department, Yueyang Hospital of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, 110 Ganhe Road, Hongkou District, Shanghai, 200437, China.
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Zhou J, Pathak JL, Liu Q, Hu S, Cao T, Watanabe N, Huo Y, Li J. Modes and Mechanisms of Salivary Gland Epithelial Cell Death in Sjogren's Syndrome. Adv Biol (Weinh) 2023; 7:e2300173. [PMID: 37409392 DOI: 10.1002/adbi.202300173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/16/2023] [Indexed: 07/07/2023]
Abstract
Sjogren's syndrome is an autoimmune disease in middle and old-aged women with a dry mucosal surface, which is caused by the dysfunction of secretory glands, such as the oral cavity, eyeballs, and pharynx. Pathologically, Sjogren's syndrome are characterized by lymphocyte infiltration into the exocrine glands and epithelial cell destruction caused by autoantibodies Ro/SSA and La/SSB. At present, the exact pathogenesis of Sjogren's syndrome is unclear. Evidence suggests epithelial cell death and the subsequent dysfunction of salivary glands as the main causes of xerostomia. This review summarizes the modes of salivary gland epithelial cell death and their role in Sjogren's syndrome progression. The molecular mechanisms involved in salivary gland epithelial cell death during Sjogren's syndrome as potential leads to treating the disease are also discussed.
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Affiliation(s)
- Jiannan Zhou
- Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510182, China
| | - Janak Lal Pathak
- Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510182, China
| | - Qianwen Liu
- Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510182, China
| | - Shilin Hu
- Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510182, China
| | - Tingting Cao
- Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510182, China
| | - Nobumoto Watanabe
- Chemical Biology Research Group, RIKEN Center for Sustainable Resource Science, Wako, Saitama, 351-0198, Japan
| | - Yongliang Huo
- Experimental Animal Center, Guangzhou Medical University, Guangzhou, Guangdong, 511436, China
| | - Jiang Li
- Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510182, China
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Ruscogenin Ameliorated Sjögren's Syndrome by Inhibiting NLRP3 Inflammasome Activation. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:6425121. [PMID: 35800007 PMCID: PMC9256408 DOI: 10.1155/2022/6425121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/04/2022] [Indexed: 12/22/2022]
Abstract
This article investigated the role and the specific mechanism of Ruscogenin in Sjögren's syndrome (SS). NOD/ShiLtJ mice were treated with Ruscogenin, and acinar cells isolated from submandibular glands were treated with TNF-α, Ruscogenin and transfected with NLRP3 overexpression plasmid. Salivary flow rate (SFR) was measured at weeks 11, 13, 15, 17, and 20. Histological analysis of the submandibular glands was conducted by hematoxylin-eosin staining assay. IL-6, IL-17, TNF-α, and IL-1β mRNA expression was detected through qRT-PCR. AQP 5, AQP 4, P2X7R, NLRP3, caspase 1, IL-1β, Bax, and Bcl-2 protein levels were tested by western blot. Cell apoptosis was assessed through acridine orange and propidium iodide (AO/PI) staining assay and flow cytometry assay. Ruscogenin ameliorated the SFR and submandibular gland inflammation of NOD/ShiLtJ mice. Ruscogenin promoted the preservation of acinar cells and suppressed inflammation-related factors (P2X7R, NLRP3, caspase 1, and IL-1β) in submandibular gland tissues of NOD/ShiLtJ mice. Ruscogenin inhibited acinar cell apoptosis in NOD/ShiLtJ mice and reversed TNF-α-induced apoptosis and inflammation of acinar cells. NLRP3 overexpression reversed the repressive effect of Ruscogenin on TNF-α-induced inflammation and apoptosis of acinar cells. Ruscogenin ameliorated SS by inhibiting NLRP3 inflammasome activation.
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Salem A, Salo T. Nothing to sneeze at: Histamine and histamine receptors in oral carcinogenesis. Oral Dis 2020; 27:1090-1096. [PMID: 32395857 DOI: 10.1111/odi.13411] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 12/25/2022]
Abstract
Oral squamous cell carcinoma (OSCC), the most common oral malignancy, shows an increasing rate of incidence worldwide. In spite of the recent advances in cancer research, OSCC therapy continues to have unfavourable outcomes, and thus, patient's prognosis remains relatively poor. Current research has been devoted to identifying novel therapeutic targets also in the tumour microenvironment (TME). Histamine and its G-protein-coupled receptors (H1R-H4R) play vital roles in multiple cancer-associated processes in TME, where histamine is mainly produced by mast cells. However, oral epithelial cells were recently shown to produce low concentrations of histamine in autocrine and paracrine modes. These findings, together with the discovery of the high-affinity histamine H4 receptor, have led to a massive increase in our understanding of histamine functions. In this review, we aim to summarize the most recent findings regarding histamine and its receptors and their involvement in oral carcinogenesis-from oral potentially malignant disorders (OPMDs) to invasive OSCC. Importantly, histamine receptors are differentially expressed in OPMDs and OSCC. Furthermore, H1R and H4R are associated with clinicopathological characteristics of OSCC patients, suggesting a role in prognosis. Due to the enormous success of histamine-based medications, histamine receptors may also represent promising and viable drug targets in oral cancer.
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Affiliation(s)
- Abdelhakim Salem
- Department of Oral and Maxillofacial Diseases, Clinicum, University of Helsinki, Helsinki, Finland.,Translational Immunology Research Program (TRIMM), Research Program Unit (RPU), University of Helsinki, Helsinki, Finland
| | - Tuula Salo
- Department of Oral and Maxillofacial Diseases, Clinicum, University of Helsinki, Helsinki, Finland.,Translational Immunology Research Program (TRIMM), Research Program Unit (RPU), University of Helsinki, Helsinki, Finland.,Cancer and Translational Medicine Research Unit, University of Oulu, Oulu, Finland.,Oulu University Hospital, Oulu, Finland.,Helsinki University Hospital (HUS), Helsinki, Finland
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Salem A, Almahmoudi R, Hagström J, Stark H, Nordström D, Salo T, Eklund KK. Human β-Defensin 2 Expression in Oral Epithelium: Potential Therapeutic Targets in Oral Lichen Planus. Int J Mol Sci 2019; 20:ijms20071780. [PMID: 30974892 PMCID: PMC6479702 DOI: 10.3390/ijms20071780] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/02/2019] [Accepted: 04/09/2019] [Indexed: 12/24/2022] Open
Abstract
Human β-defensin 2 (hBD-2) is a potent antimicrobial peptide that participates in defense against invading bacteria. We recently showed that bacterial components and histamine, through histamine H4 receptor (H4R), are involved in the pathogenesis of the potentially malignant lesion, oral lichen planus (OLP). However, the underlying mechanisms remain unknown. We, therefore, investigated the role of hBD2–histamine crosstalk signaling in promoting OLP pathology. Biopsies from OLP and oral tongue squamous cell carcinoma (OTSCC) patients, and healthy controls were used. Two OTSCC cell lines and normal human oral keratinocytes (HOKs) were used. HBD-2 and other targets were mapped by immunostaining and analyzed by ImageJ2 software. The highly sensitive droplet-digital PCR technology and qRT-PCR were utilized to study the clinically derived and in vitro samples, respectively. H4R was challenged with the specific agonist HST-10 and inverse agonist ST-1007. HBD-2 was highly induced in OLP lesions. In contrast, hBD2 expression was attenuated in OTSCC tissues, while very low levels of hBD-2 messenger RNA (mRNA) were observed in OTSCC cells. Together with tumor necrosis factor-α (TNF-α), histamine upregulated hBD-2 mRNA expression in HOKs. Activation of H4R seems to modulate the expression of epithelial hBD-2. These findings suggest the involvement of hBD-2 in the pathogenesis of OLP and may, thus, be harnessed for therapeutic interventions in OLP.
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Affiliation(s)
- Abdelhakim Salem
- Department of Clinical Medicine, Clinicum, University of Helsinki, 00014 Helsinki, Finland.
- Translational Immunology Research Program, University of Helsinki, 00014 Helsinki, Finland.
- Department of Oral and Maxillofacial Diseases, Clinicum, University of Helsinki, 00014 Helsinki, Finland.
| | - Rabeia Almahmoudi
- Department of Oral and Maxillofacial Diseases, Clinicum, University of Helsinki, 00014 Helsinki, Finland.
| | - Jaana Hagström
- Department of Pathology, Helsinki University Hospital, Helsinki, Finland and Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland.
| | - Holger Stark
- Institute of Pharmaceutical and Medicinal Chemistry, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany.
| | - Dan Nordström
- Department of Internal Medicine, Helsinki University and Helsinki Hospital, 00014 Helsinki, Finland.
| | - Tuula Salo
- Translational Immunology Research Program, University of Helsinki, 00014 Helsinki, Finland.
- Department of Oral and Maxillofacial Diseases, Clinicum, University of Helsinki, 00014 Helsinki, Finland.
- Medical Research Centre, Oulu University Hospital, 90220 Oulu, Finland.
- Cancer and Translational Medicine Research Unit, University of Oulu, FI-90014 Oulu, Finland.
| | - Kari K Eklund
- Translational Immunology Research Program, University of Helsinki, 00014 Helsinki, Finland.
- Department of Internal Medicine, Helsinki University and Helsinki Hospital, 00014 Helsinki, Finland.
- Department of Rheumatology, Helsinki University and Helsinki University Hospital, and Orton Orthopedic Hospital and Research Institute, 00014 Helsinki, Finland.
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González DA, Barbieri van Haaster MM, Quinteros Villarruel E, Brandt M, Benítez MB, Stranieri GM, Orman B. Histamine stimulates secretion of extracellular vesicles with nucleotidase activity in rat submandibular gland. Arch Oral Biol 2017; 85:201-206. [PMID: 29127888 DOI: 10.1016/j.archoralbio.2017.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Extracellular vesicles released by different cells have been isolated from diverse fluids including saliva. We previously reported that rat submandibular glands secrete nanovesicles that catalyze hydrolysis of ATP, ADP and AMP, which are actors of the purinergic signaling system along with adenosine. Extracellular nucleotides like ATP and adenosine are involved in the regulation of inflammatory processes and apoptosis. Histamine, a widely distributed biogenic amine, is involved in inflammatory response. OBJECTIVE To test if activation of histamine receptors in rat submandibular gland promotes changes in the release of vesicles with nucleotidase activity that could modulate purinergic signaling. METHODS Rat submandibular glands were incubated in the absence or presence of histamine and JNJ7777120, an antagonist for H4 receptors. Extracellular vesicles were isolated from incubation media by differential centrifugation. Vesicular nucleotidase activity was measured following Pi release by 3mM MgATP, MgADP or MgAMP. RESULTS Histamine increased the release of vesicles with nucleotidase activity in a concentration dependent manner. JNJ7777120 significantly reduced this effect. Vesicular nucleotidases obtained in the absence or presence of histamine promoted Pi production from ATP, ADP and AMP. CONCLUSION The results show a relationship between histamine and the regulation of purinergic signaling, which could be important in the modulation of inflammatory processes.
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Affiliation(s)
- Débora Alejandra González
- Universidad de Buenos Aires, Facultad de Odontología, Cátedra de Biofísica y Bioestadística, M. T. de Alvear 2142, Ciudad Autónoma de Buenos Aires, 1122, Argentina.
| | - Martín Matías Barbieri van Haaster
- Universidad de Buenos Aires, Facultad de Odontología, Cátedra de Biofísica y Bioestadística, M. T. de Alvear 2142, Ciudad Autónoma de Buenos Aires, 1122, Argentina
| | - Emmanuel Quinteros Villarruel
- Universidad de Buenos Aires, Facultad de Odontología,C átedra de Farmacología, M. T. de Alvear 2142, Ciudad Autónoma de Buenos Aires, 1122, Argentina
| | - Macarena Brandt
- Universidad de Buenos Aires, Facultad de Odontología, Cátedra de Biofísica y Bioestadística, M. T. de Alvear 2142, Ciudad Autónoma de Buenos Aires, 1122, Argentina
| | - María Belén Benítez
- Universidad de Buenos Aires, Facultad de Odontología,C átedra de Farmacología, M. T. de Alvear 2142, Ciudad Autónoma de Buenos Aires, 1122, Argentina
| | - Graciela Mabel Stranieri
- Universidad de Buenos Aires, Facultad de Odontología,C átedra de Farmacología, M. T. de Alvear 2142, Ciudad Autónoma de Buenos Aires, 1122, Argentina
| | - Betina Orman
- Universidad de Buenos Aires, Facultad de Odontología,C átedra de Farmacología, M. T. de Alvear 2142, Ciudad Autónoma de Buenos Aires, 1122, Argentina
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Xu T, Xie W, Ma Y, Zhou S, Zhang L, Chen J, Cai M, Sun R, Zhang P, Yu S, Xu Z, Jiang W, Wu M. Leptin/OB-R pathway promotes IL-4 secretion from B lymphocytes and induces salivary gland epithelial cell apoptosis in Sjögren's syndrome. Oncotarget 2017; 8:63417-63429. [PMID: 28969001 PMCID: PMC5609933 DOI: 10.18632/oncotarget.18823] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 06/01/2017] [Indexed: 12/16/2022] Open
Abstract
Sjögren's syndrome (SjS) is a chronic autoimmune epithelitis in which cell apoptosis promotes the formation of inflammatory lesions. We used immunohistochemistry and TUNEL to assay B cell infiltration and apoptosis in salivary gland tissue from 16-week-old NOD/LtJ mice with SjS. In co-cultures of primary salivary glandepithelial cells (SGECs) and spleen B cells, we assessed SGEC viability and apoptosis using CCK8 assays and flow cytometry. ELISAs were employed to assess cytokine levels in culture medium. Leptin protein, leptin receptor (OB-R), pro- and anti-apoptotic proteins, and Jak2/Stat3/ERK signaling molecules were analyzed using western blotting. B cell infiltration and salivary gland apoptosis were increased in salivary tissue from mice with SjS. Leptin treatment had no effect on cell viability or apoptosis among B cells and primary SGECs. B cell and SGEC co-culture systems showed that leptin increased apoptosis induced by B lymphocytes, reduced SGEC cell viability, and promoted IL-4 secretion from B cells. This suggests Leptin/OB-R signaling stimulates B cells-induced SGEC apoptosis via IL-4 secretion and OB-R-Jak2-Stat3 activation.
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Affiliation(s)
- Ting Xu
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Wen Xie
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Yingchun Ma
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Shiliang Zhou
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Lu Zhang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Jinyun Chen
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Mingyuan Cai
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Rurong Sun
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Peirong Zhang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Shaobo Yu
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Zheng Xu
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Wanlan Jiang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
| | - Min Wu
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Jiangsu, Changzhou 213003, China
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Salem A, Rozov S, Al-Samadi A, Stegajev V, Listyarifah D, Kouri VP, Han X, Nordström D, Hagström J, Eklund K. Histamine metabolism and transport are deranged in human keratinocytes in oral lichen planus. Br J Dermatol 2017; 176:1213-1223. [DOI: 10.1111/bjd.14995] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 12/14/2022]
Affiliation(s)
- A. Salem
- Department of Medicine; University of Helsinki; Helsinki Finland
- Department of Oral and Maxillofacial Diseases; University of Helsinki; Helsinki Finland
| | - S. Rozov
- Department of Anatomy; University of Helsinki; Helsinki Finland
| | - A. Al-Samadi
- Department of Oral and Maxillofacial Diseases; University of Helsinki; Helsinki Finland
| | - V. Stegajev
- Department of Medicine; University of Helsinki; Helsinki Finland
| | - D. Listyarifah
- Department of Medicine; University of Helsinki; Helsinki Finland
- Department of Oral and Maxillofacial Diseases; University of Helsinki; Helsinki Finland
| | - V.-P. Kouri
- Department of Medicine; University of Helsinki; Helsinki Finland
| | - X. Han
- Department of Medicine; University of Helsinki; Helsinki Finland
| | - D. Nordström
- Department of Medicine; University of Helsinki; Helsinki Finland
- Department of Rheumatology, Internal Medicine and Rehabilitation; University of Helsinki; Helsinki Finland
- Helsinki University Central Hospital; Helsinki Finland
| | - J. Hagström
- Helsinki University Central Hospital; Helsinki Finland
- Department of Pathology and Oral Pathology; University of Helsinki; Helsinki Finland
| | - K.K. Eklund
- Department of Medicine; University of Helsinki; Helsinki Finland
- Department of Rheumatology, Internal Medicine and Rehabilitation; University of Helsinki; Helsinki Finland
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Histamine H4 receptor activation alleviates neuropathic pain through differential regulation of ERK, JNK, and P38 MAPK phosphorylation. Pain 2015; 156:2492-2504. [DOI: 10.1097/j.pain.0000000000000319] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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