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El-Zaatari M, Bishu S, Zhang M, Grasberger H, Hou G, Haley H, Humphries B, Syu LJ, Dlugosz AA, Luker K, Luker GD, Eaton K, Kamada N, Cascalho M, Kao JY. Aim2-mediated/IFN-β-independent regulation of gastric metaplastic lesions via CD8+ T cells. JCI Insight 2020; 5:94035. [PMID: 32053518 DOI: 10.1172/jci.insight.94035] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 02/12/2020] [Indexed: 01/24/2023] Open
Abstract
Development of gastric cancer is often preceded by chronic inflammation, but the immune cellular mechanisms underlying this process are unclear. Here we demonstrated that an inflammasome molecule, absent in melanoma 2 (Aim2), was upregulated in patients with gastric cancer and in spasmolytic polypeptide-expressing metaplasia of chronically Helicobacter felis-infected stomachs in mice. However, we found that Aim2 was not necessary for inflammasome function during gastritis. In contrast, Aim2 deficiency led to an increase in gastric CD8+ T cell frequency, which exacerbated metaplasia. These gastric CD8+ T cells from Aim2-/- mice were found to have lost their homing receptor expression (sphingosine-1-phosphate receptor 1 [S1PR1] and CD62L), a feature of tissue-resident memory T cells. The process was not mediated by Aim2-dependent regulation of IFN-β or by dendritic cell-intrinsic Aim2. Rather, Aim2 deficiency contributed to an increased production of CXCL16 by B cells, which could suppress S1PR1 and CD62L in CD8+ T cells. This study describes a potentially novel function of Aim2 that regulates CD8+ T cell infiltration and retention within chronically inflamed solid organ tissue. This function operates independent of the inflammasome, IFN-β, or dendritic cells. We provide evidence that B cells can contribute to this mechanism via CXCL16.
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Affiliation(s)
- Mohamad El-Zaatari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Shrinivas Bishu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Min Zhang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Helmut Grasberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Guoqing Hou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Henry Haley
- Department of Radiology, Microbiology and Immunology, and Biomedical Engineering
| | - Brock Humphries
- Department of Radiology, Microbiology and Immunology, and Biomedical Engineering
| | - Li-Jyun Syu
- Department of Dermatology, School of Medicine
| | | | - Kathy Luker
- Department of Radiology, Microbiology and Immunology, and Biomedical Engineering
| | - Gary D Luker
- Department of Radiology, Microbiology and Immunology, and Biomedical Engineering
| | | | - Nobuhiko Kamada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Marilia Cascalho
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - John Y Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
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Wang SM, Roth MJ, Murphy GA, Dawsey SM, Fan JH, Taylor PR, Qiao YL, Abnet CC. Serologic Profile of Antiparietal Cell Antibodies, Pepsinogens, and H. pylori and Risk of Upper Gastrointestinal Cancer: A Nested Case-Control Study in China. Cancer Epidemiol Biomarkers Prev 2019; 28:2022-2029. [PMID: 31501152 DOI: 10.1158/1055-9965.epi-19-0512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/26/2019] [Accepted: 09/03/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Autoimmune gastritis is understudied and possibly associated with gastric noncardia adenocarcinoma (GNCA) and esophageal squamous cell carcinoma (ESCC) in Western populations when it presents as pernicious anemia. METHODS A nested case-control study within a Chinese cohort included 100 ESCC, 200 gastric cardia adenocarcinoma (GCA), and 200 GNCA cases diagnosed between 1986 and 2001 and 400 controls. Serostatus of antiparietal cell antibodies (APCA), Helicobacter pylori antibodies, and pepsinogens were measured using commercial kits and serum collected at baseline. We used logistic regression to calculate odds ratios (OR) and 95% confidence interval (CI) for associations between serologic biomarkers and cancer risk adjusted for numerous potential confounders. RESULTS There was an average interval of 8 years between baseline blood draw and cancer diagnosis. The baseline prevalence of APCA seropositivity was 10.0% and 14.5% in subjects who developed GCA and GNCA, respectively. APCA seropositivity was inversely associated with later development of GCA (OR = 0.42; 95% CI, 0.24-0.75), but not significantly associated with later development of GNCA (OR = 0.82; 95% CI, 0.50-1.36) or ESCC (OR = 1.05; 95% CI, 0.58-1.88). APCA seropositivity was significantly associated with low pepsinogen I/II ratios (OR = 3.69; 95% CI, 1.66-8.21), and individuals with low pepsinogen I/II ratios who were seronegative for APCA had the highest risk of both GCA and GNCA. CONCLUSIONS APCA seropositivity measured years prior to diagnosis was associated with prevalent atrophic gastritis but inversely associated with incident GCA in this Chinese population. IMPACT APCA may contribute to a growing list of serologic markers that can improve risk stratification for gastric cancer.
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Affiliation(s)
- Shao-Ming Wang
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Mark J Roth
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Gwen A Murphy
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Sanford M Dawsey
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Jin-Hu Fan
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Philip R Taylor
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - You-Lin Qiao
- Department of Cancer Epidemiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Christian C Abnet
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland.
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Bang CS, Lee JJ, Baik GH. Prediction of Chronic Atrophic Gastritis and Gastric Neoplasms by Serum Pepsinogen Assay: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy. J Clin Med 2019; 8:jcm8050657. [PMID: 31083485 PMCID: PMC6572271 DOI: 10.3390/jcm8050657] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/06/2019] [Accepted: 05/08/2019] [Indexed: 12/16/2022] Open
Abstract
Serum pepsinogen assay (sPGA), which reveals serum pepsinogen (PG) I concentration and the PG I/PG II ratio, is a non-invasive test for predicting chronic atrophic gastritis (CAG) and gastric neoplasms. Although various cut-off values have been suggested, PG I ≤70 ng/mL and a PG I/PG II ratio of ≤3 have been proposed. However, previous meta-analyses reported insufficient systematic reviews and only pooled outcomes, which cannot determine the diagnostic validity of sPGA with a cut-off value of PG I ≤70 ng/mL and/or PG I/PG II ratio ≤3. We searched the core databases (MEDLINE, Cochrane Library, and Embase) from their inception to April 2018. Fourteen and 43 studies were identified and analyzed for the diagnostic performance in CAG and gastric neoplasms, respectively. Values for sensitivity, specificity, diagnostic odds ratio, and area under the curve with a cut-off value of PG I ≤70 ng/mL and PG I/PG II ratio ≤3 to diagnose CAG were 0.59, 0.89, 12, and 0.81, respectively and for diagnosis of gastric cancer (GC) these values were 0.59, 0.73, 4, and 0.7, respectively. Methodological quality and ethnicity of enrolled studies were found to be the reason for the heterogeneity in CAG diagnosis. Considering the high specificity, non-invasiveness, and easily interpretable characteristics, sPGA has potential for screening of CAG or GC.
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Affiliation(s)
- Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, Gangwon-do 24253, Korea.
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24253, Korea.
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24253, Korea.
| | - Jae Jun Lee
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon 24253, Korea.
- Department of Anesthesiology and Pain Medicine, Hallym University College of Medicine, Chuncheon 24253, Korea.
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, Gangwon-do 24253, Korea.
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24253, Korea.
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El-Zaatari M, Bass AJ, Bowlby R, Zhang M, Syu LJ, Yang Y, Grasberger H, Shreiner A, Tan B, Bishu S, Leung WK, Todisco A, Kamada N, Cascalho M, Dlugosz AA, Kao JY. Indoleamine 2,3-Dioxygenase 1, Increased in Human Gastric Pre-Neoplasia, Promotes Inflammation and Metaplasia in Mice and Is Associated With Type II Hypersensitivity/Autoimmunity. Gastroenterology 2018; 154:140-153.e17. [PMID: 28912017 PMCID: PMC5742059 DOI: 10.1053/j.gastro.2017.09.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/30/2017] [Accepted: 09/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Chronic gastrointestinal inflammation increases the risk of cancer by mechanisms that are not well understood. Indoleamine-2,3-dioxygenase 1 (IDO1) is a heme-binding enzyme that regulates the immune response via catabolization and regulation of tryptophan availability for immune cell uptake. IDO1 expression is increased during the transition from chronic inflammation to gastric metaplasia. We investigated whether IDO1 contributes to the inflammatory response that mediates loss of parietal cells leading to metaplasia. METHODS Chronic gastric inflammation was induced in Ido1-/- and CB57BL/6 (control) mice by gavage with Helicobacter felis or overexpression of interferon gamma in gastric parietal cells. We also performed studies in Jh-/- mice, which are devoid of B cells. Gastric tissues were collected and analyzed by flow cytometry, immunostaining, and real-time quantitative polymerase chain reaction. Plasma samples were analyzed by enzyme-linked immunosorbent assay. Gastric tissues were obtained from 20 patients with gastric metaplasia and 20 patients without gastric metaplasia (controls) and analyzed by real-time quantitative polymerase chain reaction; gastric tissue arrays were analyzed by immunohistochemistry. We collected genetic information on gastric cancers from The Cancer Genome Atlas database. RESULTS H felis gavage induced significantly lower levels of pseudopyloric metaplasia in Ido1-/- mice, which had lower frequencies of gastric B cells, than in control mice. Blood plasma from H felis-infected control mice had increased levels of autoantibodies against parietal cells, compared to uninfected control mice, but this increase was lower in Ido1-/- mice. Chronically inflamed stomachs of Ido1-/- mice had significantly lower frequencies of natural killer cells in contact with parietal cells, compared with stomachs of control mice. Jh-/- mice had lower levels of pseudopyloric metaplasia than control mice in response to H felis infection. Human gastric pre-neoplasia and carcinoma specimens had increased levels of IDO1 messenger RNA compared with control gastric tissues, and IDO1 protein colocalized with B cells. Co-clustering of IDO1 messenger RNA with B-cell markers was corroborated by The Cancer Genome Atlas database. CONCLUSIONS IDO1 mediates gastric metaplasia by regulating the B-cell compartment. This process appears to be associated with type II hypersensitivity/autoimmunity. The role of autoimmunity in the progression of pseudopyloric metaplasia warrants further investigation.
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Affiliation(s)
- Mohamad El-Zaatari
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, Michigan.
| | - Adam J. Bass
- Department of Medical Oncology and the Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Reanne Bowlby
- Canada’s Michael Smith Genome Sciences Centre, BC Cancer Agency, Vancouver, BC, Canada
| | - Min Zhang
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Li-Jyun Syu
- Department of Dermatology, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Yitian Yang
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Helmut Grasberger
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Andrew Shreiner
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Bei Tan
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Shrinivas Bishu
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Wai K. Leung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Andrea Todisco
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Nobuhiko Kamada
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Marilia Cascalho
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrzej A. Dlugosz
- Department of Dermatology, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John Y. Kao
- Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
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El-Zaatari M, Kao JY. Role of Dietary Metabolites in Regulating the Host Immune Response in Gastrointestinal Disease. Front Immunol 2017; 8:51. [PMID: 28191010 PMCID: PMC5269446 DOI: 10.3389/fimmu.2017.00051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/12/2017] [Indexed: 12/28/2022] Open
Abstract
The host immune response to gastrointestinal (GI) infections, hypersensitivity reactions, or GI cancers comprises numerous pathways that elicit responses on different host cells. Some of these include (1) the stimulation of mast cells via their IgE receptor, (2) the production of antibodies leading to antibody-mediated cytotoxic T/natural killer cell killing, (3) the activation of the complement pathway, and (4) the activation of the adaptive immune response via antigen-presenting cell, T cell, and B cell interactions. Within the plethora of these different responses, several host immune cells represent major key players such as those of myeloid lineage (including neutrophils, macrophages, myeloid-derived suppressor cells) or lymphoid lineage (including T and B cells). In this review, we focus on newly identified metabolites and metabolite receptors that are expressed by either myeloid or lymphoid lineages. Irrespective of their source, these metabolites can in certain instances elicit responses on a wide range of cell types. The myeloid-expressed metabolic enzymes and receptors which we will discuss in this review include arginase 2 (Arg2), indoleamine-2,3-dioxygenase 1 (IDO1), hydroxycarboxylic acid receptor 2 (Hcar2; also called GPR109A), and immunoresponsive gene 1 (Irg1). We will also review the role of the lymphoid-expressed metabolite receptor that binds to the sphingosine-1-phosphate (S1P) sphingolipid. Moreover, we will describe the synthesis and metabolism of retinoic acid, and its effect on T cell activation. The review will then discuss the function of these metabolites in the context of GI disease. The review provides evidence that metabolic pathways operate in a disease- and context-dependent manner-either independently or concomitantly-in the GI tract. Therefore, an integrated approach and combinatorial analyses are necessary to devise new therapeutic strategies that can synergistically improve prognoses.
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Affiliation(s)
- Mohamad El-Zaatari
- Division of Gastroenterology, Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - John Y. Kao
- Division of Gastroenterology, Department of Internal Medicine-Gastroenterology, University of Michigan, Ann Arbor, MI, USA
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Cabrera de León A, Almeida González D, Almeida AA, González Hernández A, Carretero Pérez M, Rodríguez Pérez MDC, Guillén VG, Brito Díaz B. Factors associated with parietal cell autoantibodies in the general population. Immunol Lett 2012; 147:63-6. [PMID: 22771341 DOI: 10.1016/j.imlet.2012.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 05/29/2012] [Accepted: 06/21/2012] [Indexed: 02/09/2023]
Abstract
The presence in serum of parietal cell autoantibodies (PCA) is a characteristic of autoimmune gastritis. We determined the prevalence of PCA in the general population and investigate their association with type 2 diabetes, insulin resistance and lifestyle factors related with autoimmune gastritis. A cross-sectional study was performed, involving 429 individuals enrolled in a cohort study of the general population of the Canary Islands. All participants underwent physical examination, provided a blood sample and responded to a questionnaire regarding health and lifestyle factors. Serum concentrations of PCA, soluble CD40 ligand (sCD40L), C-peptide and glucose (to determine insulin resistance) were measured. The association of PCA with the other factors was determined with bivariate analysis, and logistic regression models were used to adjust the associations for age and sex. The prevalence of PCA was 7.8% (95% CI=10.3-5.3). The factors associated with PCA were female sex (p=0.032), insulin resistance (p=0.016), menopause (p=0.029) and sCD40L (p=0.019). Alcohol consumption (p=0.006) and smoking (p=0.005) were associated with low prevalences of PCA. After adjustment for age and sex, the association with PCA was confirmed for smoking (OR=0.1 [0.0-0.9]), alcohol consumption (OR=0.3 [0.1-0.9]), insulin resistance (OR=2.4 [1.1-4.9]), female sex (OR=2.4 [1.1-5.3]), sCD40L (OR=3.7 [1.2-11.4]) and menopause (OR=5.3 [1.2-23.3]). In conclusion, smoking and alcohol consumption acted as protective factors against the appearance of PCA in the general population, whereas female sex, menopause, insulin resistance and elevated serum sCD40L were risk markers for PCA. In patients who smoke or drink alcohol, clinicians should be cautious when using PCA to rule out autoimmune gastritis.
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Affiliation(s)
- Antonio Cabrera de León
- Research Unit, at Nuestra Señora de la Candelaria University Hospital, Santa Cruz de Tenerife, Spain.
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Dinis-Ribeiro M, Areia M, de Vries AC, Marcos-Pinto R, Monteiro-Soares M, O’Connor A, Pereira C, Pimentel-Nunes P, Correia R, Ensari A, Dumonceau JM, Machado JC, Macedo G, Malfertheiner P, Matysiak-Budnik T, Megraud F, Miki K, O’Morain C, Peek RM, Ponchon T, Ristimaki A, Rembacken B, Carneiro F, Kuipers EJ. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Virchows Arch 2011; 460:19-46. [DOI: 10.1007/s00428-011-1177-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 10/13/2011] [Accepted: 10/19/2011] [Indexed: 12/16/2022]
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8
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Kikuchi R, Abe Y, Iijima K, Koike T, Ara N, Uno K, Asanuma K, Asano N, Imatani A, Shimosegawa T. Low serum levels of pepsinogen and gastrin 17 are predictive of extensive gastric atrophy with high-risk of early gastric cancer. TOHOKU J EXP MED 2011; 223:35-44. [PMID: 21222340 DOI: 10.1620/tjem.223.35] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Atrophic gastritis (AG) is a well-recognized high-risk condition for developing gastric cancer (GC). Gastrin 17 (G17), a hormone secreted from antral G cells, regulates gastric acid secretion, and its serum level is a possible indicator of antral atrophy. Serum pepsinogen is well established as the indicator of AG involving the corpus. Here we investigated whether serum PG and G17 levels would be useful for determining the topographic pattern of AG and estimating the risk of GC. Enrolled were 122 Japanese patients with early GC (114 well- to moderate-differentiated cancers and 8 poorly-differentiated cancers). In addition, 178 subjects without GC were recruited as control from those undergoing endoscopic examination (non-GC group). All subjects were histologically assigned to the following four groups: non-AG, antrum-predominant AG, corpus-predominant AG, and multifocal AG, affecting the antrum and corpus. Serum concentrations of pepsinogen and G17 were determined using ELISA. Multifocal AG was more frequent in the GC group than in the adjusted non-GC group, and had the highest risk of GC (OR 25.1). Serum G17 was significantly decreased with the exacerbation of antral atrophy in the coexistence of corpus atrophy. Serum biomarker profiles showed that the low levels of pepsinogen and G17 could discriminate between multifocal AG and other types of AG, but not with pepsinogen level alone. Serologically defined multifocal AG had the highest cancer risk among other serologically defined AG groups (OR 26.9). In conclusion, the low serum levels of pepsinogen and G17 are predictive of extensive gastric atrophy with high-risk of early GC.
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Affiliation(s)
- Ryousuke Kikuchi
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Di Mario F, Cavallaro LG, Cavestro GM, Franzé A. Are there useful biomarkers for gastric cancer? Dig Liver Dis 2006; 38:308-9. [PMID: 16522379 DOI: 10.1016/j.dld.2006.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Accepted: 01/12/2006] [Indexed: 12/11/2022]
Affiliation(s)
- F Di Mario
- Department of Clinical Sciences, Section of Gastroenterology, University of Parma, 43100 Parma, Italy.
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