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Zheng A, Xu Y, Cen N, Wu B. A Lower IL-34 Expression Is Associated with Non-Healing Diabetic Foot Ulcers. Comb Chem High Throughput Screen 2024; 27:1533-1543. [PMID: 37888825 DOI: 10.2174/0113862073273222231005065757] [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: 08/08/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The non-healing of diabetic foot ulcers (DFU) is a major cause of high disability, morbidity, and mortality. Thus, new therapeutic targets and methods to help healing in patients with DFUs are major research hotspots. OBJECTIVE This study examined the molecular differences between healing and non-healing DFUs to identify genes associated with DFU healing. METHODS Differentially expressed genes (DEGs) were identified by bioinformatics. Samples were collected from patients with healing (n=10) and non-healing (n=10) DFUs from September 2021 to September 2022. Interleukin (IL)-34 expression was measured by ELISA and qRT-PCT. The fibroblasts from healing and non-healing DFU were divided according to their gene signatures and subdivided based on their gene expression profile differences. RESULTS A comparison of fibroblast subpopulation characteristics revealed that the proportion of subpopulation 4 was significantly higher in non-healing DFUs than in healing DFUs. Subpopulation 4 had 254 upregulated genes and 2402 downregulated genes in the non-healing compared with the healing DFUs. The DEGs were involved in several biological functions, including cytokine activity, receptor-ligand activity, signaling receptor activator activity, and receptor regulator activity. IL-34 was downregulated in non-healing compared with healing DFUs, suggesting a possible role of IL-34 in DFU healing. In the clinical specimens, IL-34 was significantly downregulated in non-healing DFUs, consistent with the bioinformatics results. CONCLUSION IL-34 expression is downregulated in non-healing DFU. IL-34 appears to be involved in DFU healing, but the exact causal relationship remains to be explored.
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Affiliation(s)
- Aitian Zheng
- Jinan University, Guangzhou, 511486, China
- Department of Endocrinology, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, China
| | - Yuanyuan Xu
- Department of Endocrinology, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, China
| | - Nimiao Cen
- Department of Endocrinology, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, China
| | - Biaoliang Wu
- Jinan University, Guangzhou, 511486, China
- Department of Endocrinology, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, China
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Chen N, Diao CY, Huang X, Tan WX, Chen YB, Qian XY, Gao J, Zhao DB. RhoA Promotes Synovial Proliferation and Bone Erosion in Rheumatoid Arthritis through Wnt/PCP Pathway. Mediators Inflamm 2023; 2023:5057009. [PMID: 38022686 PMCID: PMC10667059 DOI: 10.1155/2023/5057009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 10/07/2023] [Accepted: 10/07/2023] [Indexed: 12/01/2023] Open
Abstract
Ras homolog gene family member A (RhoA) plays a major role in the Wnt/planar cell polarity (PCP) pathway, which is significantly activated in patients with rheumatoid arthritis (RA). The function of RhoA in RA synovitis and bone erosion is still elusive. Here, we not only explored the impact of RhoA on the proliferation and invasion of RA fibroblast-like synoviocytes (FLSs) but also elucidated its effect on mouse osteoclast and a mouse model of collagen-induced arthritis (CIA). Results showed that RhoA was overexpressed in RA and CIA synovial tissues. Lentivirus-mediated silencing of RhoA increased apoptosis, attenuated invasion, and dramatically upregulated osteoprotegerin/receptor activator of nuclear factor-κB ligand (OPG/RANKL) ratio in RA-FLSs. Additionally, the silencing of RhoA inhibited mouse osteoclast differentiation in vitro and alleviated synovial hyperplasia and bone erosion in the CIA mouse model. These effects in RA-FLSs and osteoclasts were all regulated by RhoA/Rho-associated protein kinase 2 (ROCK2) and might interact with Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathways.
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Affiliation(s)
- Ning Chen
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
- Department of Rheumatology and Immunology, The First People's Hospital of Yancheng, The Fourth Affiliated Hospital of Nantong University, Yancheng, China
| | - Chao-Yue Diao
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xin Huang
- Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Wei-Xing Tan
- Air Force Health Care Center for Special Services, Hangzhou, China
| | - Ya-Bing Chen
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xin-Yu Qian
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jie Gao
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Dong-Bao Zhao
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai, China
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Alzoubi O, Meyer A, Gonzalez TP, Burgos AC, Sweiss N, Zomorrodi RK, Shahrara S. Significance of IL-34 and SDC-1 in the pathogenesis of RA cells and preclinical models. Clin Immunol 2023; 251:109635. [PMID: 37150238 PMCID: PMC10985830 DOI: 10.1016/j.clim.2023.109635] [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: 01/14/2023] [Revised: 01/22/2023] [Accepted: 03/18/2023] [Indexed: 05/09/2023]
Abstract
IL-34 shares a common receptor with M-CSF, while it can bind to other distinct receptors including protein-tyrosine phosphatase zeta (PTPζ), and syndecan1 (SDC-1). In physiological conditions, IL-34 has a critical role in the maintenance and development of Langerhans and microglial cells in part through PTPζ ligation. Conversely, in autoimmune diseases such as rheumatoid arthritis (RA), SDC-1-induced phosphorylation of M-CSFR was responsible for the pathological effect of IL-34 in patient cells and/or preclinical models. Intriguingly, enrichment of IL-34 is strongly linked to rheumatoid factor (RF), disease activity score (DAS)28, erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), and radiographic progression. In parallel, IL-34-induced naïve cell reprogramming into glycolytic RA CD14+CD86+GLUT1+ macrophage was dysregulated via M-CSFR or SDC-1 antibody therapy. Moreover, the inflammatory and erosive imprints of IL-34 arthritic mice were mitigated by glucose uptake inhibition and SDC-1, or RAG deficiency through nullifying macrophage metabolic rewiring and their ability to advance Th1/Th17 cell polarization. Consistently, IL-34-/- and SDC-1-/- mice could effectively impair CIA joint inflammation, osteoclast formation, and neovascularization by restraining monocyte infiltration as well as suppressing the inflammatory macrophage and T effector cell reconfiguration via metabolic deactivation. In conclusion, targeting IL-34/SDC-1 signaling, or its interconnected metabolites can uniquely intercept the crosstalk between glycolytic RA myeloid and lymphoid cells and their ability to trigger arthritis.
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Affiliation(s)
- Osama Alzoubi
- Department of Medicine, Division of Rheumatology, the University of Illinois at Chicago, IL, USA
| | - Anja Meyer
- Jesse Brown VA Medical Center, Chicago, IL, USA; Department of Medicine, Division of Rheumatology, the University of Illinois at Chicago, IL, USA
| | - Tanya Pulido Gonzalez
- Department of Medicine, Division of Rheumatology, the University of Illinois at Chicago, IL, USA
| | - Adel C Burgos
- Jesse Brown VA Medical Center, Chicago, IL, USA; Department of Medicine, Division of Rheumatology, the University of Illinois at Chicago, IL, USA
| | - Nadera Sweiss
- Department of Medicine, Division of Rheumatology, the University of Illinois at Chicago, IL, USA
| | - Ryan K Zomorrodi
- Department of Medicine, Division of Rheumatology, the University of Illinois at Chicago, IL, USA
| | - Shiva Shahrara
- Jesse Brown VA Medical Center, Chicago, IL, USA; Department of Medicine, Division of Rheumatology, the University of Illinois at Chicago, IL, USA.
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Mei D, Zhang T, Liu R, Wang P, Hu L, Xu L, Ge J, Zhang X, Wang H, Xue Z, Liang F, Yu Q, Wei W, Zhang L. hIgD-Fc-Ig fusion protein regulates T cell functions by inhibiting TCR signaling pathway in adjuvant arthritis rats. Int Immunopharmacol 2023; 119:110154. [PMID: 37062257 DOI: 10.1016/j.intimp.2023.110154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023]
Abstract
This study aimed to investigate the effect of hIgD-Fc-Ig on TCR-Lck-Erk activated by IgD in adjuvant arthritis (AA) rats. Wistar rats were divided into the normal, AA model, hIgD-Fc-Ig (1 mg/kg, 3 mg/kg and 9 mg/kg) and Etanercept (3 mg/kg) groups. The overall index of AA rats was measured every 3 days. The pathologic examination of knee joints and the proliferation of the spleen and thymus of AA rats were detected by H&E staining and CCK-8. The blood flow signal of knee joints of experimental rats was examined by US. The articular bone injury was detected by X-ray. The changes in PBMCs and spleen T cell subsets were detected by flow cytometry. The expression of CD3ε, p-Lck, p-Zap70, Ras, and p-Erk in rat spleens was detected by immunofluorescence and WB. Rat spleen T cells or Jurkat cells treated by IgD to observe the effect of hIgD-Fc-Ig on TCR and its downstream protein expression. The results showed that hIgD-Fc-Ig had a therapeutic effect on AA rats by reducing the secondary inflammation, improving pathological changes. hIgD-Fc-Ig can reduce the ratio of Th cells of PBMCs of AA rats, the ratio of Th, Th1, Th17 cells and increase the ratio of Th2, Treg cells of AA rat spleens. hIgD-Fc-Ig could down-regulate the expression of CD3ε, p-Lck, p-Zap70, Ras, p-Erk in vivo or in vitro. In conclusion, hIgD-Fc-Ig could alleviate the symptoms of AA rats and regulate T cells through TCR-Lck-Erk signaling pathway and maybe a new promising biological agent for RA.
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Affiliation(s)
- Dan Mei
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Tianjing Zhang
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Ruijin Liu
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Pan Wang
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Ling Hu
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Li Xu
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Jinru Ge
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Xianzheng Zhang
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China; Department of Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei 230032, China
| | - Han Wang
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Ziyang Xue
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Faqin Liang
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Qianqian Yu
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China
| | - Wei Wei
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China.
| | - Lingling Zhang
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Hefei 230032, China.
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Wang Z, Wang J, Lan T, Zhang L, Yan Z, Zhang N, Xu Y, Tao Q. Role and mechanism of fibroblast-activated protein-α expression on the surface of fibroblast-like synoviocytes in rheumatoid arthritis. Front Immunol 2023; 14:1135384. [PMID: 37006278 PMCID: PMC10064071 DOI: 10.3389/fimmu.2023.1135384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
Fibroblast-activated protein-α (FAP) is a type II integrated serine protease expressed by activated fibroblasts during fibrosis or inflammation. Fibroblast-like synoviocytes (FLSs) in rheumatoid arthritis (RA) synovial sites abundantly and stably overexpress FAP and play important roles in regulating the cellular immune, inflammatory, invasion, migration, proliferation, and angiogenesis responses in the synovial region. Overexpression of FAP is regulated by the initial inflammatory microenvironment of the disease and epigenetic signaling, which promotes RA development by regulating FLSs or affecting the signaling cross-linking FLSs with other cells at the local synovium and inflammatory stimulation. At present, several treatment options targeting FAP are in the process of development. This review discusses the basic features of FAP expressed on the surface of FLSs and its role in RA pathophysiology and advances in targeted therapies.
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Affiliation(s)
- Zihan Wang
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
- Graduate school, Beijing University of Chinese Medicine, Beijing, China
| | - Jinping Wang
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Tianyi Lan
- Graduate school, Beijing University of Chinese Medicine, Beijing, China
| | - Liubo Zhang
- Graduate school, Beijing University of Chinese Medicine, Beijing, China
| | - Zeran Yan
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Nan Zhang
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
| | - Yuan Xu
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Yuan Xu, ; Qingwen Tao,
| | - Qingwen Tao
- Traditional Chinese Medicine Department of Rheumatism, China-Japan Friendship Hospital, Beijing, China
- *Correspondence: Yuan Xu, ; Qingwen Tao,
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Xiang C, Li H, Tang W. Targeting CSF-1R represents an effective strategy in modulating inflammatory diseases. Pharmacol Res 2023; 187:106566. [PMID: 36423789 DOI: 10.1016/j.phrs.2022.106566] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
Colony-stimulating factor-1 receptor (CSF-1R), also known as FMS kinase, is a type I single transmembrane protein mainly expressed in myeloid cells, such as monocytes, macrophages, glial cells, and osteoclasts. The endogenous ligands, colony-stimulating factor-1 (CSF-1) and Interleukin-34 (IL-34), activate CSF-1R and downstream signaling pathways including PI3K-AKT, JAK-STATs, and MAPKs, and modulate the proliferation, differentiation, migration, and activation of target immune cells. Over the past decades, the promising therapeutic potential of CSF-1R signaling inhibition has been widely studied for decreasing immune suppression and escape in tumors, owing to depletion and reprogramming of tumor-associated macrophages. In addition, the excessive activation of CSF-1R in inflammatory diseases is consecutively uncovered in recent years, which may result in inflammation in bone, kidney, lung, liver and central nervous system. Agents against CSF-1R signaling have been increasingly investigated in preclinical or clinical studies for inflammatory diseases treatment. However, the pathological mechanism of CSF-1R in inflammation is indistinct and whether CSF-1R signaling can be identified as biomarkers remains controversial. With the background information aforementioned, this review focus on the dialectical roles of CSF-1R and its ligands in regulating innate immune cells and highlights various therapeutic implications of blocking CSF-1R signaling in inflammatory diseases.
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Affiliation(s)
- Caigui Xiang
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China; School of Pharmacy, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Heng Li
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China.
| | - Wei Tang
- Laboratory of Anti-inflammation and Immunopharmacology, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China; School of Pharmacy, University of Chinese Academy of Sciences, Beijing 100049, China.
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Park HE, Oh H, Baek JH. Interleukin-34-regulated T-cell responses in rheumatoid arthritis. Front Med (Lausanne) 2022; 9:1078350. [PMID: 36530919 PMCID: PMC9747768 DOI: 10.3389/fmed.2022.1078350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 09/10/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease with a multifaceted etiology, which primarily affects and results in the deterioration of the synovium of patients. While the exact etiology of RA is still largely unknown, there is growing interest in the cytokine interleukin-34 (IL-34) as a driver or modulator of RA pathogenesis on the grounds that IL-34 is drastically increased in the serum and synovium of RA patients. Several studies have so far revealed the relationship between IL-34 levels and RA disease progression. Nevertheless, the significance and role of IL-34 in RA have remained ambiguous, as illustrated by two most recent studies, which reported contrasting effects of genetic IL-34 deletion in RA. Of note, IL-34 is a macrophage growth factor and is increasingly perceived as a master regulator of T-cell responses in RA via macrophage-dependent as well as T cell-intrinsic mechanisms. In this regard, several studies have demonstrated that IL-34 potentiates helper T-cell (Th) responses in RA, whereas studies also suggested that IL-34 alleviates synovial inflammation, potentially by inducing regulatory T-cells (Treg). Herein, we provide an overview of the current understanding of IL-34 involvement in RA and outline IL-34-mediated mechanisms in regulating T-cell responses in RA.
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Affiliation(s)
| | | | - Jea-Hyun Baek
- School of Life Science, Handong Global University, Pohang, South Korea
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Interleukin-35 inhibits angiogenesis through T helper17/ Interleukin-17 related signaling pathways in IL-1β-stimulated SW1353 cells. Mol Immunol 2022; 147:71-80. [DOI: 10.1016/j.molimm.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/06/2022] [Accepted: 04/24/2022] [Indexed: 11/19/2022]
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Chen J, Lin X, He J, Liu J, He J, Tao C, Wang Q. Novel isatin-based hybrids as potential anti-rheumatoid arthritis drug candidates: Synthesis and biological evaluation. Bioorg Chem 2022; 128:106063. [PMID: 35930922 DOI: 10.1016/j.bioorg.2022.106063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 11/02/2022]
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Monteleone G, Franzè E, Troncone E, Maresca C, Marafini I. Interleukin-34 Mediates Cross-Talk Between Stromal Cells and Immune Cells in the Gut. Front Immunol 2022; 13:873332. [PMID: 35529879 PMCID: PMC9073079 DOI: 10.3389/fimmu.2022.873332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/25/2022] [Indexed: 12/18/2022] Open
Abstract
Initially known as a cytokine produced by and regulating the function of monocytes and macrophages, interleukin-34 (IL-34) can be synthesized by many cell types and interacts with receptors expressed by multiple immune and non-immune cells. IL-34 is constitutively expressed in the healthy human small intestine and colon and its production is markedly increased in damaged gut of patients with Crohn's disease and patients with ulcerative colitis, the main forms of chronic inflammatory bowel diseases (IBD) in human beings. Circumstantial evidence suggests that, in these pathologies, IL-34 plays a crucial role in mediating cross-talk between immune cells and stromal cells, thereby promoting activation of signalling pathways, which amplify the ongoing mucosal inflammation as well as production of fibrogenic molecules. In this article, we summarize the available data supporting the multiple effects of IL-34 in human IBD with particular attention to the role of the cytokine in immune and stromal cell interactions.
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Affiliation(s)
- Giovanni Monteleone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- *Gastroenterology Unit, Policlinico Tor Vergata, Rome, Italy
| | - Eleonora Franzè
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- *Gastroenterology Unit, Policlinico Tor Vergata, Rome, Italy
| | - Claudia Maresca
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Irene Marafini
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- *Gastroenterology Unit, Policlinico Tor Vergata, Rome, Italy
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