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Di Meo C, Tortolani D, Standoli S, Ciaramellano F, Angelucci BC, Tisi A, Kadhim S, Hsu E, Rapino C, Maccarrone M. Cannabinol modulates the endocannabinoid system and shows TRPV1-mediated anti-inflammatory properties in human keratinocytes. Biofactors 2024. [PMID: 39275884 DOI: 10.1002/biof.2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 08/27/2024] [Indexed: 09/16/2024]
Abstract
Cannabinol (CBN) is a secondary metabolite of cannabis whose beneficial activity on inflammatory diseases of human skin has attracted increasing attention. Here, we sought to investigate the possible modulation by CBN of the major elements of the endocannabinoid system (ECS), in both normal and lipopolysaccharide-inflamed human keratinocytes (HaCaT cells). CBN was found to increase the expression of cannabinoid receptor 1 (CB1) at gene level and that of vanilloid receptor 1 (TRPV1) at protein level, as well as their functional activity. In addition, CBN modulated the metabolism of anandamide (AEA) and 2-arachidonoylglicerol (2-AG), by increasing the activities of N-acyl phosphatidylethanolamines-specific phospholipase D (NAPE-PLD) and fatty acid amide hydrolase (FAAH)-the biosynthetic and degradative enzyme of AEA-and that of monoacylglycerol lipase (MAGL), the hydrolytic enzyme of 2-AG. CBN also affected keratinocyte inflammation by reducing the release of pro-inflammatory interleukin (IL)-8, IL-12, and IL-31 and increasing the release of anti-inflammatory IL-10. Of note, the release of IL-31 was mediated by TRPV1. Finally, the mitogen-activated protein kinases (MAPK) signaling pathway was investigated in inflamed keratinocytes, demonstrating a specific modulation of glycogen synthase kinase 3β (GSK3β) upon treatment with CBN, in the presence or not of distinct ECS-directed drugs. Overall, these results demonstrate that CBN modulates distinct ECS elements and exerts anti-inflammatory effects-remarkably via TRPV1-in human keratinocytes, thus holding potential for both therapeutic and cosmetic purposes.
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Affiliation(s)
- Camilla Di Meo
- Department of Veterinary Medicine, University of Teramo, Teramo, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Daniel Tortolani
- Department of Veterinary Medicine, University of Teramo, Teramo, Italy
| | - Sara Standoli
- Department of Veterinary Medicine, University of Teramo, Teramo, Italy
| | | | | | - Annamaria Tisi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Salam Kadhim
- InMed Pharmaceuticals Inc., Vancouver, BC, Canada
| | - Eric Hsu
- InMed Pharmaceuticals Inc., Vancouver, BC, Canada
| | - Cinzia Rapino
- Department of Veterinary Medicine, University of Teramo, Teramo, Italy
| | - Mauro Maccarrone
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- European Center for Brain Research (CERC), Santa Lucia Foundation IRCCS, Rome, Italy
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Obed O, Chong AC, Su M, Ong PY. Emerging drugs for the treatment of atopic dermatitis: a focus on phase 2 and phase 3 trials. Expert Opin Emerg Drugs 2024; 29:233-249. [PMID: 38662529 DOI: 10.1080/14728214.2024.2345643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/12/2024] [Indexed: 04/30/2024]
Abstract
INTRODUCTION Atopic dermatitis (AD) is an inflammatory skin condition that affects millions of pediatric and adult patients with well-studied impact on morbidity and quality of life. Management occurs in a stepwise fashion beginning with preventative measures before immunomodulators are introduced. However, challenges remain in treatment of moderate-to-severe atopic dermatitis that is refractory to first- and second-line treatments and there are only few topical anti-inflammatory options, especially for pediatric patients. AREAS COVERED New medications are required to address these gaps as lesions may persist despite treatment or patients may discontinue treatment due to actual or anticipated adverse effects of mainstay medications. Emerging research into the pathophysiology of AD and the immune system at large has provided opportunities for novel interventions aimed at stopping AD mechanisms at new checkpoints. Clinical trials for 36 agents currently in phase 2 or phase 3 are evaluated with particular focus on the studies for, B244, CBP-201, tapinarof, lebrikizumab, nemolizumab, amlitelimab, and rocatinlimab as they explore novel pathways and have some of the most promising results. EXPERT OPINION These clinical trials contribute to the evolution of AD treatment toward greater precision based on salient pathways with a particular focus on moderate-to-severe AD to enhance efficacy and minimize adverse effects.
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Affiliation(s)
- Ogechi Obed
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Albert C Chong
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Malcolm Su
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Peck Y Ong
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles; Department of Pediatrics, University of Southern California, Los Angeles, CA, USA
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Akhtar S, Ahmad F, Alam M, Ansari AW, Uddin S, Steinhoff M, Buddenkotte J, Ahmad A, Datsi A. Interleukin-31: The Inflammatory Cytokine Connecting Pruritus and Cancer. FRONT BIOSCI-LANDMRK 2024; 29:312. [PMID: 39344323 DOI: 10.31083/j.fbl2909312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/03/2024] [Accepted: 07/10/2024] [Indexed: 10/01/2024]
Abstract
Interleukin 31 (IL-31) is a proinflammatory cytokine, mainly secreted by Type II helper T cells. It signals through a heterodimeric receptor complex composed of IL-31 receptor α and oncostatin-M receptor β chain. The hallmark feature of IL-31, in its pathological role, is its ability to induce pruritus in mammals. Pruritus is a common symptom and major reason of morbidity in cancer patients, compromising their quality of life. Although, IL-31 is differentially expressed in different tumor types and could promote or inhibit cancer progression, high expression of IL-31 is a contributing factor to advanced stage tumor and severity of pruritus. The simultaneous existence of pruritus and cancer could either result from the aberrations in common proteins that co-exist in both cancer and pruritus or the therapeutic treatment of cancer could indirectly induce pruritus. Although the biology of IL-31 has predominantly been described in skin diseases such as atopic dermatitis and other inflammatory diseases, the precise role of IL-31 in the tumor biology of different cancer types remains elusive. Herein, we summarize the current understanding on the role of this cytokine in the pathogenesis of different cancers.
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Affiliation(s)
- Sabah Akhtar
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Fareed Ahmad
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Majid Alam
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Abdul Wahid Ansari
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Shahab Uddin
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Martin Steinhoff
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Department of Dermatology and Venereology, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Joerg Buddenkotte
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Department of Dermatology and Venereology, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Aamir Ahmad
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
- Dermatology Institute, Academic Health System, Hamad Medical Corporation, 3050 Doha, Qatar
| | - Angeliki Datsi
- Institute of Transplantation Diagnostics and Cell Therapeutics, University Hospital Dusseldorf, 40225 Dusseldorf, Germany
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Nakamura T, Yamamoto T. Palmoplantar pustulosis-like eruption on the palms and lower legs following nemolizumab treatment for atopic dermatitis with nodular prurigo. Int J Dermatol 2024. [PMID: 38997821 DOI: 10.1111/ijd.17374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/05/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Takehiro Nakamura
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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Pearson J, Denley T, Blubaugh A, Kim SJ, Fogle JE, Leon R, Goss C, Banovic F. Characterisation of the pruritus responses and pruritic behaviours in an interleukin 31-induced canine model of pruritus. Vet Dermatol 2024; 35:296-304. [PMID: 38149639 DOI: 10.1111/vde.13231] [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: 01/24/2023] [Revised: 10/17/2023] [Accepted: 12/14/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Intravenous administration of interleukin (IL)-31 in healthy dogs has been used as a model to assess antipruritic drugs. However, there is no known in-depth characterisation of pruritic behaviours, and the repeatability of the IL-31-induced pruritus in the individual dogs is currently unknown. OBJECTIVES To evaluate the immediate/delayed pruritus responses and the pruritic behaviours observed in the IL-31-induced pruritic model in healthy dogs after repeated IL-31 injections. ANIMALS Fifteen healthy laboratory beagles. METHODS All dogs were video-recorded for 270 min after two intravenous recombinant IL-31 injections (1.75 μg/kg) and vehicle (phosphate-buffered saline, control) injections, respectively; interventions were randomised and performed with a 2 week wash-out period. Two blinded investigators reviewed the pruritic behaviours of all video recordings. RESULTS Both canine IL-31 (IL-31_01, IL-31_02) injections significantly increased pruritic seconds and categorical minutes ('YES'/'NO' behaviour per discrete 1 min interval) in healthy dogs compared with both vehicle groups (Vehicle_01, Vehicle_02). The second intravenous canine IL-31 (IL-31_02) administered 14 days after the first IL-31 injection induced a significant increase in pruritic seconds (p = 0.021) and not pruritic categorical minutes (p = 0.231). An increase in pruritic seconds was observed in both IL-31 groups in the first 30 min post-administration, while there was no significant difference between IL-31 and vehicle groups. CONCLUSIONS AND CLINICAL RELEVANCE In conclusion, intravenous IL-31 reproducibly induces itch responses in dogs. Future evaluations of the canine IL-31 pruritic model should assess total pruritic behaviours in seconds rather than using a biased 'YES/NO' behaviour per 1 min scoring system.
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Affiliation(s)
- Jason Pearson
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Tara Denley
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Amanda Blubaugh
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Sujung Jun Kim
- Boehringer Ingelheim Animal Health, Athens, Georgia, USA
| | | | - Renato Leon
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Caleb Goss
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Frane Banovic
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
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6
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Shao Y, Wang D, Zhu Y, Xiao Z, Jin T, Peng L, Shen Y, Tang H. Molecular mechanisms of pruritus in prurigo nodularis. Front Immunol 2023; 14:1301817. [PMID: 38077377 PMCID: PMC10701428 DOI: 10.3389/fimmu.2023.1301817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
Pruritus is the most common symptom of dermatological disorders, and prurigo nodularis (PN) is notorious for intractable and severe itching. Conventional treatments often yield disappointing outcomes, significantly affecting patients' quality of life and psychological well-being. The pathogenesis of PN is associated with a self-sustained "itch-scratch" vicious cycle. Recent investigations of PN-related itch have partially revealed the intricate interactions within the cutaneous neuroimmune network; however, the underlying mechanism remains undetermined. Itch mediators play a key role in pruritus amplification in PN and understanding their action mechanism will undoubtedly lead to the development of novel targeted antipruritic agents. In this review, we describe a series of pruritogens and receptors involved in mediating itching in PN, including cytokines, neuropeptides, extracellular matrix proteins, vasculogenic substances, ion channels, and intracellular signaling pathways. Moreover, we provide a prospective outlook on potential therapies based on existing findings.
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Affiliation(s)
| | | | | | | | | | | | | | - Hui Tang
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
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Murdaca G, Gangemi S, Greco M. The IL-33/IL-31 Axis in Allergic and Immune-Mediated Diseases. Int J Mol Sci 2023; 24:9227. [PMID: 37298179 PMCID: PMC10252527 DOI: 10.3390/ijms24119227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 04/26/2023] [Accepted: 05/06/2023] [Indexed: 06/12/2023] Open
Abstract
Interleukin 31 (IL-31) belongs to the IL-6 superfamily [...].
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Affiliation(s)
- Giuseppe Murdaca
- Department of Internal Medicine, University of Genova and IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Sebastiano Gangemi
- School and Operative Unit of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy;
| | - Monica Greco
- Internal Medicine Department, San Paolo Hospital, 17100 Savona, Italy;
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Caserta S, Genovese C, Cicero N, Gangemi S, Allegra A. The Anti-Cancer Effect of Cinnamon Aqueous Extract: A Focus on Hematological Malignancies. Life (Basel) 2023; 13:life13051176. [PMID: 37240821 DOI: 10.3390/life13051176] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Cinnamon is an evergreen and tropical plant of the family Lauraceae, growing particularly in Sri Lanka, whose aqueous extract has been tested in different studies to evaluate its possible use as an anti-cancer compound. Both in vitro and in vivo experiments seem to confirm that it acts on various cellular pathways, contributing to down-regulating the activity of molecules that stimulate the proliferation and survival of cells such as the transcription factors NF-KB and AP-1, COX-2, dihydrofolate reductase and pro-angiogenic substances such as VEGF, while up-regulating the function of immune cells against tumors, such as cytotoxic CD8+ T cells. In hematological malignancies, aqueous cinnamon extract has been studied in order to understand if it is possible to count on its help, alone or in combination with traditional drugs such as doxorubicin, to treat patients. The aim of our work is to investigate results from in vitro and in vivo studies about the possible anti-cancer effect of aqueous cinnamon extract in hematological malignancies and the different pathways involved in its action. The possibility of using cinnamon extract in clinical practice is discussed; even if its use could appear very interesting, more studies are necessary to clear the real potentiality of this substance in cancer.
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Affiliation(s)
- Santino Caserta
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Via Consolare Valeria, 98125 Messina, Italy
| | - Claudia Genovese
- National Research Council, Institute for Agricultural and Forest Systems in the Mediterranean, Via Empedocle 58, 95128 Catania, Italy
| | - Nicola Cicero
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
| | - Sebastiano Gangemi
- Allergy and Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 98125 Messina, Italy
| | - Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Via Consolare Valeria, 98125 Messina, Italy
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Pearson J, Leon R, Starr H, Kim SJ, Fogle JE, Banovic F. Establishment of an Intradermal Canine IL-31-Induced Pruritus Model to Evaluate Therapeutic Candidates in Atopic Dermatitis. Vet Sci 2023; 10:vetsci10050329. [PMID: 37235412 DOI: 10.3390/vetsci10050329] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/28/2023] Open
Abstract
Pruritic models in healthy dogs utilizing intravenous administration of interleukin 31 (IL-31) bypass the "natural" itch sensation in AD, which is initiated by pruriceptive primary afferent neurons in the skin. This study aimed to evaluate the immediate/delayed pruritus responses and the pruritic behaviors observed in an intradermal IL-31-induced pruritic model of healthy dogs and the anti-pruritic effect of oclacitinib on said model. In Phase 1, all the dogs were randomized and video-recorded for 300 min after intradermal canine recombinant IL-31 injections (1.75 µg/kg) and vehicle (phosphate-buffered saline) injections. In Phase 2, all the dogs received oral oclacitinib (0.4-0.6 mg/kg, twice daily for 4 consecutive days and once daily on day 5), with the intradermal IL-31 injection performed on day 5. Two blinded investigators reviewed the pruritic behaviors in all the video recordings. Intradermal IL-31 administration to healthy dogs caused a significant increase in the total (p = 0.0052) and local (p = 0.0003) seconds of pruritic behavior compared to the vehicle control. Oral oclacitinib administration significantly reduced the total (p = 0.0011) and local (p = 0.0156) intradermal IL-31-induced pruritic seconds; there was no significant difference in pruritic seconds between the vehicle and oclacitinib within the IL-31 groups. Significant delayed pruritic responses at 150-300 min after IL-31 injections were observed, and intradermal IL-31 failed to induce acute itch (first 30 min). Intradermal injection of IL-31 induces delayed itch responses in dogs that are diminished by the effect of oclacitinib, an oral JAK inhibitor.
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Affiliation(s)
- Jason Pearson
- College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
| | - Renato Leon
- College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
| | - Haley Starr
- College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
| | - Sujung Jun Kim
- Boehringer Ingelheim Animal Health, Athens, GA 30601, USA
| | | | - Frane Banovic
- College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA
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Papa V, Li Pomi F, Borgia F, Vaccaro M, Pioggia G, Gangemi S. Immunosenescence and Skin: A State of Art of Its Etiopathogenetic Role and Crucial Watershed for Systemic Implications. Int J Mol Sci 2023; 24:ijms24097956. [PMID: 37175661 PMCID: PMC10178319 DOI: 10.3390/ijms24097956] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/23/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Immunosenescence is a complex multifactorial phenomenon consisting of wide-ranging remodeling of the immune system during the life span, resulting in an age-related qualitative-quantitative decline of immune cells and cytokines. A growing body of evidence in the international literature is highlighting the etiopathogenetic role of skin immunosenescence in the onset of various dermatologic conditions. Skin immunosenescence also serves as an interesting watershed for the onset of system-wide conditions in the context of allergic inflammation. Moreover, in recent years, an increasingly emerging and fascinating etiopathogenetic parallelism has been observed between some mechanisms of immunosenescence, both at cutaneous and systemic sites. This would help to explain the occurrence of apparently unconnected comorbidities. Throughout our review, we aim to shed light on emerging immunosenescent mechanisms shared between dermatologic disorders and other organ-specific diseases in the context of a more extensive discussion on the etiopathogenetic role of skin immunosenescence. A promising future perspective would be to focus on better understanding the mutual influence between skin and host immunity, as well as the influence of high inter-individual variability on immunosenescence/inflammaging. This can lead to a more comprehensive "immunobiographic" definition of each individual.
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Affiliation(s)
- Vincenzo Papa
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
| | - Federica Li Pomi
- Section of Dermatology, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Francesco Borgia
- Section of Dermatology, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Mario Vaccaro
- Section of Dermatology, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), 98164 Messina, Italy
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
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11
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Borgia F, Li Pomi F, Alessandrello C, Vaccaro M, Gangemi S. Potential Role of Innate Lymphoid Cells in the Pathogenesis and Treatment of Skin Diseases. J Clin Med 2023; 12:jcm12083043. [PMID: 37109379 PMCID: PMC10144013 DOI: 10.3390/jcm12083043] [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: 03/16/2023] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 04/29/2023] Open
Abstract
Group 2 innate lymphoid cells (ILC2s) are lymphoid cells that are resident in mucosal tissues, especially the skin, which, once stimulated by epithelial cell-derived cytokines, release IL-5, IL-13, and IL-4, as the effectors of type 2 immune responses. This research aims to evaluate the role of ILC2s in the pathogenesis of skin diseases, with a particular focus on inflammatory cutaneous disorders, in order to also elucidate potential therapeutic perspectives. The research has been conducted in articles, excluding reviews and meta-analyses, on both animals and humans. The results showed that ILC2s play a crucial role in the pathogenesis of systemic skin manifestations, prognosis, and severity, while a potential antimelanoma role is emerging from the new research. Future perspectives could include the development of new antibodies targeting or stimulating ILC2 release. This evidence could add a new therapeutic approach to inflammatory cutaneous conditions, including allergic ones.
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Affiliation(s)
- Francesco Borgia
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Federica Li Pomi
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Clara Alessandrello
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
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Blockage of the IL-31 Pathway as a Potential Target Therapy for Atopic Dermatitis. Pharmaceutics 2023; 15:pharmaceutics15020577. [PMID: 36839897 PMCID: PMC9961325 DOI: 10.3390/pharmaceutics15020577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
Atopic dermatitis (AD), a pruritic, inflammatory chronic disease with multifactorial pathogenesis, has been a therapeutic challenge. Novel target treatments aim to reduce not only the immunologic dysfunction and microbiome dysbiosis but also the recovery of the damaged skin barrier. The current review focuses on the interleukin 31 (IL-31) pathway and AD and offers an overview of the current clinical studies with monoclonal antibodies blocking this cascade. Pruritus, the key symptom of AD, has substantial participation of the IL-31 complex and activation of relevant signaling pathways. Epidermal keratinocytes, inflammatory cells, and cutaneous peripheral nerves express the interleukin-31 receptor α-chain (IL-31RA), upregulated by Staphylococcus aureus toxins or Th2 cytokines involved in AD. Nemolizumab is a humanized monoclonal antibody that antagonizes IL-31RA, inhibiting the IL-31 cascade and therefore contributing to reducing the pruritus and inflammation and recovering the damaged skin barrier in AD patients. Phases 2 and 3 clinical trials with nemolizumab in AD show a suitable safety profile, with a fast, efficient, and sustained reduction of pruritus and severity scores, especially when associated with topical treatment. Deciphering the full interplay of the IL-31 pathway and AD may expand the potential of nemolizumab as a targeted therapy for AD and other pruritic conditions.
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13
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Tortolani D, Di Meo C, Standoli S, Ciaramellano F, Kadhim S, Hsu E, Rapino C, Maccarrone M. Rare Phytocannabinoids Exert Anti-Inflammatory Effects on Human Keratinocytes via the Endocannabinoid System and MAPK Signaling Pathway. Int J Mol Sci 2023; 24:2721. [PMID: 36769042 PMCID: PMC9917187 DOI: 10.3390/ijms24032721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
Increasing evidence supports the therapeutic potential of rare cannabis-derived phytocannabinoids (pCBs) in skin disorders such as atopic dermatitis, psoriasis, pruritus, and acne. However, the molecular mechanisms of the biological action of these pCBs remain poorly investigated. In this study, an experimental model of inflamed human keratinocytes (HaCaT cells) was set up by using lipopolysaccharide (LPS) in order to investigate the anti-inflammatory effects of the rare pCBs cannabigerol (CBG), cannabichromene (CBC), Δ9-tetrahydrocannabivarin (THCV) and cannabigerolic acid (CBGA). To this aim, pro-inflammatory interleukins (IL)-1β, IL-8, IL-12, IL-31, tumor necrosis factor (TNF-β) and anti-inflammatory IL-10 levels were measured through ELISA quantification. In addition, IL-12 and IL-31 levels were measured after treatment of HaCaT cells with THCV and CBGA in the presence of selected modulators of endocannabinoid (eCB) signaling. In the latter cells, the activation of 17 distinct proteins along the mitogen-activated protein kinase (MAPK) pathway was also investigated via Human Phosphorylation Array. Our results demonstrate that rare pCBs significantly blocked inflammation by reducing the release of all pro-inflammatory ILs tested, except for TNF-β. Moreover, the reduction of IL-31 expression by THCV and CBGA was significantly reverted by blocking the eCB-binding TRPV1 receptor and by inhibiting the eCB-hydrolase MAGL. Remarkably, THCV and CBGA modulated the expression of the phosphorylated forms (and hence of the activity) of the MAPK-related proteins GSK3β, MEK1, MKK6 and CREB also by engaging eCB hydrolases MAGL and FAAH. Taken together, the ability of rare pCBs to exert an anti-inflammatory effect in human keratinocytes through modifications of eCB and MAPK signaling opens new perspectives for the treatment of inflammation-related skin pathologies.
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Affiliation(s)
- Daniel Tortolani
- Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
- European Center for Brain Research (CERC), Santa Lucia Foundation IRCCS, 00143 Rome, Italy
| | - Camilla Di Meo
- Department of Bioscience and Technology for Food Agriculture and Environment, University of Teramo, 64100 Teramo, Italy
| | - Sara Standoli
- Department of Bioscience and Technology for Food Agriculture and Environment, University of Teramo, 64100 Teramo, Italy
| | | | - Salam Kadhim
- InMed Pharmaceuticals Inc., Vancouver, BC V6C 1B4, Canada
| | - Eric Hsu
- InMed Pharmaceuticals Inc., Vancouver, BC V6C 1B4, Canada
| | - Cinzia Rapino
- Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Mauro Maccarrone
- European Center for Brain Research (CERC), Santa Lucia Foundation IRCCS, 00143 Rome, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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14
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Douladiris N, Vakirlis E, Vassilopoulou E. Atopic Dermatitis and Water: Is There an Optimum Water Intake Level for Improving Atopic Skin? CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020273. [PMID: 36832402 PMCID: PMC9954916 DOI: 10.3390/children10020273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/20/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
Water is a vital nutrient with innumerable functions for every living cell. The functions of human skin include protection against dehydration of the body. Atopic dermatitis (AD) is a chronic pruritic inflammatory skin disease that presents with dry skin, erythematous and eczematous lesions, and lichenification. This paper discusses the question of whether extra water intake in children with AD affects skin hydration and the skin barrier function. Among the methods used to treat dry skin, topical leave-on products are the first-line treatment, intended to improve hydration and the skin barrier function. The effectiveness of adequate water intake as a measure to treat dry skin is still under debate. Normal skin hydration increases with dietary water intake, particularly in those with prior lower water consumption. Skin dryness in AD is instrumental to the itch and inflammation cycle, contributing to barrier impairment and aggravating disease severity and flares. Certain emollients provide significant hydration to AD skin, with relief of dryness and reduction in barrier impairment, disease severity, and flares. Further investigations are needed to evaluate the optimum water intake levels in children with AD, as important questions remain unanswered, namely, does oral hydration provide relief of skin dryness and reduce barrier impairment, disease severity, and flares; is there any additional benefit from using mineral or thermal spring water; or is there a need to specifically study the fluid/water intake in children with AD and food allergy (FA) restrictions?
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Affiliation(s)
- Nikolaos Douladiris
- Allergy Unit, 2nd Pediatric Clinic, University of Athens, 11527 Athens, Greece
- Correspondence:
| | - Efstratios Vakirlis
- First Department of Dermatology and Venereology, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Emilia Vassilopoulou
- Department of Nutritional Sciences and Dietetics, International Hellenic University, 57400 Thessaloniki, Greece
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15
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Borgia F, Custurone P, Li Pomi F, Vaccaro M, Alessandrello C, Gangemi S. IL-33 and IL-37: A Possible Axis in Skin and Allergic Diseases. Int J Mol Sci 2022; 24:ijms24010372. [PMID: 36613827 PMCID: PMC9820694 DOI: 10.3390/ijms24010372] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Interleukin (IL)-37 and IL-33 are among the latest cytokines identified, playing a role in several inflammatory conditions, spanning from systemic conditions to tumors to localized diseases. As newly discovered interleukins, their role is still scarcely understood, but their potential role as therapeutic targets or disease activity markers suggests the need to reorganize the current data for a better interpretation. The aim of this review is to collect and organize data produced by several studies to create a complete picture. The research was conducted on the PubMed database, and the resulting articles were sorted by title, abstract, English language, and content. Several studies have been assessed, mostly related to atopic dermatitis and immunologic pathways. Collective data demonstrates a pro-inflammatory role of IL-33 and an anti-inflammatory one for IL-37, possibly related to each other in an IL-33/IL-37 axis. Although further studies are needed to assess the safety and plausibility of targeting these two interleukins for patients affected by skin conditions, the early results indicate that both IL-33 and IL-37 represent markers of disease activity.
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Affiliation(s)
- Francesco Borgia
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
- Correspondence:
| | - Paolo Custurone
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Federica Li Pomi
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Clara Alessandrello
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
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16
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Borgia F, Li Pomi F, Vaccaro M, Alessandrello C, Papa V, Gangemi S. Oxidative Stress and Phototherapy in Atopic Dermatitis: Mechanisms, Role, and Future Perspectives. Biomolecules 2022; 12:1904. [PMID: 36551332 PMCID: PMC9775940 DOI: 10.3390/biom12121904] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Atopic dermatitis is a chronic inflammatory skin disease in which the overproduction of reactive oxygen species plays a pivotal role in the pathogenesis and persistence of inflammatory lesions. Phototherapy represents one of the most used therapeutic options, with benefits in the clinical picture. Studies have demonstrated the immunomodulatory effect of phototherapy and its role in reducing molecule hallmarks of oxidative stress. In this review, we report the data present in literature dealing with the main signaling molecular pathways involved in oxidative stress after phototherapy to target atopic dermatitis-affected cells. Since oxidative stress plays a pivotal role in the pathogenesis of atopic dermatitis and its flare-up, new research lines could be opened to study new drugs that act on this mechanism, perhaps in concert with phototherapy.
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Affiliation(s)
- Francesco Borgia
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Federica Li Pomi
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy
| | - Clara Alessandrello
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
| | - Vincenzo Papa
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy
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17
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Lapkina NA, Baranov AA, Abaytova NE, Levshin NY, Rechkina OP, Leontyeva EA, Avdeyeva AS, Artyukhov AS, Nasonov EL. IL-31 and IL-33 in rheumatoid arthritis patients. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-554-559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective – to investigate clinical and diagnostic significance of IL-31 and IL-33 determination in patients with rheumatoid arthritis (RA).Material and methods. 154 patients with a reliable diagnosis of RA were examined. Serum levels of IL-31 and IL-33 were studied using multiplex xMAP technology on Bio-PlexTM 200 System analyzer (BIO-RAD, USA). The upper limit of the norm in the study of 20 healthy donor sera was (M+3σ): IL-31 – 15.08 pg/ml, IL-33 – 3.40 pg/ml.Results. IL-31 (Me (25th; 75th percentile) – 13.75 (5.63; 308.52) and 6.10 (2.87; 8.62) pg/ml (p<0.001), IL-33 – 18.86 (7.45; 65.95) and 0.52 (0.17; 0.78) pg/ml (p><0.001) levels were observed in RA patients in comparison with the control group. An increase in IL-33 concentration (more than 3.40 pg/ml) was observed in 87.0% of patients, and IL-31 (more than 15.08 pg/ml) in 48.1% of patients with RA. An increase in IL-33 alone was observed in 42.2% (65 of 154 patients) with RA, while an isolated increase in IL-31 concentration was observed in only 2 (1.3%) patients. Simultaneous hyperproduction of IL-33 and IL-31 occurred in 69 (44.9%) patients. We revealed positive correlation of clinical and laboratory parameters of RA with cytokine concentration: SDAI correlated with IL-33 (r=0.36; p><0.05); CRP – with IL-31 (r=0.49; p><0,05) and IL-33 (r=0.40; p><0.05). Conclusion. Concentrations of IL-31 and IL-33 are elevated in RA patients and correlate with the indices of inflammatory activity of the disease.>< 0.001), IL-33 – 18.86 (7.45; 65.95) and 0.52 (0.17; 0.78) pg/ml (p<0.001) levels were observed in RA patients in comparison with the control group. An increase in IL-33 concentration (more than 3.40 pg/ml) was observed in 87.0% of patients, and IL-31 (more than 15.08 pg/ml) in 48.1% of patients with RA. An increase in IL-33 alone was observed in 42.2% (65 of 154 patients) with RA, while an isolated increase in IL-31 concentration was observed in only 2 (1.3%) patients. Simultaneous hyperproduction of IL-33 and IL-31 occurred in 69 (44.9%) patients. We revealed positive correlation of clinical and laboratory parameters of RA with cytokine concentration: SDAI correlated with IL-33 (r=0.36; p><0.05); CRP – with IL-31 (r=0.49; p><0,05) and IL-33 (r=0.40; p><0.05). Conclusion. Concentrations of IL-31 and IL-33 are elevated in RA patients and correlate with the indices of inflammatory activity of the disease.>< 0.001) levels were observed in RA patients in comparison with the control group. An increase in IL-33 concentration (more than 3.40 pg/ml) was observed in 87.0% of patients, and IL-31 (more than 15.08 pg/ml) in 48.1% of patients with RA. An increase in IL-33 alone was observed in 42.2% (65 of 154 patients) with RA, while an isolated increase in IL-31 concentration was observed in only 2 (1.3%) patients. Simultaneous hyperproduction of IL-33 and IL-31 occurred in 69 (44.9%) patients. We revealed positive correlation of clinical and laboratory parameters of RA with cytokine concentration: SDAI correlated with IL-33 (r=0.36; p<0.05); CRP – with IL-31 (r=0.49; p><0,05) and IL-33 (r=0.40; p><0.05). Conclusion. Concentrations of IL-31 and IL-33 are elevated in RA patients and correlate with the indices of inflammatory activity of the disease.>< 0.05); CRP – with IL-31 (r=0.49; p< ,05) and IL-33 (r=0.40; p<0.05)Conclusion. Concentrations of IL-31 and IL-33 are elevated in RA patients and correlate with the indices of inflammatory activity of the disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University of the Ministry
of Health Care of Russian Federation (Sechenov University)
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18
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Circulating Microparticles Are Differentially Increased in Lowlanders and Highlanders with High Altitude Induced Pulmonary Hypertension during the Cold Season. Cells 2022; 11:cells11192932. [PMID: 36230894 PMCID: PMC9563667 DOI: 10.3390/cells11192932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
The role of microparticles (MPs) and cold in high altitude pulmonary hypertension (HAPH) remains unexplored. We investigated the impact of long-term cold exposure on the pulmonary circulation in lowlanders and high-altitude natives and the role of MPs. Pulmonary hemodynamics were evaluated using Doppler echocardiography at the end of the colder and warmer seasons. We further examined the miRNA content of MPs isolated from the study participants and studied their effects on human pulmonary artery smooth muscle (hPASMCs) and endothelial cells (hPAECs). Long-term exposure to cold environment was associated with an enhanced pulmonary artery pressure in highlanders. Plasma levels of CD62E-positive and CD68-positive MPs increased in response to cold in lowlanders and HAPH highlanders. The miRNA-210 expression contained in MPs differentially changed in response to cold in lowlanders and highlanders. MPs isolated from lowlanders and highlanders increased proliferation and reduced apoptosis of hPASMCs. Further, MPs isolated from warm-exposed HAPH highlanders and cold-exposed highlanders exerted the most pronounced effects on VEGF expression in hPAECs. We demonstrated that prolonged exposure to cold is associated with elevated pulmonary artery pressures, which are most pronounced in high-altitude residents. Further, the numbers of circulating MPs are differentially increased in lowlanders and HAPH highlanders during the colder season.
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19
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Erbescu A, Papuc SM, Budisteanu M, Arghir A, Neagu M. Re-emerging concepts of immune dysregulation in autism spectrum disorders. Front Psychiatry 2022; 13:1006612. [PMID: 36339838 PMCID: PMC9626859 DOI: 10.3389/fpsyt.2022.1006612] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by communication and social interaction deficits, and by restricted interests and stereotyped, repetitive behavior patterns. ASD has a strong genetic component and a complex architecture characterized by the interplay of rare and common genetic variants. Recently, increasing evidence suggest a significant contribution of immune system dysregulation in ASD. The present paper reviews the latest updates regarding the altered immune landscape of this complex disorder highlighting areas with potential for biomarkers discovery as well as personalization of therapeutic approaches. Cross-talk between the central nervous system and immune system has long been envisaged and recent evidence brings insights into the pathways connecting the brain to the immune system. Disturbance of cytokine levels plays an important role in the establishment of a neuroinflammatory milieu in ASD. Several other immune molecules involved in antigen presentation and inflammatory cellular phenotypes are also at play in ASD. Maternal immune activation, the presence of brain-reactive antibodies and autoimmunity are other potential prenatal and postnatal contributors to ASD pathophysiology. The molecular players involved in oxidative-stress response and mitochondrial system function, are discussed as contributors to the pro-inflammatory pattern. The gastrointestinal inflammation pathways proposed to play a role in ASD are also discussed. Moreover, the body of evidence regarding some of the genetic factors linked to the immune system dysregulation is reviewed and discussed. Last, but not least, the epigenetic traits and their interactions with the immune system are reviewed as an expanding field in ASD research. Understanding the immune-mediated pathways that influence brain development and function, metabolism, and intestinal homeostasis, may lead to the identification of robust diagnostic or predictive biomarkers for ASD individuals. Thus, novel therapeutic approaches could be developed, ultimately aiming to improve their quality of life.
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Affiliation(s)
- Alina Erbescu
- Victor Babes National Institute of Pathology, Bucharest, Romania.,Faculty of Biology, Doctoral School, University of Bucharest, Bucharest, Romania
| | | | - Magdalena Budisteanu
- Victor Babes National Institute of Pathology, Bucharest, Romania.,Prof. Dr. Alex. Obregia Clinical Hospital of Psychiatry, Bucharest, Romania.,Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Aurora Arghir
- Victor Babes National Institute of Pathology, Bucharest, Romania
| | - Monica Neagu
- Victor Babes National Institute of Pathology, Bucharest, Romania.,Faculty of Biology, Doctoral School, University of Bucharest, Bucharest, Romania.,Colentina Clinical Hospital, Bucharest, Romania
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