Effect of environmental pollutants on the production of pro-inflammatory cytokines by normal human dermal keratinocytes

Unraveling the skin; a comprehensive review of atopic dermatitis, current understanding, and approaches

Atopic dermatitis, also known as atopic eczema, is a chronic inflammatory skin disease characterized by red pruritic skin lesions, xerosis, ichthyosis, and skin pain. Among the social impacts of atopic dermatitis are difficulties and detachment in relationships and social stigmatization. Additionally, atopic dermatitis is known to cause sleep disturbance, anxiety, hyperactivity, and depression. Although the pathological process behind atopic dermatitis is not fully known, it appears to be a combination of epidermal barrier dysfunction and immune dysregulation. Skin is the largest organ of the human body which acts as a mechanical barrier to toxins and UV light and a natural barrier against water loss. Both functions face significant challenges due to atopic dermatitis. The list of factors that can potentially trigger or contribute to atopic dermatitis is extensive, ranging from genetic factors, family history, dietary choices, immune triggers, and environmental factors. Consequently, prevention, early clinical diagnosis, and effective treatment may be the only resolutions to combat this burdensome disease. Ensuring safe and targeted drug delivery to the skin layers, without reaching the systemic circulation is a promising option raised by nano-delivery systems in dermatology. In this review, we explored the current understanding and approaches of atopic dermatitis and outlined a range of the most recent therapeutics and dosage forms brought by nanotechnology. This review was conducted using PubMed, Google Scholar, and ScienceDirect databases.

Association of air quality index (AQI) with incidence of atopic dermatitis in Taiwan: A nationwide population-based cohort study

BACKGROUND

Air pollutants may aggravate atopic dermatitis (AD). However, the association between Air Quality Index (AQI) and incidence of AD remains unknown.

OBJECTIVE

To investigate association between AQI and incidence of AD, using the nationwide cohort in the Taiwan National Health Insurance Research Database (NHIRD).

METHODS

We included 21,278,938 participants from the NHIRD not diagnosed with AD before 2008. Long-term average AQI value, obtained from the Taiwan Air Quality Monitoring System Network, before AD diagnosis was calculated and linked for each participant.

RESULTS

199,205 incident cases of AD were identified from 2008 to 2018. Participants were classified into 4 quantiles (Q) by AQI value. With the lowest quantile, Q1, as reference, the AD risk increased significantly in the Q2 group (adjusted hazard ratio [aHR]: 1.29, 95% confidence interval [CI]: 1.04-1.65), Q3 group (aHR: 4.71, 95% CI: 3.78-6.04), and was highest in the Q4 group (aHR: 13.20, 95% CI: 10.86-16.60). As AQI treated as a continuous variable, an increase of 1 unit of AQI value added 7% of AD risk (aHR, 1.07, 95% CI: 1.07-1.08).

LIMITATIONS

The NHIRD lacks detailed information on individual subjects.

CONCLUSIONS

The results demonstrated a significant positive association between AQI and incidence of AD with a clear dose-response relationship.

Air Pollution and Atopic Dermatitis, from Molecular Mechanisms to Population-Level Evidence: A Review

Atopic dermatitis (AD) has increased in prevalence to become the most common inflammatory skin condition globally, and geographic variation and migration studies suggest an important role for environmental triggers. Air pollution, especially due to industrialization and wildfires, may contribute to the development and exacerbation of AD. We provide a comprehensive, multidisciplinary review of existing molecular and epidemiologic studies on the associations of air pollutants and AD symptoms, prevalence, incidence, severity, and clinic visits. Cell and animal studies demonstrated that air pollutants contribute to AD symptoms and disease by activating the aryl hydrocarbon receptor pathway, promoting oxidative stress, initiating a proinflammatory response, and disrupting the skin barrier function. Epidemiologic studies overall report that air pollution is associated with AD among both children and adults, though the results are not consistent among cross-sectional studies. Studies on healthcare use for AD found positive correlations between medical visits for AD and air pollutants. As the air quality worsens in many areas globally, it is important to recognize how this can increase the risk for AD, to be aware of the increased demand for AD-related medical care, and to understand how to counsel patients regarding their skin health. Further research is needed to develop treatments that prevent or mitigate air pollution-related AD symptoms.

Carbonaceous Nanoparticle Air Pollution: Toxicity and Detection in Biological Samples

Among the different air pollutants, particulate matter (PM) is of great concern due to its abundant presence in the atmosphere, which results in adverse effects on the environment and human health. The different components of PM can be classified based on their physicochemical properties. Carbonaceous particles (CPs) constitute a major fraction of ultrafine PM and have the most harmful effects. Herein, we present a detailed overview of the main components of CPs, e.g., carbon black (CB), black carbon (BC), and brown carbon (BrC), from natural and anthropogenic sources. The emission sources and the adverse effects of CPs on the environment and human health are discussed. Particularly, we provide a detailed overview of the reported toxic effects of CPs in the human body, such as respiratory effects, cardiovascular effects, neurodegenerative effects, carcinogenic effects, etc. In addition, we also discuss the challenges faced by and limitations of the available analytical techniques for the qualitative and quantitative detection of CPs in atmospheric and biological samples. Considering the heterogeneous nature of CPs and biological samples, a detailed overview of different analytical techniques for the detection of CPs in (real-exposure) biological samples is also provided. This review provides useful insights into the classification, toxicity, and detection of CPs in biological samples.

Star fruit extract and C-glycosylated flavonoid components have potential to prevent air pollutant-induced skin inflammation and premature aging

Air pollution adversely affects skin, leading to skin inflammation and premature skin aging. Plant derived antioxidant compounds have been considered to be promising in discovery of effective agents for the protection of skin from the damage by air pollutants. Our previous studies demonstrated that Averrhoa carambola fruit (known as star fruit) is rich in flavonoid C-glycosides with unique structures and potent antioxidant activity. Thus, the star fruit extract (SFE) and main flavonoid C-glycoside components, carambolasides I, J, and P (1-3), carambolaflavone B (4), and isovitexin 2″-O-α-L-rhamnoside (5), were investigated for the activity against air pollutant stress in human epidermis. As a result, SFE and compounds 1-5 exhibited significant inhibitory activity against protein carbonylation in oxidative-stressed stratum corneum with the best activity being shown by compound 3. SFE and compounds 2-5 were also active against engine exhaust-induced protein carbonylation in stratum corneum. When further evaluated, SFE and compound 3 significantly inhibited gene expression of the key inflammation mediators IL-1α and COX-2 in PM-stressed keratinocytes. The results indicated that SFE and the flavonoid C-glycosides are potentially effective against air pollutant-induced skin inflammation and premature aging.

The association between short-term ambient air pollution and acne vulgaris outpatient visits: a hospital-based time-series analysis in Xi'an

Recent studies have suggested that exposure to ambient airborne pollutants is associated with inflammatory skin diseases, but the epidemiological evidence regarding the association between air pollution and acne vulgaris is limited. To address that, a hospital-based time-series analysis was conducted in Xi'an, a metropolitan in northwest China. A total of 71,625 outpatient visits for acne from 2010 to 2013 were identified. The mean daily concentrations of PM10, SO2, and NO2 were 142.6 μg/m3, 44.7 μg/m3, and 48.5 μg/m3, and all were higher than WHO air quality guidelines. A generalized additive model was used to analyze the relationship between short-term ambient air pollution exposure and outpatient visits for acne. The gender- and age-specific analyses were conducted as well. The results showed that the increase of SO2 and NO2 concentrations corresponded to a significant rise in the number of outpatient visits for acne at lag 0 in both single-lag and cumulative exposure models. Both SO2 and NO2 were positively associated with acne outpatient visits for both males and females. In age-specific analyses, the effect estimate of PM10 was only significant for adults over 30 years old; SO2 was significantly associated with acne visits in children and adolescents (<21 years) and young adults (21-30 years); and NO2 was significantly associated with acne visits in all age subgroups. In conclusion, short-term exposure to ambient air pollutants (PM10, SO2, or NO2) with the average levels above WHO limits was associated with increased risk of outpatient visits for both teenage acne and adult acne. Moreover, the effects of air pollutants may vary with age.

Short-term exposure of PM2.5 and PM10 increases the number of outpatients with eczema in Guangzhou: A time-series study

Background

The worldwide prevalence of eczema has continued to rise over the past decades. This has led to the emphasis on the association between air pollution and eczema. This study investigated the relationship between daily exposure to air pollution and the number of eczema outpatient visits in Guangzhou with the overarching goal of providing novel insights on the interventions for eczema aggravation and prevention.

Methods

Daily air pollution data, meteorological data, and the number of eczema outpatients were obtained from 18 January 2013 to 31 December 2018 in Guangzhou. A generalized additive model with Poisson distribution was used to assess the association between the number of eczema outpatient visits and short-term exposure to PM_2.5 and PM₁₀. In addition, the association of PM_2.5 and PM₁₀ by age (<65 years, ≥65 years) and gender was evaluated.

Results

A total of 293,343 eczema outpatient visits were recorded. The obtained results indicated that a 10 μg/m³ increase of the same day/lag 1 day/lag 2 days PM_2.5 was associated with increments of 2.33%, 1.81%, and 0.95% in eczema outpatient risk, respectively. On the other hand, a 10 μg/m³ increase of PM₁₀ was associated with eczema outpatients risk increments of 1.97%, 1.65%, and 0.98% respectively. Furthermore, the associations of PM on the increment of eczema were similar in the male and female groups. Results obtained after age stratified analyses indicated that the strongest positive association between PM_2.5 exposure and eczema was observed at lag 0 day with the percent changes being 4.72% and 3.34% in <12 years old, ≥12 and <65 years old, and ≥65 years old groups, respectively.

Conclusion

Short-term exposure to PM_2.5 and PM₁₀ increases the number of eczema outpatients, especially among children and the elderly. The relationship between air quality trends and hospital resource arrangement should be paid attention to by hospital managers which may aid in disease prevention and lower the health burden.

Association of Wildfire Air Pollution and Health Care Use for Atopic Dermatitis and Itch

IMPORTANCE

Air pollution is a worldwide public health issue that has been exacerbated by recent wildfires, but the relationship between wildfire-associated air pollution and inflammatory skin diseases is unknown.

OBJECTIVE

To assess the associations between wildfire-associated air pollution and clinic visits for atopic dermatitis (AD) or itch and prescribed medications for AD management.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional time-series study assessed the associations of air pollution resulting from the California Camp Fire in November 2018 and 8049 dermatology clinic visits (4147 patients) at an academic tertiary care hospital system in San Francisco, 175 miles from the wildfire source. Participants included pediatric and adult patients with AD or itch from before, during, and after the time of the fire (October 2018 through February 2019), compared with those with visits in the same time frame of 2015 and 2016, when no large wildfires were near San Francisco. Data analysis was conducted from November 1, 2019, to May 30, 2020.

EXPOSURES

Wildfire-associated air pollution was characterized using 3 metrics: fire status, concentration of particulate matter less than 2.5 μm in diameter (PM2.5), and satellite-based smoke plume density scores.

MAIN OUTCOMES AND MEASURES

Weekly clinic visit counts for AD or itch were the primary outcomes. Secondary outcomes were weekly numbers of topical and systemic medications prescribed for AD in adults.

RESULTS

Visits corresponding to a total of 4147 patients (mean [SD] age, 44.6 [21.1] years; 2322 [56%] female) were analyzed. The rates of visits for AD during the Camp Fire for pediatric patients were 1.49 (95% CI, 1.07-2.07) and for adult patients were 1.15 (95% CI, 1.02-1.30) times the rate for nonfire weeks at lag 0, adjusted for temperature, relative humidity, patient age, and total patient volume at the clinics for pediatric patients. The adjusted rate ratios for itch clinic visits during the wildfire weeks were 1.82 (95% CI, 1.20-2.78) for the pediatric patients and 1.29 (95% CI, 0.96-1.75) for adult patients. A 10-μg/m3 increase in weekly mean PM2.5 concentration was associated with a 7.7% (95% CI, 1.9%-13.7%) increase in weekly pediatric itch clinic visits. The adjusted rate ratio for prescribed systemic medications in adults during the Camp Fire at lag 0 was 1.45 (95% CI, 1.03-2.05).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that short-term exposure to air pollution due to the wildfire was associated with increased health care use for patients with AD and itch. These results may provide a better understanding of the association between poor air quality and skin health and guide health care professionals' counseling of patients with skin disease and public health practice.

The impact of air pollution on skin and related disorders: A comprehensive review

As the largest organ in the body, human skin is constantly exposed to harmful compounds existing in the surrounding environment as the first-line barrier. Studies have indicated that exposure to high concentrations of many environmental factors, such as ultraviolet (UV) radiation, outdoor air pollutants, including polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs), particulate matter (PM), heavy metals, gaseous pollutants, such as carbon monoxide (CO), nitric oxides (NO_x ), sulfur oxide (SO₂ ), ozone (O₃ ), and indoor air pollutants (solid fuels consumption), might interrupt the skin's normal barrier function. Besides, the intensity of the pollutants and the length of exposure might be a contributing factor. Air pollutants are believed to induce or exacerbate a range of skin conditions, such as aging, inflammatory diseases (atopic dermatitis, cellulitis, and psoriasis), acne, hair loss, and even skin cancers (mainly melanoma and Squamous Cell Carcinoma) through various mechanisms. The interaction between pollutants and the skin might differ based on each agent's particular characteristics. Also, damaging the skin barrier seems to be closely related to the increased production of reactive oxygen species (ROS), induction of oxidative stress, activation of aryl hydrocarbon receptor (AhR), and inflammatory cytokines. This article reviews recent studies on the correlation between air pollutants and skin diseases, along with related mechanisms.

The role of xenobiotics in triggering psoriasis

Psoriasis is a common inflammatory skin disease affecting approximately 2% of the world population. A complex interplay of genetic predisposition and risk factors contributes to the risk of its onset. Several xenobiotics have been implicated in the pathogenesis of psoriasis. Drugs are among the most investigated trigger factors; strong association with disease induction or exacerbation has been reported for β-blockers, lithium, NSAIDs and ACE inhibitors, all of which are commonly used in the management of various comorbidities in psoriasis patients. Furthermore, inhibitors of TNF have a well-documented potential for triggering new-onset psoriasis when used for other indications (e.g. Crohn's disease or rheumatoid arthritis), while post-marketing data have revealed the same association for ustekinumab. Several other drugs have been connected with psoriasis, but the evidence is less compelling. Smoking and alcohol have been reported to increase the risk for occurrence of psoriasis, but can also affect unfavorably the course of the disease and its response to treatment. Furthermore, exposure to secondhand smoke, especially in childhood, also mediates the risk. Emerging data now suggest that air pollution also has a detrimental effect on skin disease, including psoriasis, but this association needs further investigation. Understanding of the toxic effect of xenobiotics on the initiation and clinical course of psoriasis can contribute to its better control, as it can help with the avoidance of triggering factors and, in some cases, influence the success of pharmacological treatment. It, therefore, has an important place in the comprehensive management of psoriasis.

Impact of airborne particulate matter on skin: a systematic review from epidemiology to in vitro studies

BACKGROUND

Air pollution is killing close to 5 million people a year, and harming billions more. Air pollution levels remain extremely high in many parts of the world, and air pollution-associated premature deaths have been reported for urbanized areas, particularly linked to the presence of airborne nano-sized and ultrafine particles.

MAIN TEXT

To date, most of the research studies did focus on the adverse effects of air pollution on the human cardiovascular and respiratory systems. Although the skin is in direct contact with air pollutants, their damaging effects on the skin are still under investigation. Epidemiological data suggested a correlation between exposure to air pollutants and aggravation of symptoms of chronic immunological skin diseases. In this study, a systematic literature review was conducted to understand the current knowledge on the effects of airborne particulate matter on human skin. It aims at providing a deeper understanding of the interactions between air pollutants and skin to further assess their potential risks for human health.

CONCLUSION

Particulate matter was shown to induce a skin barrier dysfunction and provoke the formation of reactive oxygen species through direct and indirect mechanisms, leading to oxidative stress and induced activation of the inflammatory cascade in human skin. Moreover, a positive correlation was reported between extrinsic aging and atopic eczema relative risk with increasing particulate matter exposure.

Proinflammatory properties and oxidative effects of atmospheric particle components in human keratinocytes

The skin is one of the main organs exposed to airborne particulate matter (PM), which may contain various pollutants linked to a wide range of adverse health endpoints. In the present work, we analyzed the proinflammatory and oxidative effects of some PM components leading to inflammatory responses, cell proliferation or cell death. We investigated four redox-active chemicals, such as Cu (II) metal and quinones generated from polycyclic aromatic hydrocarbons (PAHs), i.e., 9,10 phenanthrenequinone and isomers 1,2 and 1,4 naphthoquinone. We performed in vitro biological tests on human keratinocyte (HaCaT) cells and also acellular assays based on the oxidation of dithiothreitol and ascorbic acid, antioxidants to assess the oxidative potential (OP). We found that treated keratinocytes showed increased activation of the redox-sensitive transcription factor NFκB and increased transcript levels of the NFκB-dependent gene IL8. Moreover, the treatment with Cu(II) and quinones increased the activities and the expression of genes involved in the redox response, SOD1 and GPX, suggesting that PM components induced cellular damage due to redox imbalances. Finally, we found alteration of the mitochondrial ultrastructure and increased apoptosis after 24 h of treatment. The results presented suggest that all of the analyzed pollutant components are able to modulate similar signal transduction pathways, resulting in activation of inflammatory processes in the skin, followed by oxidative damage. Altogether these observations indicate that exposure of skin to air pollutants modifies the redox equilibrium of keratinocytes, which could explain the increased skin damage observed in populations that live in high-pollution cities.

Afzelin suppresses proinflammatory responses in particulate matter-exposed human keratinocytes

Particulate matter (PM), a widespread airborne contaminant, is a complex mixture of solid and liquid particles suspended in the air. Recent studies have demonstrated that PM induces oxidative stress and inflammatory reactions, and may cause certain skin diseases. Afzelin is a flavonoid isolated from Thesium chinense Turcz, which has anti‑inflammatory, anticancer and antibacterial properties. Therefore, the present study aimed to investigate if afzelin affected inflammatory responses in human keratinocytes exposed to PM. HaCaT cells were treated with PM (25 µg/cm2) in the presence or absence of afzelin (200 µM). Here, standard reference material 1649b was used as PM. Cell viability was assessed using the water‑soluble tetrazolium salt‑1 assay. The generation of reactive oxygen species (ROS) was measured using the dichloro‑dihydro‑​fluorescein diacetate assay. Gene and protein expression were investigated using reverse transcription‑quantitative polymerase chain reaction and western blot analysis, respectively. Levels of secreted inflammatory cytokines were measured using ELISA. The results suggested that afzelin inhibited PM‑induced proinflammatory cytokine mRNA expression and protein secretion in HaCaT cells. In addition, afzelin suppressed PM‑induced intracellular ROS generation, and p38 mitogen‑activated protein kinase and transcription factor activator protein‑1 component c‑Fos and c‑Jun activation. The results indicated that afzelin exerts anti‑inflammatory and antioxidant effects in PM‑exposed HaCaT. Afzelin may have potential for preventing PM‑induced inflammatory skin diseases.

Ambient air pollution and the hospital outpatient visits for eczema and dermatitis in Beijing: a time-stratified case-crossover analysis

BACKGROUND

Eczema and dermatitis are a group of common skin conditions with multiple risk factors. Evidence of the effects of air pollutants on eczema and dermatitis remains limited. This study aimed to investigate the effects of short-term exposure to air pollution on eczema and dermatitis in Beijing.

METHODS

A time-stratified case-crossover design was used to assess the associations between short-term changes in air pollution and the hospital outpatient visits for eczema and dermatitis in Beijing.

RESULTS

A total of 157 595 outpatient visits for eczema and dermatitis were recorded from April 1, 2012 to April 30, 2014. All pollutants showed significant positive associations with the number of outpatient visits for eczema and dermatitis on lag 0 (the current day). Per IQR increase in PM2.5, PM10, NO2 and SO2 was associated with 3.81% (95% CI: 2.92-4.7%), 3.18% (95% CI: 2.39-3.97%), 5.43% (95% CI: 4.43-6.43%) and 5.57% (95% CI: 4.55-6.58%) increases in outpatient visits for eczema and dermatitis on lag 0. Associations of air pollutants with eczema and dermatitis outpatient visits varied with the seasons and were stronger among older people and females. Also, an association of consecutive days' high concentration pollution with increased outpatient visits was observed.

CONCLUSIONS

Exposure to air pollution increases the exacerbation of eczema and dermatitis and stronger positive associations between air pollutants and outpatient visits for eczema and dermatitis were found among the aged, females and when high concentration air pollution occurs continuously.

Antioxidants from Plants Protect against Skin Photoaging

Exposure to UV light triggers the rapid generation and accumulation of reactive oxygen species (ROS) in skin cells, with consequent increase in oxidative stress and thus in photoaging. Exogenous supplementation with dietary antioxidants and/or skin pretreatment with antioxidant-based lotions before sun exposure might be a winning strategy against age-related skin pathologies. In this context, plants produce many secondary metabolites to protect themselves from UV radiations and these compounds can also protect the skin from photoaging. Phenolic compounds, ascorbic acid and carotenoids, derived from different plant species, are able to protect the skin by preventing UV penetration, reducing inflammation and oxidative stress, and influencing several survival signalling pathways. In this review, we focus our attention on the double role of oxidants in cell metabolism and on environmental and xenobiotic agents involved in skin photoaging. Moreover, we discuss the protective role of dietary antioxidants from fruits and vegetables and report their antiaging properties related to the reduction of oxidative stress pathways.

Involvement of the nuclear structural proteins in aging-related responses of human skin to the environmental stress

Human skin is a stratified endocrine organ with primary roles in protection against detrimental biochemical and biophysical factors in the environment. Environmental stress causes gradual accumulation of the macromolecular damage and clinical manifestations consistent with chronic inflammatory conditions and premature aging of the skin. Structural proteins of cell nucleus, the nuclear lamins and lamina-associated proteins, play an important role in the regulation of a number of signal transduction pathways associated with stress. The nuclear lamina proteins have been implicated in a number of degenerative disorders with frequent clinical manifestations of the skin conditions related to premature aging. Analysis of the molecular signatures in response of the skin to a range of damaging factors not only points at the likely involvement of the nuclear lamina in transmission of the signals between the environment and cell nucleus but also defines skin's sensitivity to stress, and therefore the capacities to counteract external damage in aging.

Proteome-wide changes in primary skin keratinocytes exposed to diesel particulate extract-A role for antioxidants in skin health

BACKGROUND

Skin acts as a protective barrier against direct contact with pollutants but inhalation and systemic exposure have indirect effect on keratinocytes. Exposure to diesel exhaust has been linked to increased oxidative stress.

OBJECTIVE

To investigate global proteomic alterations in diesel particulate extract (DPE)/its vapor exposed skin keratinocytes.

METHODS

We employed Tandem Mass Tag (TMT)-based proteomics to study effect of DPE/DPE vapor on primary skin keratinocytes.

RESULTS

We observed an increased expression of oxidative stress response protein NRF2, upon chronic exposure of primary keratinocytes to DPE/its vapor which includes volatile components such as polycyclic aromatic hydrocarbons (PAHs). Mass spectrometry-based quantitative proteomics led to identification 4490 proteins of which 201 and 374 proteins were significantly dysregulated (≥1.5 fold, p≤0.05) in each condition, respectively. Proteins involved in cellular processes such as cornification (cornifin A), wound healing (antileukoproteinase) and differentiation (suprabasin) were significantly downregulated in primary keratinocytes exposed to DPE/DPE vapor. These results were corroborated in 3D skin models chronically exposed to DPE/DPE vapor. Bioinformatics analyses indicate that DPE and its vapor affect distinct molecular processes in skin keratinocytes. Components of mitochondrial oxidative phosphorylation machinery were seen to be exclusively overexpressed upon chronic DPE vapor exposure. In addition, treatment with an antioxidant like vitamin E partially restores expression of proteins altered upon exposure to DPE/DPE vapor.

CONCLUSIONS

Our study highlights distinct adverse effects of chronic exposure to DPE/DPE vapor on skin keratinocytes and the potential role of vitamin E in alleviating adverse effects of environmental pollution.

Oxidative damage and impairment of protein quality control systems in keratinocytes exposed to a volatile organic compounds cocktail

Compelling evidence suggests that volatile organic compounds (VOCs) have potentially harmful effects to the skin. However, knowledge about cellular signaling events and toxicity subsequent to VOC exposure to human skin cells is still poorly documented. The aim of this study was to focus on the interaction between 5 different VOCs (hexane, toluene, acetaldehyde, formaldehyde and acetone) at doses mimicking chronic low level environmental exposure and the effect on human keratinocytes to get better insight into VOC-cell interactions. We provide evidence that the proteasome, a major intracellular proteolytic system which is involved in a broad array of processes such as cell cycle, apoptosis, transcription, DNA repair, protein quality control and antigen presentation, is a VOC target. Proteasome inactivation after VOC exposure is accompanied by apoptosis, DNA damage and protein oxidation. Lon protease, which degrades oxidized, dysfunctional, and misfolded proteins in the mitochondria is also a VOC target. Using human skin explants we found that VOCs prevent cell proliferation and also inhibit proteasome activity in vivo. Taken together, our findings provide insight into potential mechanisms of VOC-induced proteasome inactivation and the cellular consequences of these events.

Association of Short-Term Exposure to Ambient Fine Particulate Matter with Skin Symptoms in Schoolchildren: A Panel Study in a Rural Area of Western Japan

Numerous studies have unmasked the deleterious effects of particulate matter less than 2.5 μm (PM_2.5) on health. However, epidemiologic evidence focusing on the effects of PM_2.5 on skin health remains limited. An important aspect of Asian dust (AD) in relationship to health is the amount of PM_2.5 contained therein. Several studies have demonstrated that AD can aggravate skin symptoms. The current study aimed to investigate the effects of short-term exposure to PM_2.5 and AD particles on skin symptoms in schoolchildren. A total of 339 children recorded daily skin symptom scores during February 2015. Light detection and ranging were used to calculate AD particle size. Generalized estimating equation logistic regression analyses were used to estimate the associations among skin symptoms and the daily levels of PM_2.5 and AD particles. Increases in the levels of PM_2.5 and AD particles were not related to an increased risk of skin symptom events, with increases of 10.1 μg/m³ in PM_2.5 and 0.01 km^-1 in AD particles changing odds ratios by 1.03 and 0.99, respectively. These results suggest that short-term exposure to PM_2.5 and AD does not impact skin symptoms in schoolchildren.

Recognizing the impact of ambient air pollution on skin health

Ambient air pollution is a known public health hazard that negatively impacts non-cutaneous organs; however, our knowledge regarding the effects on skin remains limited. Current scientific evidence suggests there are four mechanisms by which ambient air pollutants cause adverse effects on skin health: (i) generation of free radicals, (ii) induction of inflammatory cascade and subsequent impairment of skin barrier, (iii) activation of the aryl hydrocarbon receptor (AhR) and (iv) alterations to skin microflora. In this review, we provide a comprehensive overview on ambient air pollutants and their relevant sources, and highlight current evidence of the effects on skin.

Vitamin C Compound Mixtures Prevent Ozone-Induced Oxidative Damage in Human Keratinocytes as Initial Assessment of Pollution Protection

Introduction

One of the main functions of cutaneous tissues is to protect our body from the outdoor insults. Ozone (O₃) is among the most toxic stressors to which we are continuously exposed and because of its critical location, the skin is one of the most susceptible tissues to the oxidative damaging effect of O₃. O₃ is not able to penetrate the skin, and although it is not a radical per se, the damage is mainly a consequence of its ability to induce oxidative stress via the formation of lipid peroxidation products.

Aim of Study

In this study we investigated the protective effect of defined “antioxidant” mixtures against O₃ induced oxidative stress damage in human keratinocytes and understand their underlying mechanism of action.

Results

Results showed that the mixtures tested were able to protect human keratinocytes from O₃-induced cytotoxicity, inhibition of cellular proliferation, decrease the formation of HNE protein adducts, ROS, and carbonyls levels. Furthermore, we have observed the decreased activation of the redox sensitive transcription factor NF-kB, which is involved in transcribing pro-inflammatory cytokines and therefore constitutes one of the main players associated with O₃ induced skin inflammation. Cells exposed to O₃ demonstrated a dose dependent increase in p65 subunit nuclear expression as a marker of NF-kB activation, while pre-treatment with the mixtures abolished NF-kB nuclear translocation. In addition, a significant activation of Nrf2 in keratinocytes treated with the mixtures was also observed.

Conclusion

Overall this study was able to demonstrate a protective effect of the tested compounds versus O_3-induced cell damage in human keratinocytes. Pre-treatment with the tested compounds significantly reduced the oxidative damage induced by O₃ exposure and this protective effect was correlated to the abolishment of NF-kB nuclear translocation, as well as activation of Nrf2 nuclear translocation activating the downstream defence enzymes involved in cellular detoxification process.

Coupled cell networks are target cells of inflammation, which can spread between different body organs and develop into systemic chronic inflammation

Several organs in the body comprise cells coupled into networks. These cells have in common that they are excitable but do not express action potentials. Furthermore, they are equipped with Ca²⁺ signaling systems, which can be intercellular and/or extracellular. The transport of small molecules between the cells occurs through gap junctions comprising connexin 43. Examples of cells coupled into networks include astrocytes, keratinocytes, chondrocytes, synovial fibroblasts, osteoblasts, connective tissue cells, cardiac and corneal fibroblasts, myofibroblasts, hepatocytes, and different types of glandular cells. These cells are targets for inflammation, which can be initiated after injury or in disease. If the inflammation reaches the CNS, it develops into neuroinflammation and can be of importance in the development of systemic chronic inflammation, which can manifest as pain and result in changes in the expression and structure of cellular components. Biochemical parameters of importance for cellular functions are described in this review.

Ocular injury by transient formaldehyde exposure in a rabbit eye model

Formaldehyde (FA) is frequently used in sterilizing surgical instruments and materials. Exposure to FA is highly concerned for eye tissues. Rabbit corneal epithelial cells were examined for changes after FA exposure. Our results showed that cell survival decreased 7 days after transient 3 min exposure to more than 100 ppm FA by trypan blue staining while MTT assay detected significant decrease at 20 ppm at 24 hours observation. The decrease of cell survival rate was concentration (up to 600 ppm)- and observation time (1–7 day)- dependent. The cell number decreased after 100 ppm FA exposure for more than 10 min at 7-day observation. The FA treated cells showed increased apoptosis/necrosis and cell cycle accumulation at sub G1 phase as well as mitochondria clustering around nucleus. The in vivo rabbit eye exposure for tear production by Schirmer’s test revealed that the FA-induced overproduction of tear also exhibited observation time (1–10 day)- and FA concentration (20–300 ppm for 5 min exposure)-dependent. Activated extracellular signal-regulated kinase (pERK2) in cornea explants by western blotting was reduced and increased c-Jun amino - terminal kinase (JNK) activation (pJNK) in cornea and conjunctiva was evident at 2 month after exposure to 50–200 ppm FA for 5 min. In conclusion, injury to the eye with transient exposure of up to 100 ppm FA for 3 min decreased corneal cell survival while a more sensitive MTT test detected the cell decrease at 20 ppm FA exposure. Morphology changes can be observed even at 5 ppm FA exposure for 3 min at 7 days after. The FA exposure also increased apoptotic/necrotic cells and sub-G1 phase in cell cycle. Long term effect (2 months after exposure) on the eye tissues even after the removal of FA can be observed with persistent JNK activation in cornea and conjunctiva.

Inflammation-related effects of diesel engine exhaust particles: studies on lung cells in vitro

Diesel exhaust and its particles (DEP) have been under scrutiny for health effects in humans. In the development of these effects inflammation is regarded as a key process. Overall, in vitro studies report similar DEP-induced changes in markers of inflammation, including cytokines and chemokines, as studies in vivo. In vitro studies suggest that soluble extracts of DEP have the greatest impact on the expression and release of proinflammatory markers. Main DEP mediators of effects have still not been identified and are difficult to find, as fuel and engine technology developments lead to continuously altered characteristics of emissions. Involved mechanisms remain somewhat unclear. DEP extracts appear to comprise components that are able to activate various membrane and cytosolic receptors. Through interactions with receptors, ion channels, and phosphorylation enzymes, molecules in the particle extract will trigger various cell signaling pathways that may lead to the release of inflammatory markers directly or indirectly by causing cell death. In vitro studies represent a fast and convenient system which may have implications for technology development. Furthermore, knowledge regarding how particles elicit their effects may contribute to understanding of DEP-induced health effects in vivo, with possible implications for identifying susceptible groups of people and effect biomarkers.

In vivo effects of the soluble fraction of light cycle oil on immune functions in the European sea bass, Dicentrarchus labrax (Linné)

Hydrocarbons are major contaminants that may affect biota at various trophic levels in estuaries and coastal ecosystems. The effects of accidental pollution by light cycle oil (LCO), a refined product of heavy fuel oil, on bioaccumulation, depuration processes and immune-related parameters in the European sea bass, Dicentrarchus labrax, were investigated in the laboratory after 7 days of exposure and a 2-week recovery period. Exposure of fish to the soluble fraction of LCO (1600ngL(-1)) for 7 days led to the bioaccumulation of some polycyclic aromatic hydrocarbons (PAHs) in muscles: naphthalene, acenaphthene, fluorene, phenanthrene and anthracene. After 7 days of recovery period, half-elimination of naphthalene was reported in fish muscles due to facilitated diffusive loss by the epithelium and a faster elimination rate proven by the presence of a high level of naphthalene biliary metabolites. The other bioaccumulated molecules displayed a slower depuration rate due to their elimination by the formation of hydrophobic metabolites excreted through bile or urine. Three days after the beginning of the recovery period, each contaminated fish showed severe external lesions (tissue necrosis, suppurative exudates, haemorrhagic area). The hypothesis of a possible link with inflammatory phenomenon was supported by (i) an inversion of the leucocyte sub-population percentage, (ii) a significant up-expression in the spleen of the tumour necrosis factor alpha gene, (iii) a significant increase in ACH(50). Moreover, the lack of C3 gene regulation in the spleen suggested a non-renewal of this component. The reduction of phagocytic activity and lysozyme concentration reflected immune suppression. Finally, LCO toxicity in this fish was clearly demonstrated to be related to inflammatory reaction and immune depletion.

In vitro biocompatibility of chitosan porous skin regenerating templates (PSRTs) using primary human skin keratinocytes

Biopolymer chitosan (beta-1,4-d-glucosamine) comprises the copolymer mixture of N-acetylglucosamine and glucosamine. The natural biocompatibility and biodegradability of chitosan have recently highlighted its potential use for applications in wound management. Chemical and physical modifications of chitosan influence its biocompatibility and biodegradability, but it is unknown as to what degree. Hence, the biocompatibility of the chitosan porous skin regenerating templates (PSRT 82, 87 and 108) was determined using an in vitro toxicology model at the cellular and molecular level on primary normal human epidermal keratinocytes (pNHEK). Cytocompatibility was accessed by using a 3-[4,5-dimethyl-2-thiazolyl]-2,5-diphenyl tetrazolium bromide (MTT) assay from 24 to 72h. To assess the genotoxicity of the PSRTs, DNA damage to the pNHEK was evaluated by using the Comet assay following direct contact with the various PSRTs. Furthermore, the skin pro-inflammatory cytokines TNF-alpha and IL-8 were examined to evaluate the tendency of the PSRTs to provoke inflammatory responses. All PSRTs were found to be cytocompatible, but only PSRT 108 was capable of stimulating cell proliferation. While all of the PSRTs showed some DNA damage, PSRT 108 showed the least DNA damage followed by PSRT 87 and 82. PSRT 87 and 82 induced a higher secretion of TNF-alpha and IL-8 in the pNHEK cultures than did PSRT 108. Hence, based on our experiments, PSRT 108 is the most biocompatible wound dressing of the three tested.

In vitro models in biocompatibility assessment for biomedical-grade chitosan derivatives in wound management

One of the ultimate goals of wound healing research is to find effective healing techniques that utilize the regeneration of similar tissues. This involves the modification of various wound dressing biomaterials for proper wound management. The biopolymer chitosan (beta-1,4-D-glucosamine) has natural biocompatibility and biodegradability that render it suitable for wound management. By definition, a biocompatible biomaterial does not have toxic or injurious effects on biological systems. Chemical and physical modifications of chitosan influence its biocompatibility and biodegradability to an uncertain degree. Hence, the modified biomedical-grade of chitosan derivatives should be pre-examined in vitro in order to produce high-quality, biocompatible dressings. In vitro toxicity examinations are more favorable than those performed in vivo, as the results are more reproducible and predictive. In this paper, basic in vitro tools were used to evaluate cellular and molecular responses with regard to the biocompatibility of biomedical-grade chitosan. Three paramount experimental parameters of biocompatibility in vitro namely cytocompatibility, genotoxicity and skin pro-inflammatory cytokine expression, were generally reviewed for biomedical-grade chitosan as wound dressing.

Hormetic Dose-Response Relationships in Immunology: Occurrence, Quantitative Features of the Dose Response, Mechanistic Foundations, and Clinical Implications

This article provides an assessment of the occurrence of immune-system-related hormetic-like biphasic dose-response relationships. Such dose-response relationships are extensive, with over 90 different immune response-related endpoints reported, induced by over 70 endogenous agonists, over 100 drugs, and over 40 environmental contaminants. Such hormetic responses were reported in over 30 animal models, over a dozen mammalian and human cell lines. These findings demonstrate that immune-system-related hormetic-like biphasic dose-response relationships are common and highly generalizable according to model, endpoint, and chemical class. The quantitative features of the dose response are generally consistent with previously published examples of hormetic dose responses for other biological endpoints. These findings were generally recognized and explicitly discussed by the original authors, often with consideration given to possible mechanistic foundations as well as numerous clinical implications. Despite the recognition by individual authors of the hormetic nature of these observed responses, the overall widespread nature of immune-related hormetic responses has been only little appreciated, with a general lack of insight into the highly generalizable nature of this phenomenon as well as the complex regulatory networks affecting biological switching mechanisms that result in the hormetic responses.

Diesel exhaust enhanced susceptibility to influenza infection is associated with decreased surfactant protein expression

We have previously shown that exposure of respiratory epithelial cells to diesel exhaust (DE) enhances susceptibility to influenza infection and increases the production of interleukin (IL)-6 and interferon (IFN)-beta. The purpose of this study was to confirm and expand upon these in vitro results by assessing the effects of DE exposure on the progression of influenza infection and on development of associated pulmonary immune and inflammatory responses in vivo. BALB/c mice were exposed to air or to DE containing particulate matter at concentrations of 0.5 or 2 mg/m(3) for 4 h/day for 5 days and subsequently instilled with influenza A/Bangkok/1/79 virus. Exposure to 0.5 mg/m(3) (but not the higher 2-mg/m(3) dose) of DE increased susceptibility to influenza infection as demonstrated by a significant increase in hemagglutinin (HA) mRNA levels, a marker of influenza copies, and greater immunohistochemical staining for influenza virus protein in the lung. The enhanced susceptibility to infection observed in mice exposed to 0.5 mg/m(3) of DE was associated with a significant increase in the expression of IL-6, while antiviral lung IFN levels were unaffected. Analysis of the expression and production of surfactant proteins A and D, which are components of the interferon-independent antiviral defenses, showed that these factors were decreased following exposure to 0.5 mg/m(3) of DE but not to the higher 2-mg/m(3) concentration. Taken together, the results demonstrate that exposure to DE enhances the susceptibility to respiratory viral infections by reducing the expression and production of antimicrobial surfactant proteins.

Formaldehyde exposure induces airway inflammation by increasing eosinophil infiltrations through the regulation of reactive oxygen species production

Formaldehyde (FA) is a well-known cytotoxic irritant to the airways, but the mechanism of airway inflammation due to FA has not been clarified. In the present study, C57BL/6 mice were exposed to two concentrations (5 and 10ppm) of FA for 6h/day, 5days/week, for 2 weeks. The FA-exposed mice had much higher number of CCR3(+) eosinophils than control mice, and showed upregulated gene expression of CC-chemokine receptor-3 (CCR3), eotaxin and intercellular adhesion molecules-1 (ICAM-1) as well as an increased expression of proinflammatory and Th2 cytokines, such as interleukin (IL)-1β, IL-4 and IL-5. In addition, FA exposure revealed a considerable increase in the serum levels of IgG1, IgG3, IgA and IgE compared to controls. Histopathological analysis of the lung tissues demonstrated eosinophils and mononuclear cell infiltration of the alveolar cell walls and alveolar spaces. Gene expression of thioredoxin (TRX), redox-regulating antioxidant proteins, was markedly suppressed in FA-exposed mice, and thereby intracellular ROS levels were increased along with increased FA concentration. These results were consistent with an increase in the number of CCR3-expressing eosinophils, and indicate that FA-induced ROS was generated from eosinophils recruited to the inflammatory sites of the airways.

Diesel exhaust particulate-induced activation of Stat3 requires activities of EGFR and Src in airway epithelial cells

In vivo exposure to diesel exhaust particles (DEP) elicits acute inflammatory responses in the lung characterized by inflammatory cell influx and elevated expression of mediators such as cytokines and chemokines. Signal transducers and activators of transcription (STAT) proteins are a family of cytoplasmic transcription factors that are key transducers of signaling in response to cytokine and growth factor stimulation. One member of the STAT family, Stat3, has been implicated as a regulator of inflammation but has not been studied in regard to DEP exposure. The results of this study show that DEP induces Stat3 phosphorylation as early as 1 h following stimulation and that phosphorylated Stat3 translocates into the nucleus. Inhibition of epidermal growth factor receptor (EGFR) and Src activities by the inhibitors PD-153035 and PP2, respectively, abolished the activation of Stat3 by DEP, suggesting that Stat3 activation by DEP requires EGFR and Src kinase activation. The present study suggests that oxidative stress induced by DEP may play a critical role in activating EGFR signaling, as evidenced by the fact that pretreatment with antioxidant prevented the activation of EGFR and Stat3. These findings demonstrate that DEP inhalation can activate proinflammatory Stat3 signaling in vitro.

Activation of nuclear factor kappa B by diesel exhaust particles in mouse epidermal cells through phosphatidylinositol 3-kinase/Akt signaling pathway

Diesel exhaust particles (DEP) induce intense inflammatory and allergic immune responses. The epidermal cells receive much exposure to DEP, and are an important source of pro-inflammatory cytokines and other inflammatory mediators. Transcription factors, such as nuclear factor kappa B (NF-kappaB) and activator protein 1 (AP-1), regulate the expression of these mediators. We hypothesize that the transcription factors are target of DEP action. The current study sought to determine whether DEP-activated NF-kappaB and AP-1 in a mouse epidermal cell line, JB6 P(+) cells. Using stable transfectants of JB6 P(+) cells expressing NF-kappaB or AP-1 luciferase reporter constructs, we demonstrated that exposure to DEP at a non-cytotoxic concentration significantly enhanced the transactivation of NF-kappaB, but not AP-1. Furthermore, DEP promoted phosphorylation of Akt, a substrate of phosphatidylinositol 3-kinase (PI3K), on Ser-473 and Thr-308 in a PI3K-dependent manner, and enhanced phosphorylation of down-stream p70/p85 S6 kinases (p70/p85S6K) as well as glycogen synthase kinase-3beta (GSK-3beta). Blockage of PI3K activation eliminated DEP-stimulated NF-kappaB transactivation. Although SAPK/JNK pathway was modestly activated by DEP, it was not involved in NF-kappaB transactivation. DEP had little effect on the phosphorylation of ERKs and p38 MAPK. Thus, DEP-induced transactivation of NF-kappaB is mediated by PI3K/Akt signaling pathway.

The diesel exhaust component pyrene induces expression of IL-8 but not of eotaxin

Environmental pollutants can influence the expression of immunoregulatory molecules and, in this way, promote allergies. The local synthesis of proinflammatory chemokines is an important aspect in the development of allergic airway inflammation. We have characterized the influence of pyrene, a polycyclic aromatic hydrocarbon (PAH) contained, for example, in diesel exhaust particles (DEP), on transcription and secretion of the chemokines interleukin-8 (IL-8) and eotaxin. Reporter genes under control of the respective promoters were tested in the human cell lines A549 and HeLa, mRNA production was assayed in A549 cells and protein production was measured by ELISA in cell supernatants from primary human fibroblasts. Pyrene content of cell supernatants was measured by analytical HPLC. Promoter activity, mRNA production and protein expression of IL-8 were increased by pyrene. The activating effect in reporter gene studies was abolished by mutating either an NF-kappaB or an AP-1 binding site in the IL-8 promoter. In contrast, pyrene showed no effect on transcription from the eotaxin promoter, despite the important role of this chemokine in asthma. Our data show that pyrene has specific effects on chemokine synthesis, which are not restricted to mediators primarily associated with atopic diseases. Pyrene also affected cells not derived from lung tissue, which suggests a broader immunoregulatory influence for this pollutant.

Effect of formaldehyde on the expression of adhesion molecules in nasal microvascular endothelial cells: the role of formaldehyde in the pathogenesis of sick building syndrome

BACKGROUND

Formaldehyde is associated with sick building syndrome (SBS), a set of diffuse and irritative symptoms predominantly involving the eyes and the respiratory tract. However, its pathophysiological mechanism in SBS has not yet been clarified.

OBJECTIVE

In this study we investigated the effect of formaldehyde on the expression of adhesion molecules on human mucosal microvascular endothelial cells (HMMECs). Furthermore, we investigated the effect of formaldehyde on adhesiveness of HMMECs to eosinophils.

MATERIALS AND METHODS

HMMECs were incubated with various concentrations of formaldehyde (1 ng/mL-1 microg/mL) for 24 h, and the expressions of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule (VCAM-1) on HMMECs were evaluated by flow cytometry. The change in the expression of ICAM-1 and VCAM-1 mRNA was then evaluated by reverse transcriptase polymerase chain reaction. To understand the role of formaldehyde in eosinophilic inflammation of the nasal mucosa, we examined the effects of formaldehyde on the adhesiveness between HMMECs and eosinophils by eosinophil adhesion assay.

RESULTS

Formaldehyde increased the surface expressions of ICAM-1 and VCAM-1 on HMMECs. Formaldehyde also induced ICAM-1 and VCAM-1 mRNA. In addition, the adhesiveness between HMMECs and eosinophils was also increased by formaldehyde.

CONCLUSION

These in vitro studies suggest that formaldehyde may play a role as the irritant of the nasal mucosa by increasing the expressions of adhesion molecules on HMMECs and by enhancing the adhesiveness between HMMECs and eosinophils.

Reactions of keratinocytes to in vitro millimeter wave exposure

The effects of millimeter waves (MW) on human keratinocytes were studied in vitro using the HaCaT keratinocyte cell line. MW-induced modulation of keratinocyte function was studied in proliferation, adhesion, chemotaxis, and interleukin-1beta (IL-1beta) production assays. Spontaneous proliferation, adhesion to tissue culture plate, random migration, and IL-8- and RANTES induced chemotaxis were not affected by exposure of cells to millimeter waves under the following conditions: frequency, 61.22 GHz; SAR, 770 W/kg; duration of exposure, 15-30 min. However, MW irradiation resulted in a modest but statistically significant increase in the intracellular level of IL-1beta. These data suggest that exposure of human skin (with keratinocytes being the major component of epidermis) to MW can cause activation of basal keratinocytes resulting in an elevated level of IL-1beta production.

Effect of high population density environment on skin barrier function in mice

Previous reports have demonstrated that stressful stimuli markedly influenced physiological conditions and homeostasis. In this study, we examined the influence of high population density environment on barrier function and water retention property of skin in mice. Overcrowding stress induced dramatic body weight reduction and significant increase in adrenal gland weight. Macroscopic skin appearance showed moderate exfoliation and slight wrinkle formation in the stress group. Moreover epidermis hyperplasia not concomitant with inflammatory reactions such as infiltration of immunocytes and vasodilation was observed in the skin from the stress group. Skin surface conductance in the stress group was significantly lower than in the control group. On the other hand, transepidermal water loss in the stress group increased significantly, compared to the control group. Moreover, transdermal penetration of indomethacin and nicotinic acid amide was enhanced significantly. These results suggest that overcrowding stress induced impairment of barrier function and water retention property. To elucidate the mechanism of overcrowding stress-induce dry skin, contents of ceramide and pyrrolidone carboxylic acid, which are the important compounds contributing to those functions were evaluated. Both of them in stratum corneum declined significantly in the stress group. Taken together, these results demonstrate that overcrowding stress induced dry skin, and that the impairment of barrier function and water retention property correlated with decrease in ceramide and pyrrolidone carboxylic acid.

Elevated nitric oxide/peroxynitrite mechanism for the common etiology of multiple chemical sensitivity, chronic fatigue syndrome, and posttraumatic stress disorder

Various types of evidence implicate nitric oxide and an oxidant, possibly peroxynitrite, in MCS and chemical intolerance (CI). The positive feedback loops proposed earlier for CFS may explain the chronic nature of MCS (CI) as well as several of its other reported properties. These observations raise the possibility that this proposed elevated nitric oxide/peroxynitrite mechanism may be the mechanism of a new disease paradigm, answering the question raised by Miller earlier: "Are we on the threshold of a new theory of disease?"