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Jansen J, Garmyn M, Güvenç C. The Effect of Body Mass Index on Melanoma Biology, Immunotherapy Efficacy, and Clinical Outcomes: A Narrative Review. Int J Mol Sci 2024; 25:6433. [PMID: 38928137 PMCID: PMC11204248 DOI: 10.3390/ijms25126433] [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: 04/29/2024] [Revised: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024] Open
Abstract
Recent studies indicate that a higher body mass index (BMI) might correlate with improved responses to melanoma treatment, especially with immune checkpoint inhibitors (ICIs), despite the general association of obesity with an increased risk of cancer and higher mortality rates. This review examines the paradoxical relationship between BMI and clinical outcomes in melanoma patients by exploring molecular links, the efficacy of immunotherapy, and patient survival outcomes. Our comprehensive literature search across the PubMed and Embase databases revealed a consistent pattern: increased BMI is associated with a better prognosis in melanoma patients undergoing ICI treatment. This "obesity paradox" might be explained by the metabolic and immunological changes in obesity, which could enhance the effectiveness of immunotherapy in treating melanoma. The findings highlight the complexity of the interactions between obesity and melanoma, suggesting that adipose tissue may modulate the immune response and treatment sensitivity favorably. Our review highlights the need for personalized treatment strategies that consider the metabolic profiles of patients and calls for further research to validate BMI as a prognostic factor in clinical settings. This nuanced approach to the obesity paradox in melanoma could significantly impact treatment planning and patient management.
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Affiliation(s)
| | | | - Canan Güvenç
- Department of Dermatology, University Hospitals Leuven, 3000 Leuven, Belgium; (J.J.); (M.G.)
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Katsimpris A, Antoniadis AG, Dessypris N, Karampinos K, Gogas HJ, Petridou ET. Associations of Dietary Factors with Cutaneous Melanoma: A Case-Control Study in Greece with Literature Review. Oncol Res Treat 2024; 47:206-217. [PMID: 38471487 PMCID: PMC11078323 DOI: 10.1159/000538278] [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: 07/08/2023] [Accepted: 03/06/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION It has been postulated that nutrition may influence the risk for cutaneous melanoma (CM); therefore, we aimed to assess the associations of food groups and individual nutrient intakes with CM in a Greek population. METHODS In this case-control study, 151 patients with histologically confirmed CM, newly diagnosed and treated in the Oncology Department of the "Laikon" University Hospital (Athens, Greece), and 151 age- and sex-matched healthy individuals residing in the Athens metropolitan area, recruited among participants for routine health examinations, were included. All participants completed a questionnaire comprising anthropometric measurements, sociodemographic, lifestyle, and health-related variables. A validated, semiquantitative food frequency questionnaire was used to assess average consumption of 136 food items during the 12 months preceding the onset of disease. Multivariate conditional regression models were used to derive odds ratios (ORs) with 95% confidence intervals (95% CI) regarding the association of nine food groups and seven macronutrients with CM. RESULTS Statistically significant positive associations with CM were found with higher energy intake (OR: 1.67, 95% CI: 1.22-2.30) and intake of saturated fatty acids (OR: 2.28, 95% CI: 1.00-5.28), after adjusting for sun sensitivity, major depression history, and alcohol intake. Inverse associations with higher intake of milk and dairy products (OR: 0.65, 95% CI: 0.48-0.88), fruits (OR: 0.68, 95% CI: 0.51-0.90), added lipids (OR: 0.65, 95% CI: 0.47-0.91), and sugars and syrups (OR: 0.70, 95% CI: 0.53-0.93) were also observed. CONCLUSIONS Beyond intrinsic risk factors, our results support associations of CM with multiple food groups and nutrients; if confirmed by prospective studies, these findings can add further knowledge about this fatal cancer.
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Affiliation(s)
| | - Antonios G. Antoniadis
- First Department of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, Zografou, Greece
| | - Nick Dessypris
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Zografou, Greece
| | - Konstantinos Karampinos
- Department of Medicine, School of Medicine, National and Kapodistrian University of Athens, Zografou, Greece
| | - Helen J. Gogas
- First Department of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, Zografou, Greece
| | - Eleni T. Petridou
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Zografou, Greece
- Hellenic Society for Social Pediatrics and Health Promotion, Athens, Greece
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Cai B, Lin Q, Ke R, Shan X, Yu J, Ni X, Lin X, Wang B. Causal association between serum 25-Hydroxyvitamin D levels and cutaneous melanoma: a two-sample Mendelian randomization study. Front Oncol 2023; 13:1154107. [PMID: 37664026 PMCID: PMC10470627 DOI: 10.3389/fonc.2023.1154107] [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: 01/30/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Background Despite numerous observational studies on the association between serum 25-Hydroxyvitamin D levels and cutaneous melanoma, causal inferences remain ambiguous due to confounding and reverse causality. This study aimed to elucidate the causal relationship between serum 25-Hydroxyvitamin D levels and melanoma incidence using Mendelian randomization (MR). Methods A two-sample MR was conducted using genetic variants associated with serum 25-Hydroxyvitamin D levels as instrumental variables. Summary statistics for these variants were derived from genome-wide association studies, and those for melanoma risk were obtained from a comprehensive melanoma case-control study. Robustness of the results was assessed through sensitivity analyses, including the "leave-one-out" approach and tests for potential pleiotropy. Results The MR analysis provided substantial evidence of a positive causal relationship between serum 25-Hydroxyvitamin D levels and the incidence of cutaneous melanoma, suggesting that each unit increase in serum 25-Hydroxyvitamin D levels corresponds with an increased risk of melanoma. Tests for pleiotropy showed minimal effects, and the sensitivity analysis confirmed no disproportionate influence by any individual single nucleotide polymorphism (SNP). Conclusion The findings indicated a potentially causal positive association between serum 25-Hydroxyvitamin D levels and melanoma risk, challenging traditional beliefs about vitamin D's role in melanoma. This emphasizes the need for a balanced and personalized approach to vitamin D supplementation and sun exposure, particularly in high-risk populations. These results should be interpreted with caution due to potential unrecognized pleiotropy and confounding factors. Future research should focus on validating these findings in diverse populations and exploring underlying biological mechanisms.
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Affiliation(s)
- Beichen Cai
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Oral Diseases, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Institute for Translational Medicine, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, Fujian, China
| | - Qian Lin
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Institute for Translational Medicine, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, Fujian, China
| | - Ruonan Ke
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xiuying Shan
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jiaqi Yu
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Institute for Translational Medicine, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, Fujian, China
| | - Xuejun Ni
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Xinjian Lin
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Key Laboratory of Gastrointestinal Cancer, Fujian Medical University, Ministry of Education, Fuzhou, Fujian, China
| | - Biao Wang
- Department of Plastic Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Oral Diseases, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, Fujian, China
- Department of Plastic Surgery, National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Fujian Key Laboratory of Translational Research in Cancer and Neurodegenerative Diseases, Institute for Translational Medicine, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, Fujian, China
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Roccuzzo G, Moirano G, Fava P, Maule M, Ribero S, Quaglino P. Obesity and immune-checkpoint inhibitors in advanced melanoma: A meta-analysis of survival outcomes from clinical studies. Semin Cancer Biol 2023; 91:27-34. [PMID: 36871633 DOI: 10.1016/j.semcancer.2023.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
Obesity is a chronic inflammatory condition that has been associated with different types of cancer. However, its role in melanoma incidence, progression, and response to immune-checkpoint-inhibitors (ICI) is still controversial. On the one hand, increased levels of lipids and adipokines can promote tumor proliferation and several genes associated with fatty acid metabolism have been found to be upregulated in melanomas. On the other hand, immunotherapy seems to be more effective in obese animal models, presumably due to an increase in CD8 + and subsequent decrease in PD-1 + T-cells in the tumor microenvironment. In humans, several studies have investigated the role of BMI (body mass index) and other adiposity-related parameters as potential prognostic markers of survival in advanced melanoma patients treated with ICI. The aim of this research has been to systematically review the scientific literature on studies evaluating the relationship between overweight/obesity and survival outcomes in patients with advanced melanoma treated with ICI and to perform a meta-analysis on those sharing common characteristics. After screening 1070 records identified through a literature search, 18 articles assessing the role of BMI-related exposure in relation to survival outcomes in ICI-treated patients with advanced melanoma were included in our review. In the meta-analysis of the association between overweight (defined as BMI>25 or BMI 25-30), overall survival (OS), and progression free survival (PFS), 7 studies were included, yielding a summary HR of 0.87 (95% CI: 0.74-1.03) and 0.96 (95% CI: 0.86-1.08), respectively. Our results show that, despite few suggestive findings, the use of BMI as a valuable predictor of melanoma patients' survival in terms of PFS and OS should not be currently recommended, due to the limited evidence available.
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Affiliation(s)
- Gabriele Roccuzzo
- Section of Dermatology, Department of Medical Sciences, University of Turin, Turin 10126, Torino, Italy.
| | - Giovenale Moirano
- Cancer Epidemiology Unit and CPO-Piemonte, Department of Medical Sciences, University of Torino, 10126 Torino, Italy; Postgraduate School in Biostatistics, Department of Public Health and Pediatrics, University of Turin, 10126 Torino, Italy
| | - Paolo Fava
- Section of Dermatology, Department of Medical Sciences, University of Turin, Turin 10126, Torino, Italy
| | - Milena Maule
- Cancer Epidemiology Unit and CPO-Piemonte, Department of Medical Sciences, University of Torino, 10126 Torino, Italy
| | - Simone Ribero
- Section of Dermatology, Department of Medical Sciences, University of Turin, Turin 10126, Torino, Italy
| | - Pietro Quaglino
- Section of Dermatology, Department of Medical Sciences, University of Turin, Turin 10126, Torino, Italy
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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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Wang K, Luo Q, Zhang Y, Xie X, Cheng W, Yao Q, Chen Y, Ren H, Li J, Pan Z. LINC01296 promotes proliferation of cutaneous malignant melanoma by regulating miR-324-3p/MAPK1 axis. Aging (Albany NY) 2022; 15:2877-2890. [PMID: 36462499 PMCID: PMC10188354 DOI: 10.18632/aging.204413] [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: 07/26/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To investigate the functions and potential molecular mechanism of LINC01296 regarding the progression of cutaneous malignant melanoma (CMM) by the regulation of miR-324-3p/MAPK1 axis. METHODS The candidate differential lncRNAs of CMM were selected from GEPIA database, and quantitative real-time PCR (qRT-PCR) was utilized to assess the expression level of LINC01296 in human CMM tissues and cell lines. Cell proliferation assay, Colony formation assay, Ethynyl-2'-deoxyuridine (EDU) assay in vitro and tumorigenicity assays in nude mice in vivo were performed to examine the functions of LINC01296. Bioinformatics analysis, luciferase reporter assay and rescue experiments were also gained an insight into the underlying mechanisms of LINC01296 in CMM cell lines by miR-324-3p/MAPK1 axis. RESULTS In this study, the up-regulation of LINC01296 was found in CMM tissues and cell lines. Functionally, the over-expression of LINC01296 promoted the proliferation in CMM cell lines. In addition, immunochemistry analysis confirmed that the levels of MAPK1 and Ki-67 in sh-LINC01296-xenografted tumors was weaker than that in sh-NC-xenografted tumors. Then, bioinformatics analysis confirmed that LINC01296 interacted with miR-324-3p. Further investigations showed that MAPK1, which collected from the potential related genes of LINC01296, was the conjugated mRNA of miR-324-3p by luciferase reporter assay. Finally, the rescue experiments suggested the positive regulatory association among LINC01296 and MAPK1, which showed that MAPK1 could reverse the promoting-effect of LINC01296 in CMM cells in vitro. CONCLUSIONS Therefore, our findings provided insight into the mechanisms of LINC01296 via miR-324-3p/MAPK1 axis in CMM, and revealed an alternative target for the diagnosis and treatment of CMM.
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Affiliation(s)
- Kang Wang
- Department of General Surgery, Gaoyou People’s Hospital, Yangzhou 225600, China
| | - Qing Luo
- Department of Dermatology, The First People’s Hospital of Lianyungang, Lianyungang Clinical Medical College of Nanjing Medical University, Lianyungang 222002, China
| | - Yingfeng Zhang
- Department of General Surgery, Gaoyou People’s Hospital, Yangzhou 225600, China
| | - Xin Xie
- Department of General Surgery, Gaoyou People’s Hospital, Yangzhou 225600, China
| | - Wenhao Cheng
- Department of Dermatology, The First People’s Hospital of Lianyungang, Lianyungang Clinical Medical College of Nanjing Medical University, Lianyungang 222002, China
| | - Qiunan Yao
- Department of Dermatology, The First People’s Hospital of Lianyungang, Lianyungang Clinical Medical College of Nanjing Medical University, Lianyungang 222002, China
| | - Yingying Chen
- Department of General Medicine, The First People’s Hospital of Lianyungang, Lianyungang Clinical Medical College of Nanjing Medical University, Lianyungang 222002, China
| | - Hong Ren
- Department of Dermatology, The First People’s Hospital of Lianyungang, Lianyungang Clinical Medical College of Nanjing Medical University, Lianyungang 222002, China
| | - Jiuping Li
- Department of General Surgery, Gaoyou People’s Hospital, Yangzhou 225600, China
| | - Zuanqin Pan
- Department of General Surgery, Gaoyou People’s Hospital, Yangzhou 225600, China
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Kumar P, Brazel D, DeRogatis J, Valerin JBG, Whiteson K, Chow WA, Tinoco R, Moyers JT. The cure from within? a review of the microbiome and diet in melanoma. Cancer Metastasis Rev 2022; 41:261-280. [PMID: 35474500 PMCID: PMC9042647 DOI: 10.1007/s10555-022-10029-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/28/2022] [Indexed: 12/17/2022]
Abstract
Therapy for cutaneous melanoma, the deadliest of the skin cancers, is inextricably linked to the immune system. Once thought impossible, cures for metastatic melanoma with immune checkpoint inhibitors have been developed within the last decade and now occur regularly in the clinic. Unfortunately, half of tumors do not respond to checkpoint inhibitors and efforts to further exploit the immune system are needed. Tantalizing associations with immune health and gut microbiome composition suggest we can improve the success rate of immunotherapy. The gut contains over half of the immune cells in our bodies and increasingly, evidence is linking the immune system within our gut to melanoma development and treatment. In this review, we discuss the importance the skin and gut microbiome may play in the development of melanoma. We examine the differences in the microbial populations which inhabit the gut of those who develop melanoma and subsequently respond to immunotherapeutics. We discuss the role of dietary intake on the development and treatment of melanoma. And finally, we review the landscape of published and registered clinical trials therapeutically targeting the microbiome in melanoma through dietary supplements, fecal microbiota transplant, and microbial supplementation.
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Affiliation(s)
- Priyanka Kumar
- Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Danielle Brazel
- Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Julia DeRogatis
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine, CA, USA
| | - Jennifer B Goldstein Valerin
- Division of Hematology and Oncology, Department of Medicine, University of California Irvine, 101 The City Drive South, Building 200, Orange, CA, 92868, USA
| | - Katrine Whiteson
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine, CA, USA
| | - Warren A Chow
- Division of Hematology and Oncology, Department of Medicine, University of California Irvine, 101 The City Drive South, Building 200, Orange, CA, 92868, USA
| | - Roberto Tinoco
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of California, Irvine, CA, USA
| | - Justin T Moyers
- Division of Hematology and Oncology, Department of Medicine, University of California Irvine, 101 The City Drive South, Building 200, Orange, CA, 92868, USA.
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Darlenski R, Mihaylova V, Handjieva-Darlenska T. The Link Between Obesity and the Skin. Front Nutr 2022; 9:855573. [PMID: 35369048 PMCID: PMC8965625 DOI: 10.3389/fnut.2022.855573] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Obesity as a multi-organ disease that affects the entire human organism. Notably, the skin is no exclusion from this postulate. Skin changes in obese patients have been widely studied with regards to mechanical friction, skin infections, and skin hypertrophic conditions, such as acanthosis nigricans and, most commonly, fibromas (skin tags). Almost 60–70% of obese patients present with a variety of skin changes. Herein, we discuss our own experience and review the complex skin changes in obesity. The role of metabolic syndrome and obesity are responsible for the epidemiological prevalence and are involved in the pathogenesis of chronic inflammatory skin diseases, such as psoriasis, atopic dermatitis, and skin malignancies. Here, we comment on the role of nutritional interventions in these patients as it has been proven that low-calorie diet and weight loss is related to improvement of inflammatory skin diseases. The readership of this paper will receive up-to-date overview on the connection between obesity and the skin that is of a practical importance to any clinician working in the field.
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Affiliation(s)
- Razvigor Darlenski
- Department of Dermatology and Venereology, Acibadem Cityclinic Tokuda Hospital, Sofia, Bulgaria
- Department of Dermatology and Venereology, Trakia University, Stara Zagora, Bulgaria
- *Correspondence: Razvigor Darlenski,
| | - Vesselina Mihaylova
- Department of Pharmacology and Toxicology, Medical Faculty, Medical University, Sofia, Bulgaria
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