nach oben

Erschienen in:

13.09.2017 | Original Research Paper

Ouabain attenuates ovalbumin-induced airway inflammation

verfasst von: José Guilherme F. M. Galvão, Luiz Henrique Agra Cavalcante-Silva, Deyse Cristina M. Carvalho, Laércia Karla D. P. Ferreira, Talissa Mozzini Monteiro, Adriano Francisco Alves, Larissa Adilis M. P. Ferreira, Francisco Allysson A. F. Gadelha, Marcia Regina Piuvezam, Sandra Rodrigues-Mascarenhas

Erschienen in: Inflammation Research | Ausgabe 12/2017

Einloggen, um Zugang zu erhalten

Abstract

Purpose

Ouabain, an Na⁺/K⁺-ATPase inhibitor hormone, presents immunomodulatory actions, including anti-inflammatory effect on acute inflammation models.

Methods

In the present study, the effect of ouabain in a model of allergic airway inflammation induced by ovalbumin (OVA) was assessed.

Results

Initially, it was observed that ouabain treatment inhibited cellular migration induced by OVA on bronchoalveolar lavage fluid (BALF), mostly granulocytes, without modulating macrophage migration. In addition, it was observed, by flow cytometry, that ouabain reduces CD3^high lymphocytes cells on BALF. Furthermore, treatment with ouabain decreased IL-4 and IL-13 levels on BALF. Ouabain also promoted pulmonary histological alterations, including decreased cell migration into peribronchiolar and perivascular areas, and reduced mucus production in bronchioles regions observed through hematoxylin–eosin (HE) and by periodic acid-Schiff stain, respectively. Allergic airway inflammation is characterized by high OVA-specific IgE serum titer. This parameter was also reduced by the treatment with ouabain.

Conclusions

Therefore, our data demonstrate that ouabain negatively modulates allergic airway inflammation induced by OVA.

Schoner W. Endogenous cardiac glycosides, a new class of steroid hormones. Eur J Biochem. 2002;269:2440–8. doi:10.1046/j.1432-1033.2002.02911.x.CrossRefPubMed

Erdmann E, Schoner W. Ouabain-receptor interactions in (Na⁺K⁺)-ATPase preparations from different tissues and species determination of kinetic constants and dissociation constants. BBA Biomembr. 1973;307:386–98. doi:10.1007/BF00501108.CrossRef

Bagrov AY, Roukoyatkina NI, Pinaev AG, Dmitrieva RI, Fedorova OV. Effects of two endogenous Na⁺, K⁺-ATPase inhibitors, marinobufagenin and ouabain, on isolated rat aorta. Eur J Pharmacol. 1995;274:151–8. doi:10.1016/0014-2999(94)00735-P.CrossRefPubMed

Hamlyn JM, Blaustein MP, Bova S, DuCharme DW, Harris DW, Mandel F, et al. Identification and characterization of a ouabain-like compound from human plasma. Proc Natl Acad Sci USA. 1991;88:6259–63. doi:10.1073/pnas.88.21.9907-d.CrossRefPubMedPubMedCentral

Ferrandi M, Manunta P, Balzan S, Hamlyn JM, Bianchi G, Ferrari P. Ouabain-like factor quantification in mammalian tissues and plasma: comparison of two independent assays. Hypertension. 1997;30:886–96. doi:10.1161/01.HYP.30.4.886.CrossRefPubMed

Schoner W, Bauer N, Müller-Ehmsen J, Krämer U, Hambarchian N, Schwinger R, et al. Ouabain as a mammalian hormone. Ann N Y Acad Sci. 2003;986:678–84. doi:10.1111/j.1749-6632.2003.tb07282.x.CrossRefPubMed

Bagrov AY, Shapiro JI. Endogenous digitalis: pathophysiologic roles and therapeutic applications. Nat Clin Pract Nephrol. 2008;4:378–92. doi:10.1038/ncpneph0848.CrossRefPubMedPubMedCentral

Tymiak AA, Norman JA, Bolgar M, DiDonato GC, Lee H, Parker WL, et al. Physicochemical characterization of a ouabain isomer isolated from bovine hypothalamus. Proc Natl Acad Sci USA. 1993;90:8189–93.CrossRefPubMedPubMedCentral

Kawamura A, Guo J, Itagaki Y, Bell C, Wang Y, Haupert GT, et al. On the structure of endogenous ouabain. Proc Natl Acad Sci USA. 1999;96:6654–9. doi:10.1073/pnas.96.12.6654.CrossRefPubMedPubMedCentral

10.

Schoner W. Ouabain, a new steroid hormone of adrenal gland and hypothalamus. Exp Clin Endocrinol Diabetes. 2000;108:449–54. doi:10.1055/s-2000-8140.CrossRefPubMed

11.

Goto A, Yamada K, Nagoshi H, Terano Y, Omata M. Stress-induced elevation of ouabain like compound in rat plasma and adrenal. Hypertension. 1995;26:1173–6. doi:10.1161/01.HYP.26.6.1173.CrossRefPubMed

12.

Bauer N, Müller-Ehmsen J, Krämer U, Hambarchian N, Zobel C, Schwinger RH, et al. Ouabain-like compound changes rapidly on physical exercise in humans and dogs: effects of β-blockade and angiotensin-converting enzyme inhibition. Hypertension. 2005;45:1024–8. doi:10.1161/01.HYP.0000165024.47728.f7.CrossRefPubMed

13.

Quastel MR, Kaplan JG. Inhibition by ouabain of human lymphocyte transformation induced by phytohaemagglutinin in vitro. Nature. 1968;219:198–200. doi:10.1038/219198a0.CrossRefPubMed

14.

Olej B, de La Rocque L, Castilho FP, Mediano IF, Campos MM, Rumjanek VM. Effect of ouabain on lymphokine-activated killer cells. Int J Immunopharmacol. 1994;16:769–74. doi:10.1016/0192-0561(94)90097-3.CrossRefPubMed

15.

Olej B, dos Santos NF, Leal L, Rumjanek VM. Ouabain induces apoptosis on PHA-activated lymphocytes. Biosci Rep. 1998;18:1–7. doi:10.1023/A:1022259832207.CrossRefPubMed

16.

Szamel M, Schneider S, Resch K. Functional interrelationship between Na⁺/K⁺-ATPase and lysolecithin acyltransferase in plasma membranes of mitogen-stimulated rabbit thymocytes. J Biol Chem. 1981;256:9198–204.PubMed

17.

Rodrigues-Mascarenhas S, Bloise FF, Moscat J, Rumjanek VM. Ouabain inhibits p38 activation in thymocytes. Cell Biol Int. 2008;32:1323–8. doi:10.1016/j.cellbi.2008.07.012.CrossRefPubMed

18.

Valente RC, Nascimento CR, Araujo EG, Rumjanek VM. mCD14 expression in human monocytes is downregulated by ouabain via transactivation of epithelial growth factor receptor and activation of p38 mitogen-activated protein kinase. Neuroimmunomodulation. 2009;16:228–36. doi:10.1159/000212383.CrossRefPubMed

19.

Teixeira MP, Rumjanek VM. Ouabain affects the expression of activation markers, cytokine production, and endocytosis of human monocytes. Mediat Inflamm. 2014. doi:10.1155/2014/760368.

20.

Nascimento CR, Valente RC, Echevarria-Lima J, Fontes CF, de Araujo-Martins L, Araujo EG, et al. The influence of ouabain on human dendritic cells maturation. Mediat Inflamm. 2014. doi:10.1155/2014/494956.

21.

Rodrigues-Mascarenhas S, Echevarria-Lima J, Fernandes dos Santos N, Rumjanek VM. CD69 expression induced by thapsigargin, phorbol ester and ouabain on thymocytes is dependent on external Ca²⁺ entry. Life Sci. 2003;73:1037–51. doi:10.1016/S0024-3205(03)00377-1.CrossRefPubMed

22.

Rodrigues-Mascarenhas S, dos Santos NF, Rumjanek VM. Synergistic effect between ouabain and glucocorticoids for the induction of thymic atrophy. Biosci Rep. 2006;26:159–69. doi:10.1007/s10540-006-9012-1.CrossRefPubMed

23.

Da Silva JMC, das Neves Azevedo A, dos Santos Barbosa RP, Vianna TA, Fittipaldi J, Teixeira MP, et al. Dynamics of murine B lymphocytes is modulated by in vivo treatment with steroid ouabain. Immunobiology. 2016;221:368–76. doi:10.1016/j.imbio.2015.09.020.CrossRefPubMed

24.

De Vasconcelos DI, Leite JA, Carneiro LT, Piuvezam MR, de Lima MR, de Morais LC, et al. Anti-inflammatory and antinociceptive activity of ouabain in mice. Mediat Inflamm. 2011. doi:10.1155/2011/912925.

25.

Leite JA, Alves AK, Galvão JGFM, Teixeira MP, Cavalcante-Silva LHA, Scavone C, et al. Ouabain modulates zymosan-induced peritonitis in mice. Mediat Inflamm. 2015. doi:10.1155/2015/265798.

26.

Medzhitov R. Origin and physiological roles of inflammation. Nature. 2008;454:428–35. doi:10.1038/nature07201.CrossRefPubMed

27.

Lambrecht BN, Hammad H. The immunology of asthma. Nat Immunol. 2015;16:45–56. doi:10.1038/ni.3049.CrossRefPubMed

28.

De Monchy JGR, Kauffman HF, Venge P, Koëter GH, Jansen HM, Sluiter HJ, et al. Bronchoalveolar eosinophilia during allergen-induced late asthmatic reactions. Am Rev Respir Dis. 1985;131:373–6. doi:10.1164/arrd.1985.131.3.373.PubMed

29.

Woodruff PG, Modrek B, Choy DF, Jia G, Abbas AR, Ellwanger A, et al. T-helper type 2-driven inflammation defines major subphenotypes of asthma. Am J Respir Crit Care Med. 2009;180:388–95. doi:10.1164/rccm.200903-0392OC.CrossRefPubMedPubMedCentral

30.

Robinson DS, Hamid Q, Ying S, Tsicopoulos A, Barkans J, Bentley AM, et al. Predominant Th2-like bronchoalveolar T lymphocyte population in atopic asthma. N Engl J Med. 1992;326:298–304. doi:10.1056/NEJM199201303260504.CrossRefPubMed

31.

Woodruff PG, Boushey HA, Dolganov GM, Barker CS, Yang YH, Donnelly S, et al. Genome-wide profiling identifies epithelial cell genes associated with asthma and with treatment response to corticosteroids. Proc Natl Acad Sci USA. 2007;104:15858–63. doi:10.1073/pnas.0707413104.CrossRefPubMedPubMedCentral

32.

Cheng D, Xue Z, Yi L, Shi H, Zhang K, Huo X, et al. Epithelial interleukin-25 is a key mediator in Th2-high, corticosteroid-responsive asthma. Am J Respir Crit Care Med. 2014;190:639–48. doi:10.1164/rccm.201403-0505OC.CrossRefPubMedPubMedCentral

33.

Urwin DL, Schwenger GT, Groth DM, Sanderson CJ. Distal regulatory elements play an important role in regulation of the human IL-5 gene. Eur J Immunol. 2004;34:3633–43. doi:10.1002/eji.200425279.CrossRefPubMed

34.

Agrawal KP, Reed CE, Hyatt RE, Imber WE, Krell WS. Airway responses to inhaled ouabain in subjects with and without asthma. Mayo Clin Proc. 1986;61:778–84. doi:10.1016/S0025-6196(12)64816-2.CrossRefPubMed

35.

Senol M, Ozerol IH, Patel AV, Skoner DP. The effect of Na⁺–K⁺ ATPase inhibition by ouabain on histamine release from human cutaneous mast cells. Mol Cell Biochem. 2007;294:25–9. doi:10.1007/s11010-006-9180-0.CrossRefPubMed

36.

Lago J, Alfonso A, Vieytes MR, Botana LM. Ouabain-induced enhancement of rat mast cells response. Modulation by protein phosphorylation and intracellular pH. Cell Signal. 2001;13:515–24. doi:10.1016/S0898-6568(01)00169-3.CrossRefPubMed

37.

Vieira GC, De Lima JF, De Figueiredo RC, Mascarenhas SR, Bezerra-Santos CR, Piuvezam MR. Inhaled Cissampelos sympodialis down-regulates airway allergic reaction by reducing lung CD3⁺ T cells. Phytother Res. 2012;27:916–25. doi:10.1002/ptr.4791.CrossRefPubMed

38.

Holt PG, Rose AH, Batty JE, Turner KJ. Introduction of adjuvant-independent IgE responses in inbred mice: primary, secondary and persistent IgE responses to ovalbumin and ovomucoid. Int Arch Allergy Appl Immunol. 1981;65:42–50. doi:10.1159/000232736.CrossRefPubMed

39.

Jacob PL, Leite JA, Alves AK, Rodrigues YK, Amorim FM, Néris PL, et al. Immunomodulatory activity of ouabain in Leishmania leishmania amazonensis infected Swiss mice. Parasitol Res. 2013;112:1313–21. doi:10.1007/s00436-012-3146-9.CrossRefPubMed

40.

Venkayya R, Lam M, Willkom M, Grünig G, Corry DB, Erle DJ. The Th2 lymphocyte products IL-4 and IL-13 rapidly induce airway hyperresponsiveness through direct effects on resident airway cells. Am J Respir Cell Mol Biol. 2002;26:202–8. doi:10.1165/ajrcmb.26.2.4600.CrossRefPubMed

41.

Deo SS, Mistry KJ, Kakade AM, Niphadkar PV. Role played by Th2 type cytokines in IgE mediated allergy and asthma. Lung India. 2010;27:66–71. doi:10.4103/0970-2113.63609.CrossRefPubMedPubMedCentral

42.

Cowden JM, Riley JP, Ma JY, Thurmond RL, Dunford PJ. Histamine H4 receptor antagonism diminishes existing airway inflammation and dysfunction via modulation of Th2 cytokines. Respir Res. 2010;11:1–12. doi:10.1186/1465-9921-11-86.CrossRef

43.

Van Rijt LS, Vos N, Hijdra D, de Vries VC, Hoogsteden HC, Lambrecht BN. Airway eosinophils accumulate in the mediastinal lymph nodes but lack antigen-presenting potential for naive T cells. J Immunol. 2003;171:3372–8. doi:10.4049/jimmunol.171.7.3372.CrossRefPubMed

44.

Yousefi S, Simon D, Simon HU. Eosinophil extracellular DNA traps: molecular mechanisms and potential roles in disease. Curr Opin Immunol. 2012;24:736–9. doi:10.1016/j.coi.2012.08.010.CrossRefPubMed

45.

Ninsontia C, Chanvorachote P. Ouabain mediates integrin switch in human lung cancer cells. Anticancer Res. 2014;34:5495–502.PubMed

46.

Takada Y, Matsuo K, Ogura H, Bai L, Toki A, Wang L, et al. Odoroside A and ouabain inhibit Na⁺/K⁺-ATPase and prevent NF-kappaB-inducible protein expression by blocking Na⁺-dependent amino acid transport. Biochem Pharmacol. 2009;78:1157–66. doi:10.1016/j.bcp.2009.06.027.CrossRefPubMed

47.

Pongrakhananon V, Chunhacha P, Chanvorachote P. Ouabain suppresses the migratory behavior of lung cancer cells. PLoS One. 2013;8:e68623. doi:10.1371/journal.pone.0068623.CrossRefPubMedPubMedCentral

48.

Shin HK, Ryu BJ, Choi SW, Kim SH, Lee K. Inactivation of Src-to-ezrin pathway: a possible mechanism in the ouabain-mediated inhibition of A549 cell migration. Biomed Res Int. 2015;2015:537136. doi:10.1155/2015/537136.PubMedPubMedCentral

49.

Gonçalves-de-Albuquerque CF, Burth P, Silva AR, de Moraes IM, Oliveira FM, Santelli RE, et al. Murine lung injury caused by Leptospira interrogans glycolipoprotein, a specific Na/K-ATPase inhibitor. Respir Res. 2014;15:1–12. doi:10.1186/s12931-014-0093-2.CrossRef

50.

Azzawi M, Johnston PW, Majumdar S, Kay AB, Jeffery PK. T lymphocytes and activated eosinophils in airway mucosa in fatal asthma and cystic fibrosis. Am Rev Respir Dis. 1992;145:1477–82.CrossRefPubMed

51.

Bystrom J, Amin K, Bishop-Bailey D. Analysing the eosinophil cationic protein—a clue to the function of the eosinophil granulocyte. Respir Res. 2011;12:1465–9921.CrossRef

52.

Amin K. The role of mast cells in allergic inflammation. Respir Med. 2012;106:9–14.CrossRefPubMed

53.

Carlson M, Peterson C, Venge P. The influence of IL-3, IL-5, and GM-CSF on normal human eosinophil and neutrophil C3b induced degranulation. Allergy. 1993;48:437–42.PubMed

54.

Wilson JW, Djukanović R, Howarth PH, Holgate ST. Lymphocyte Activation in bronchoalveolar lavage and peripheral blood in atopic asthma. Am Rev Respir Dis. 1992;4:958–60. doi:10.1164/ajrccm/145.4_Pt_1.958.CrossRef

55.

Slager RE, Li H, Moore W, Hawkins G, Peters SP, Busse WW, et al. Predictive model of severe atopic asthma phenotypes using interleukin-4/13 pathway polymorphisms. Am J Respir Crit Care Med. 2011;183:1332. doi:10.1164/ajrccm-conference.2011.183.1_MeetingAbstracts.A1332.

56.

Mattila PS, Ullman KS, Fiering S, et al. The action of cyclosporin A and FK506 suggest a novel step in the activation of T lymphocytes. EMBO J. 1990;9:4425–33.PubMedPubMedCentral

57.

Rao A, Luo C, Hogan PG. Transcription factors of the NFAT family: regulation and function. Annu Rev Immunol. 1997;15:707–47.CrossRefPubMed

58.

Diehl S, Krahl T, Rinaldi L, Norton R, Irvin GC, Rincón M. Inhibition of NFAT specifically in T cells prevents allergic pulmonary inflammation. J Immunol. 2004;172:3597–603. doi:10.4049/jimmunol.172.6.3597.CrossRefPubMed

59.

Brusselle GG, Kips JC, Tavernier JH, van der Heyden JG, Cuvelier CA, Pauwels RA, et al. Attenuation of allergic airway inflammation in IL-4 deficient mice. Clin Exp Allergy. 1994;24:73–80. doi:10.1111/j.1365-2222.1994.tb00920.x.CrossRefPubMed

60.

Corry DB, Folkesson HG, Warnock ML, Erle DJ, Matthay MA, Wiener-Kronish JP, et al. Interleukin 4, but not interleukin 5 or eosinophils, is required in a murine model of acute airway hyperreactivity. J Exp Med. 1996;183:109–17. doi:10.1084/jem.183.1.109.CrossRefPubMed

61.

Wills-Karp M, Luyimbazi J, Xu X, Schofield B, Neben TY, Karp CL, et al. Interleukin-13: central mediator of allergic asthma. Science. 1998;282:2258–61. doi:10.1007/s11882-004-0057-6.CrossRefPubMed

62.

Rosenstein RK, Bezbradica JS, Yu S, Medzhitov R. Signaling pathways activated by a protease allergen in basophils. Proc Natl Acad Sci USA. 2014;111:E4963–71. doi:10.1073/pnas.1418959111.CrossRefPubMedPubMedCentral

63.

Liew FY. T(H)1 and T(H)2 cells: a historical perspective. Nat Rev Immunol. 2002;2:55–60. doi:10.1038/nri705.CrossRefPubMed

64.

Huang TJ, MacAry P, Eynott P, et al. Allergen-specific Th1 cells counteract effecrent Th2 cell-dependent bronchial hyperresponsiveness and eosinophilic inflammation, partly via IFN-g. J Immunol. 2001;166:207–17.CrossRefPubMed

65.

Cohn L, Homer RJ, Niu N, Bottomly K. T helper 1 cells and interferon gamma regulate allergic airway inflammation and mucus production. J Exp Med. 1999;190:1309–18.CrossRefPubMedPubMedCentral

66.

Boumpas DT, Chrousos GP, Wilder RL, Cupps TR, Balow JE. Glucocorticoid therapy for immune-mediated diseases: basic and clinical correlates. Ann Intern Med. 1993;119:1198.CrossRefPubMed

67.

Cain DW, Cidlowski JA. Immune regulation by glucocorticoids. Nat Rev Immunol. 2017;17:233–47. doi:10.1038/nri.2017.1.CrossRefPubMed

68.

De Bosscher K, Haegeman G. Minireview: latest perspectives on anti-inflammatory actions of glucocorticoids. Mol Endocrinol. 2008;23:281–91.CrossRefPubMed

69.

Wang D, Müller N, McPherson KG, Reichardt HM. Glucocorticoids engage different signal transduction pathways to induce apoptosis in thymocytes and mature T cells. J. Immunol. 2006;176:1695–702.CrossRefPubMed

70.

Franchimont D, Galon J, Gadina M, Visconti R, Zhou Y, Aringer M, et al. Inhibition of Th1 immune response by glucocorticoids: dexamethasone selectively inhibits IL-12-induced Stat4 phosphorylation in T lymphocytes. J. Immunol. 2000;164:1768–74.CrossRefPubMed

71.

Barnes PJ. Th2 cytokines and asthma: an introduction. Respir Res. 2001;2:64–5.CrossRefPubMedPubMedCentral

72.

Paiva LS, Costa KM, Canto FB, Cabral VR, Fucs R, Nobrega A, et al. Modulation of mature B cells in mice following treatment with ouabain. Immunobiology. 2011;216:1038–43. doi:10.1016/j.imbio.2011.03.002.CrossRefPubMed

73.

Geha RS, Jabara HH, Brodeur SR. The regulation of immunoglobulin E class-switch recombination. Nat Rev Immunol. 2003;3:721–32. doi:10.1038/nri1181.CrossRefPubMed

Titel: Ouabain attenuates ovalbumin-induced airway inflammation
verfasst von: José Guilherme F. M. Galvão
Luiz Henrique Agra Cavalcante-Silva
Deyse Cristina M. Carvalho
Laércia Karla D. P. Ferreira
Talissa Mozzini Monteiro
Adriano Francisco Alves
Larissa Adilis M. P. Ferreira
Francisco Allysson A. F. Gadelha
Marcia Regina Piuvezam
Sandra Rodrigues-Mascarenhas
Publikationsdatum: 13.09.2017
Verlag: Springer International Publishing
Erschienen in: Inflammation Research / Ausgabe 12/2017
Print ISSN: 1023-3830
Elektronische ISSN: 1420-908X
DOI: https://doi.org/10.1007/s00011-017-1092-9

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

^{Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag}

Kostenlos registrieren

Neu im Fachgebiet Innere Medizin

16.04.2024 | Infektiologie | Nachrichten

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Springer Medizin

Ouabain attenuates ovalbumin-induced airway inflammation

Abstract

Purpose

Methods

Results

Conclusions

Leitlinien kompakt für die Innere Medizin

Neu im Fachgebiet Innere Medizin

Kein Abstrich bei chronischen Wunden ohne Entzündungszeichen!

Manche Gestagene können das Risiko für Meningeome erhöhen

Stillende Frauen haben geringeres kardiovaskuläres Risiko

Selbstexpandierende TAVI-Klappen bei kleinem Aortenanulus im Vorteil

Update Innere Medizin

Springer Medizin

Abstract

Purpose

Methods

Results

Conclusions

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 12/2017

Epigenetic involvement in etiopathogenesis and implications in treatment of systemic lupus erythematous

Regulation of sterile α- and armadillo motif (SARM) containing protein expression in Pam2CSK4- and Pam3CSK4-activated mouse macrophage cell line (RAW264.7) requires TLR9

Striking the right immunological balance prevents progression of tuberculosis

Association of SNPs/haplotypes in promoter of TNF A and IL-10 gene together with life style factors in prostate cancer progression in Indian population

Malvidin attenuates pain and inflammation in rats with osteoarthritis by suppressing NF-κB signaling pathway

SERPING1 mRNA overexpression in monocytes from HIV+ patients

Leitlinien kompakt für die Innere Medizin

Neu im Fachgebiet Innere Medizin

Kein Abstrich bei chronischen Wunden ohne Entzündungszeichen!

Manche Gestagene können das Risiko für Meningeome erhöhen

Stillende Frauen haben geringeres kardiovaskuläres Risiko

Selbstexpandierende TAVI-Klappen bei kleinem Aortenanulus im Vorteil

Update Innere Medizin