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Mohamed MZ, Morsy MA, Mohamed HH, Hafez HM. Paeonol protects against testicular ischaemia-reperfusion injury in rats through inhibition of oxidative stress and inflammation. Andrologia 2020; 52:e13599. [PMID: 32314822 DOI: 10.1111/and.13599] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/05/2020] [Accepted: 03/23/2020] [Indexed: 12/11/2022] Open
Abstract
Ischaemia-reperfusion (IR) is the most common form of testicular injury that results in oxidative damage and inflammation ending by subinfertility. Paeonol, a natural phenolic compound, exhibits antioxidant and anti-inflammatory effects. Thus, the present study investigated the role of paeonol in rat testicular IR injury. Thirty adult Wistar rats were randomly divided into five groups; sham, sham treated with paeonol, IR injury, and IR pre-treated with paeonol at low and high doses. Serum testosterone and testicular levels of malondialdehyde and reduced glutathione (GSH) besides superoxide dismutase (SOD) activity were determined. Gene quantifications for tumour necrosis factor-α (TNF-α), hypoxia-inducible factor-1α (HIF-1α) and heat shock protein 70 (HSP70) were also assessed. Histopathological pictures and the immunohistochemical expression of testicular nuclear factor erythroid 2-related factor 2 (Nrf2), interleukin-1β (IL-1β) and interleukin-6 (IL-6) were shown. Pre-treatment with paeonol prevented the drop in serum testosterone, alongside with improvement of testicular malondialdehyde and GSH levels plus SOD activity. Paeonol regained the normal spermatogenesis with prevention of IR-induced increase in TNF-α, HIF-1α and HSP70 gene expression besides IL-1β and IL-6 immunostaining and reduction in Nrf2 protein expression. Paeonol exerted a dose-dependent beneficial effect on testicular IR injury. This effect was achieved by its antioxidant and anti-inflammatory effects.
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Affiliation(s)
- Mervat Z Mohamed
- Department of Pharmacology, Faculty of Medicine, Minia University, El-Minia, Egypt
| | - Mohamed A Morsy
- Department of Pharmacology, Faculty of Medicine, Minia University, El-Minia, Egypt.,Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Hanaa H Mohamed
- Department of Histology, Faculty of Medicine, Minia University, El-Minia, Egypt
| | - Heba M Hafez
- Department of Pharmacology, Faculty of Medicine, Minia University, El-Minia, Egypt
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Baumeister J, Chatain N, Hubrich A, Maié T, Costa IG, Denecke B, Han L, Küstermann C, Sontag S, Seré K, Strathmann K, Zenke M, Schuppert A, Brümmendorf TH, Kranc KR, Koschmieder S, Gezer D. Hypoxia-inducible factor 1 (HIF-1) is a new therapeutic target in JAK2V617F-positive myeloproliferative neoplasms. Leukemia 2020; 34:1062-1074. [PMID: 31728053 DOI: 10.1038/s41375-019-0629-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/17/2019] [Accepted: 11/03/2019] [Indexed: 12/18/2022]
Abstract
Classical Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) are a heterogeneous group of hematopoietic malignancies including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The JAK2V617F mutation plays a central role in these disorders and can be found in 90% of PV and ~50-60% of ET and PMF. Hypoxia-inducible factor 1 (HIF-1) is a master transcriptional regulator of the response to decreased oxygen levels. We demonstrate the impact of pharmacological inhibition and shRNA-mediated knockdown (KD) of HIF-1α in JAK2V617F-positive cells. Inhibition of HIF-1 binding to hypoxia response elements (HREs) with echinomycin, verified by ChIP, impaired growth and survival by inducing apoptosis and cell cycle arrest in Jak2V617F-positive 32D cells, but not Jak2WT controls. Echinomycin selectively abrogated clonogenic growth of JAK2V617F cells and decreased growth, survival, and colony formation of bone marrow and peripheral blood mononuclear cells and iPS cell-derived progenitor cells from JAK2V617F-positive patients, while cells from healthy donors were unaffected. We identified HIF-1 target genes involved in the Warburg effect as a possible underlying mechanism, with increased expression of Pdk1, Glut1, and others. That was underlined by transcriptome analysis of primary patient samples. Collectively, our data show that HIF-1 is a new potential therapeutic target in JAK2V617F-positive MPN.
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Affiliation(s)
- Julian Baumeister
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Nicolas Chatain
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Annika Hubrich
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tiago Maié
- Joint Research Center for Computational Biomedicine, RWTH Aachen University, Aachen, Germany
| | - Ivan G Costa
- Joint Research Center for Computational Biomedicine, RWTH Aachen University, Aachen, Germany
| | - Bernd Denecke
- Interdisciplinary Center for Clinical Research Aachen, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Lijuan Han
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Caroline Küstermann
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Institute of Biomedical Engineering, Department of Cell Biology, RWTH Aachen University Medical School, Aachen, Germany; Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | - Stephanie Sontag
- Institute of Biomedical Engineering, Department of Cell Biology, RWTH Aachen University Medical School, Aachen, Germany; Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | - Kristin Seré
- Institute of Biomedical Engineering, Department of Cell Biology, RWTH Aachen University Medical School, Aachen, Germany; Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | - Klaus Strathmann
- Institute for Transfusion Medicine, RWTH Aachen University Medical School, Aachen, Germany
| | - Martin Zenke
- Institute of Biomedical Engineering, Department of Cell Biology, RWTH Aachen University Medical School, Aachen, Germany; Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | - Andreas Schuppert
- Joint Research Center for Computational Biomedicine, RWTH Aachen University, Aachen, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Kamil R Kranc
- Laboratory of Haematopoietic Stem Cell & Leukaemia Biology, Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London, UK
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Deniz Gezer
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.
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Bhuria V, Xing J, Scholta T, Bui KC, Nguyen MLT, Malek NP, Bozko P, Plentz RR. Hypoxia induced Sonic Hedgehog signaling regulates cancer stemness, epithelial-to-mesenchymal transition and invasion in cholangiocarcinoma. Exp Cell Res 2019; 385:111671. [PMID: 31634481 DOI: 10.1016/j.yexcr.2019.111671] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/04/2019] [Accepted: 10/05/2019] [Indexed: 12/17/2022]
Abstract
Aberrant activation of Sonic Hedgehog (SHH) pathway has been implicated in a variety of cancers including cholangiocarcinoma (CC); however, the influencing factors are still unknown. Additionally, intratumoral hypoxia is known to contribute towards therapeutic resistance through modulatory effects on various pathways. In this study, we investigated the relationship between hypoxia and SHH pathway activation and the effect of this interplay on cancer stemness and epithelial-to- mesenchymal transition (EMT) during cholangiocarcinogenesis. Hypoxia promoted SHH pathway activation, evidenced by upregulated SHH and SMO levels, and enhanced glioma-associated oncogene homolog 1 (GLI1) nuclear translocation; whereas silencing of HIF-1α impaired SHH upregulation. Hypoxia also enhanced the expression of cancer stem cell (CSC) transcription factors (NANOG, Oct4, SOX2), CD133 and EMT markers (N-cadherin, Vimentin), thereby supporting invasion. Cyclopamine treatment suppressed hypoxia induced SHH pathway activation, consequently reducing invasiveness by downregulating the expression of CSC transcription factors, CD133 and EMT. Cyclopamine induced apoptosis in CC cells under hypoxia, suggesting that hypoxia induced activation of SHH pathway has modulatory effects on CC progression. Therefore, SHH signaling is proposed as a target for CC treatment, which is refractory to standard chemotherapy.
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Affiliation(s)
- Vikas Bhuria
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany
| | - Jun Xing
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany
| | - Tim Scholta
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany
| | - Khac Cuong Bui
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany
| | - Mai Ly Thi Nguyen
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany
| | - Nisar P Malek
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany
| | - Przemyslaw Bozko
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany.
| | - Ruben R Plentz
- Department of Internal Medicine I, Medical University Hospital, Tübingen, Germany; Department of Internal Medicine II, Bremen-Nord Hospital, Bremen, Germany.
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Mansour M, Degheili J, Khalifeh I, Tamim H, Jaafar RF, El-Hout Y. Remote ischemic conditioning in a rat model of testicular torsion: does it offer testicular protection? J Pediatr Urol 2019; 15:43.e1-43.e7. [PMID: 30502312 DOI: 10.1016/j.jpurol.2018.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 09/14/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Testicular torsion is a surgical emergency mainly affecting adolescent boys, with a relatively high rate of missed torsion and testicular loss secondary to delay in prompt diagnosis and surgical intervention. With ischemic reperfusion injury as its underlying culprit, testicular torsion may respond favorably to remote ischemic conditioning (RIC) where a non-privileged site (e.g. limb) is concurrently rendered ischemic to divert the cascade of reperfusion injury from the privileged organ (e.g. testicle), thus offering a protective effect in improving salvage. This mechanism is established for other organs, whereas it has not been evaluated for testis. AIM It was aimed to evaluate RIC in a rat model of testicular torsion as a proof of principle that, similar to what has been demonstrated in other organs, RIC does offer testicular protection. STUDY DESIGN This is an animal experimental study. Thirty Sprague-Dawley male rats were divided into control group (n = 15) and experimental group (n = 15). Non-survival surgeries of right-sided spermatic cord torsion (720° counter-clockwise twist) were performed for both the groups (45 min) followed by detorsion and reperfusion (5 min) and then orchiectomy. For the experiment group, an intervention of tail clamping to create RIC was applied 5 min after torsion, then unclamping 5 min before detorsion, followed by detorsion and reperfusion for 5 min and then orchiectomy. The testicles were histologically and immunologically examined using a hypoxia inducible factor (HIF-1α) ELISA Kit. The histological findings on ischemic changes, vascular congestion, and immunohistochemistry were quantified using previously described, validated grading systems. RESULTS DISCUSSION: This is the first study to demonstrate the concept of RIC in an animal model of testicular torsion. It is limited by the non-availability of similar studies to compare outcomes and by the caution of extrapolating animal studies on humans. It does lay grounds, however, to subsequent studies to further elaborate on this concept and its clinical applicability. CONCLUSION When RIC is applied in the experimental setting of testicular torsion, there is less evidence of hypoxic injury by histology and immunohistochemistry.
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Affiliation(s)
- M Mansour
- Division of Urology, Beirut, Lebanon
| | | | - I Khalifeh
- Department of Pathology and Laboratory Medicine, Beirut, Lebanon
| | - H Tamim
- Department of Medicine, Beirut, Lebanon
| | - R F Jaafar
- Department of Surgery at the American University of Beirut-Medical Center, Beirut, Lebanon
| | - Y El-Hout
- Division of Urology, Beirut, Lebanon.
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Li L, Hao Y, Zhao Y, Wang H, Zhao X, Jiang Y, Gao F. Ferroptosis is associated with oxygen-glucose deprivation/reoxygenation-induced Sertoli cell death. Int J Mol Med 2018; 41:3051-3062. [PMID: 29436589 DOI: 10.3892/ijmm.2018.3469] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 02/02/2018] [Indexed: 11/06/2022] Open
Abstract
Sertoli cell death contributes to spermatogenesis impairment, which is associated with male infertility. Testicular ischemia‑reperfusion (I/R) injury induces the cell death of germ cells and Sertoli cells, whereas inhibition of cell death ameliorates acute testicular I/R damage. The aim of the present study was to investigate the mechanism of I/R stress-induced cell death in TM4 cells. Oxygen‑glucose deprivation and reoxygenation (OGD/R) was demonstrated to induce I/R injury and cell death in TM4 cells. Cell death was blocked by the reactive oxygen species (ROS) inhibitor N‑acetylcysteine, as well as lipid peroxidation inhibitors Liproxstatin‑1 and iron chelator deferoxamine; however, inhibitors of apoptosis, necrosis or autophagy had no effect. It was also demonstrated that iron and lipid ROS levels were elevated in I/R injury and that mitochondria decreased in size and increased in membrane density, which is indicative of ferroptosis. Furthermore, the generation of lipid ROS suggests iron accumulation and glutathione (GSH) depletion. The expression of ferroportin (Fpn) protein and mRNA was decreased in TM4 cells. Notably, overexpression of Fpn inhibited ferroptosis, lipid ROS generation and iron accumulation. In addition, GSH‑dependent peroxidase 4 (GPX4) was inactivated via GSH depletion following I/R injury, whereas GPX4 activation blocked I/R‑induced ferroptosis by reducing lipid ROS levels. The mitogen‑activated protein kinase (MAPK) pathway was also investigated in the present study; it was observed that I/R‑induced ferroptosis was blocked by inhibiting p38 MAPK activation. The results of the present study demonstrate that ferroptosis is a pervasive and dynamic type of cell death induced by OGD/R injury in Sertoli cells. This may provide a novel insight into the application of cytoprotection in testicular I/R damage‑induced cell loss.
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Affiliation(s)
- Li Li
- Department of Histology and Embryology, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China
| | - Yu Hao
- Department of Histology and Embryology, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China
| | - Yu Zhao
- Department of Histology and Embryology, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China
| | - Huijuan Wang
- Department of Histology and Embryology, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China
| | - Xiujun Zhao
- Department of Histology and Embryology, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China
| | - Yan Jiang
- Reproductive Center, Shijiazhuang No. 4 Hospital, Shijiazhuang, Hebei 050019, P.R. China
| | - Fulu Gao
- Department of Histology and Embryology, Hebei Medical University, Shijiazhuang, Hebei 050017, P.R. China
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Zhou J, Wu K, Gao D, Zhu G, Wu D, Wang X, Chen Y, Du Y, Song W, Ma Z, Authement C, Saha D, Hsieh JT, He D. Reciprocal regulation of hypoxia-inducible factor 2α and GLI1 expression associated with the radioresistance of renal cell carcinoma. Int J Radiat Oncol Biol Phys 2014; 90:942-51. [PMID: 25585786 DOI: 10.1016/j.ijrobp.2014.06.065] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/08/2014] [Accepted: 06/25/2014] [Indexed: 12/15/2022]
Abstract
PURPOSE Renal cell carcinoma (RCC) is often considered a radioresistant tumor, but the molecular mechanism underlying its radioresistance is poorly understood. This study explored the roles of hypoxia-inducible factor 2α (HIF2α) and sonic hedgehog (SHH)-GLI1 signaling in mediating the radioresistance of RCC cells and to unveil the interaction between these 2 signaling pathways. METHODS AND MATERIALS The activities of SHH-GLI1 signaling pathway under normoxia and hypoxia in RCC cells were examined by real-time polymerase chain reaction, Western blot, and luciferase reporter assay. The expression of HIF2α and GLI1 in RCC patients was examined by immunohistochemistry, and their correlation was analyzed. Furthermore, RCC cells were treated with HIF2α-specific shRNA (sh-HIF2α), GLI1 inhibitor GANT61, or a combination to determine the effect of ionizing radiation (IR) on RCC cells based on clonogenic assay and double-strand break repair assay. RESULTS RCC cells exhibited elevated SHH-GLI1 activities under hypoxia, which was mediated by HIF2α. Hypoxia induced GLI1 activation through SMO-independent pathways that could be ablated by PI3K inhibitor or MEK inhibitor. Remarkably, the SHH-GLI1 pathway also upregulated HIF2α expression in normoxia. Apparently, there was a positive correlation between HIF2α and GLI1 expression in RCC patients. The combination of sh-HIF2α and GLI1 inhibitor significantly sensitized RCC cells to IR. CONCLUSIONS Cross-talk between the HIF2α and SHH-GLI1 pathways was demonstrated in RCC. Cotargeting these 2 pathways, significantly sensitizing RCC cells to IR, provides a novel strategy for RCC treatment.
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Affiliation(s)
- Jiancheng Zhou
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China; Department of Urology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kaijie Wu
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Dexuan Gao
- Department of Urology, Shandong Provincial Hospital affiliated with Shandong University, Ji'nan, China
| | - Guodong Zhu
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Dapeng Wu
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Xinyang Wang
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Yule Chen
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Yuefeng Du
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Wenbin Song
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Zhenkun Ma
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China
| | - Craig Authement
- Department of Urology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Debabrata Saha
- Department of Urology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jer-Tsong Hsieh
- Department of Urology, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Dalin He
- Department of Urology, First Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, China.
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Yang JJ, Tao H, Li J. Hedgehog signaling pathway as key player in liver fibrosis: new insights and perspectives. Expert Opin Ther Targets 2014; 18:1011-21. [PMID: 24935558 DOI: 10.1517/14728222.2014.927443] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Activation of hepatic stellate cells (HSCs) is a pivotal cellular event in liver fibrosis. Therefore, improving our understanding of the molecular pathways that are involved in these processes is essential to generate new therapies for liver fibrosis. Greater knowledge of the role of the hedgehog signaling pathway in liver fibrosis could improve understanding of the liver fibrosis pathogenesis. AREAS COVERED The aim of this review is to describe the present knowledge about the hedgehog signaling pathway, which significantly participates in liver fibrosis and HSC activation, and look ahead on new perspectives of hedgehog signaling pathway research. Moreover, we will discuss the different interactions with hedgehog signaling pathway-regulated liver fibrosis. EXPERT OPINION The hedgehog pathway modulates several important aspects of function, including cell proliferation, activation and differentiation. Targeting the hedgehog pathway can be a promising direction in liver fibrosis treatment. We discuss new perspectives of hedgehog signaling pathway activation in liver fibrosis and HSC fate, including DNA methylation, methyl CpG binding protein 2, microRNA, irradiation and metabolism that influence hedgehog signaling pathway transduction. These findings identify the hedgehog pathway as a potentially important for biomarker development and therapeutic targets in liver fibrosis. Future studies are needed in order to find safer and more effective hedgehog-based drugs.
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Affiliation(s)
- Jing-Jing Yang
- The Second Hospital of Anhui Medical University, Department of Pharmacology , Hefei 230601 , China
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DaJusta DG, Granberg CF, Villanueva C, Baker LA. Contemporary review of testicular torsion: new concepts, emerging technologies and potential therapeutics. J Pediatr Urol 2013; 9:723-30. [PMID: 23044376 PMCID: PMC3566290 DOI: 10.1016/j.jpurol.2012.08.012] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 08/25/2012] [Indexed: 12/25/2022]
Abstract
Testicular torsion is one of the few emergencies in pediatric urology which requires an accurate and timely diagnosis in order to avoid testis loss. It is not an uncommon event affecting a young male population. In fact, testicular torsion is more common than testicular tumors for this same age group, yet testicular torsion has not been given the public attention it deserves as a male health risk. In this review we highlight the new information published over the past four years regarding testicular torsion. We will discuss a variety of topics associated with torsion including: medical legal issues, etiology and genetics, imaging diagnostics, innovative surgical techniques, management controversies, fertility, and new drug therapies.
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Affiliation(s)
- Daniel G DaJusta
- Children's Medical Center, University of Texas Southwestern Medical School, Dallas, TX, USA
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Huang SS, Cheng H, Tang CM, Nien MW, Huang YS, Lee IH, Yin JH, Kuo TBJ, Yang CCH, Tsai SK, Yang DI. Anti-oxidative, anti-apoptotic, and pro-angiogenic effects mediate functional improvement by sonic hedgehog against focal cerebral ischemia in rats. Exp Neurol 2013; 247:680-8. [PMID: 23499832 DOI: 10.1016/j.expneurol.2013.03.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/22/2013] [Accepted: 03/04/2013] [Indexed: 11/20/2022]
Abstract
Sonic hedgehog (SHH) is a morphogen important for neural development during embryogenesis. Recently, beneficial actions of SHH in ischemic injury have been noted. To test whether epidural application of the biolgically active N-terminal fragment of SHH (SHH-N) may reduce the extent of ischemic brain injury, male Long-Evans rats were exposed to a 60-min episode of middle cerebral artery occlusion (MCAO) with topical application of SHH-N and/or its specific inhibitor, cyclopamine, in fibrin glue over the peri-infarct cortex. We found that epidural application of SHH-N substaintially reduced infarct volumes after 7 days of reperfusion, which was reversed by cyclopamine; SHH-N also improved behavioral outcomes as assessed by global neurological functions, rotarod test, and grasping power test. Furthermore, SHH-N attenuated the extents of protein oxidation, lipid peroxidation, and apoptosis induced by focal ischemia/reperfusion. Immunohistochemical staining coupled with bromodeoxyuridine (BrdU) incorporation revealed that SHH-N enhanced post-ischemic angiogenesis, stimulated the proliferation of nestin-positive (nestin(+)) neural progenitor cells (NPCs), and suppressed astrocytosis. Our results thus revealed multifaceted protective mechanisms of SHH-N against focal cerebral ischemia/reperfusion.
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Affiliation(s)
- Shiang-Suo Huang
- Department of Pharmacology and Institute of Medicine, College of Medicine, Chung Shan Medical University, Taiwan
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Guven A, Ickin M, Uzun O, Bakar C, Gulec Balbay E, Balbay O. Erdosteine protects rat testis tissue from hypoxic injury by reducing apoptotic cell death. Andrologia 2012; 46:50-58. [DOI: 10.1111/and.12041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2012] [Indexed: 11/28/2022] Open
Affiliation(s)
- A. Guven
- Department of Histology and Embryology; School of Medicine; Canakkale Onsekiz Mart University; Canakkale Turkey
| | - M. Ickin
- Department of Histology and Embryology; School of Medicine; Canakkale Onsekiz Mart University; Canakkale Turkey
| | - O. Uzun
- Department of Pharmacology; Faculty of Medicine; University of Abant Izzet Baysal; Bolu Turkey
| | - C. Bakar
- Department of Public Health; Faculty of Medicine; Canakkale Onsekiz Mart University; Canakkale Turkey
| | - E. Gulec Balbay
- Department of Pulmonary Medicine, Faculty of Medicine; University of Duzce; Duzce Turkey
| | - O. Balbay
- Department of Pulmonary Medicine; Faculty of Medicine; University of Duzce; Duzce Turkey
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The hypoxic testicle: physiology and pathophysiology. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2012; 2012:929285. [PMID: 23056665 PMCID: PMC3465913 DOI: 10.1155/2012/929285] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 08/07/2012] [Accepted: 08/09/2012] [Indexed: 12/15/2022]
Abstract
Mammalian spermatogenesis is a complex biological process occurring in the seminiferous tubules in the testis. This process represents a delicate balance between cell proliferation, differentiation, and apoptosis. In most mammals, the testicles are kept in the scrotum 2 to 7°C below body core temperature, and the spermatogenic process proceeds with a blood and oxygen supply that is fairly independent of changes in other vascular beds in the body. Despite this apparently well-controlled local environment, pathologies such as varicocele or testicular torsion and environmental exposure to low oxygen (hypoxia) can result in changes in blood flow, nutrients, and oxygen supply along with an increased local temperature that may induce adverse effects on Leydig cell function and spermatogenesis. These conditions may lead to male subfertility or infertility. Our literature analyses and our own results suggest that conditions such as germ cell apoptosis and DNA damage are common features in hypoxia and varicocele and testicular torsion. Furthermore, oxidative damage seems to be present in these conditions during the initiation stages of germ cell damage and apoptosis. Other mechanisms like membrane-bound metalloproteinases and phospholipase A2 activation could also be part of the pathophysiological consequences of testicular hypoxia.
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Sugiyama A, Chiba M, Nakagami T, Kawano S, Sanada Y, Tajiri T, Toki A. Beneficial effects of (-)-epigallocatechin gallate on ischemia-reperfusion testicular injury in rats. J Pediatr Surg 2012; 47:1427-32. [PMID: 22813808 DOI: 10.1016/j.jpedsurg.2012.01.069] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 12/26/2011] [Accepted: 01/23/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE The purpose of the study was to determine the effect of (-)-epigallocatechin gallate (EGCG) on testicular ischemia-reperfusion injury in rats. METHODS Forty male Wistar rats were assigned to 5 groups. A sham operation was performed on the animals in group 1. In group 2, after 4 hours of unilateral testicular ischemia, 4 hours of testicular reperfusion was performed with EGCG administered 1 hour before reperfusion. In group 3, the same surgical procedure as in group 2 was performed, but without EGCG. Serum superoxide dismutase activity, creatine kinase, and lactate dehydrogenase were then measured in blood samples from groups 1 to 3. In group 4, after 4 hours of unilateral testicular ischemia, testicular reperfusion was performed. In group 5, the same procedure as in group 4 was performed, but with EGCG administered 1 hour before reperfusion. For groups 4 and 5, bilateral orchiectomy was performed for histologic examination 4 weeks after reperfusion was started. RESULTS Serum superoxide dismutase activity was significantly higher in group 2 than in group 3. The ratios of bilateral testicular weight, mean seminiferous tubule diameter, and germinal epithelial cell thickness were significantly higher in group 5 than in group 4. CONCLUSIONS Therapy with EGCG before reperfusion might exert protective effects via antioxidant activities in a rat experimental model of testicular ischemia-reperfusion injury.
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Affiliation(s)
- Akihide Sugiyama
- Department of Pediatric Surgery, Showa University Hospital, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8555, Japan.
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Ji H, Miao J, Zhang X, Du Y, Liu H, Li S, Li L. Inhibition of sonic hedgehog signaling aggravates brain damage associated with the down-regulation of Gli1, Ptch1 and SOD1 expression in acute ischemic stroke. Neurosci Lett 2012; 506:1-6. [DOI: 10.1016/j.neulet.2011.11.027] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 11/08/2011] [Accepted: 11/15/2011] [Indexed: 11/30/2022]
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14
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Ji H, Zhang X, Du Y, Liu H, Li S, Li L. Polydatin modulates inflammation by decreasing NF-κB activation and oxidative stress by increasing Gli1, Ptch1, SOD1 expression and ameliorates blood-brain barrier permeability for its neuroprotective effect in pMCAO rat brain. Brain Res Bull 2011; 87:50-9. [PMID: 22001340 DOI: 10.1016/j.brainresbull.2011.09.021] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 09/25/2011] [Accepted: 09/29/2011] [Indexed: 11/27/2022]
Abstract
Inflammation and oxidative stress play an important role in cerebral ischemic pathogenesis. Polydatin has been proved to elicit numerous biological effects through its anti-inflammatory and anti-oxidant properties. However, little is known regard to the mechanism of polydatin's neuroprotection in ischemic stroke. We therefore investigated the potential neuroprotective effects of polydatin and explored the underlying mechanisms. Male, Sprague-Dawley rats were subjected to permanent middle cerebral artery occlusion (pMCAO). Experiment 1 was used to evaluate the expression of glioma-associated oncogene homolog1 (Gli1), Patched-1 (Ptch1) and Superoxide dismutase 1 (SOD1) after pMCAO, six time points were included. Experiment 2 was used to detect polydatin's neuroprotection after pMCAO. Neurological deficit, brain water content and infarct size were measured at 24h and 72 h after pMCAO. Immunohistochemistry, reverse transcription-polymerase chain reaction (RT-PCR), Western Blotting, activity assay and confocal microscope were used to analyse the expression of Gli1, Ptch1, SOD1 and nuclear factor-kappa B (NF-κB). Experiment 3 was used to detect polydatin's influence on blood-brain barrier (BBB). Compared with Sham group, the expression of Gli1, Ptch1 and SOD1 were up-regulated shortly after pMCAO (P<0.05). Compared with Vehicle group, high dose of polydatin (50mg/kg) up-regulated Gli1, Ptch1, SOD1 and down-regulated NF-κB, and reduced infarct volume, brain water content and behavioral deficits (P<0.05). Meanwhile, BBB permeability was also ameliorated. The results indicated that polydatin protected the brain from damage caused by pMCAO, and this effect may be through up-regulating the expression of Gli1, Ptch1 and SOD1 and down-regulating the expression of NF-κB, and ameliorating BBB permeability.
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Affiliation(s)
- Hui Ji
- Department of Neurology, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, PR China
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He H, Zhang H, Li B, Li G, Wang Z. Blockade of the sonic hedgehog signalling pathway inhibits choroidal neovascularization in a laser-induced rat model. ACTA ACUST UNITED AC 2010; 30:659-65. [PMID: 21063852 DOI: 10.1007/s11596-010-0560-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Indexed: 10/18/2022]
Abstract
Sonic hedgehog (Shh) signaling has recently been shown to be involved in the pathological angiogenesis in response to tissue hypoxia and ischemic injury. Hypoxia/ischemia is considered to play an important role in the development of choroidal neovascularization (CNV). This study was aimed to examine the effect of blockade of the Shh signaling pathway on CNV and the underlying mechanism. A total of 64 male Brown-Norway (BN) rats were used in this study. One eye of each rat underwent laser photocoagulation. The other eye served as normal control. After the laser treatment, the 64 rats were divided into four groups (n=16 in each group): Blank control group, in which no intravitreal administration was given; cyclopamine group, recombinant Shh N-terminals protein (rShh) group and phosphate-buffered saline (PBS) group, in which cyclopamine (a Shh inhibitor), rShh (a Shh activator) and PBS were intravitreally injected into the laser-treated eyes respectively every other day for a total of four intravitreal injections immediately after the laser treatment. Fourteen days after the intravitreal administration, the changes of CNV-related variables, including positive CNV lesion percentage, CNV membrane area and CNV membrane thickness, were evaluated by fluorescein angiography, indocyanine green angiography and pathological examinations. The mRNA and protein expression of PTCH1, Gli1, HIF-1(α), VEGF and DLL4 in each group on 14 days of CNV model was detected by real-time quantitative PCR and western blot analysis, and the relationship between the Shh cascade and the HIF-1(α)-VEGF-DLL4 cascade in CNV was analyzed. The results showed that the CNV membrane area and the CNV membrane thickness were decreased by 62.5% and 41.9% in the cyclopamine group and increased by 85.7% and 64.3% in the rShh group in comparison to those in the blank control group (P<0.01 for each). There was no significant difference in the CNV membrane area and thickness between the blank control group and PBS group (P=0.102 and P=0.063, respectively). Real-time quantitative PCR revealed a 5.23-, 4.14-, 2.97-, 2.78- and 2.39-fold up-regulation of the mRNA expression of PTCH1, Gli1, HIF-1(α), VEGF and DLL4 genes in the laser-treated eyes compared with the normal control eyes in the control group. In the cyclopamine group, the mRNA and protein expression of Gli1, HIF-1(α), VEGF and DLL4 was significantly down-regulated (P<0.05 for each) while the expression of PTCH1 showed no significant changes at the mRNA (P=0.293) and protein level (P=0.304). The mRNA expression and protein expression (P=0.001 and P=0.021, respectively) of PTCH1, Gli1, HIF-1(α), VEGF and DLL4 was significantly increased in the rShh group when compared with the control group. The expression level of these genes was related to the severity of the CNV. It was concluded that intravitreal administration of cyclopamine can effectively inhibit the formation of laser-induced experimental CNV by down-regulating the expression of the HIF-1(α)-VEGF-DLL4 cascade in CNV. The Shh signaling pathway as an upstream signaling pathway of HIF-1(α)-VEGF-DLL4 cascade is implicated in the development of experimental CNV.
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Affiliation(s)
- Hua He
- Department of Ophthalmology, Huazhong University of Science and Technology, Wuhan, China.
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Sonic Hedgehog Protects Cortical Neurons Against Oxidative Stress. Neurochem Res 2010; 36:67-75. [DOI: 10.1007/s11064-010-0264-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2010] [Indexed: 12/28/2022]
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Wang G, Zhang Z, Xu Z, Yin H, Bai L, Ma Z, Decoster MA, Qian G, Wu G. Activation of the sonic hedgehog signaling controls human pulmonary arterial smooth muscle cell proliferation in response to hypoxia. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2010; 1803:1359-67. [PMID: 20840857 DOI: 10.1016/j.bbamcr.2010.09.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/14/2010] [Revised: 08/27/2010] [Accepted: 09/01/2010] [Indexed: 12/16/2022]
Abstract
The hedgehog signal pathway plays a crucial role in the angiogenesis and vascular remodeling. However, the function of this pathway in the pulmonary vascular smooth cell proliferation in response to hypoxia remains unknown. In this study, we have demonstrated that the main components of the hedgehog pathway, including sonic hedgehog (SHH), patched1 (PTCH1), smoothened (SMO), GLI and hypoxia-inducible factor 1 (HIF1) are expressed in the human pulmonary arterial smooth muscle cells (HPASMCs). Interestingly, hypoxia significantly enhanced the expression of SHH and HIF1, facilitated the translocation of GLI1 into the nuclei, and promoted the proliferation of HPASMCs. Furthermore, direct activation of the SHH pathway through incubation with the purified recombinant human SHH or with purmorphamine and SAG, two Smo agonists, also enhanced the proliferation of HPASMCs. Importantly, the treatment with anti-SHH and anti-HIF1 antibodies or cyclopamine, a specific SMO inhibitor, markedly inhibited the nuclear translocation of GLI1 and cell proliferation in the HPASMCs induced by hypoxia and activation of the SHH pathway. Moreover, the treatment with cyclopamine increased apoptosis in the hypoxic HPASMCs. These data strongly demonstrate for the first time that the SHH signaling plays a crucial role in the regulation of HPASMC growth in response to hypoxia.
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Affiliation(s)
- Guansong Wang
- Institute of Respiratory Diseases, Xinqiao Hospital of the Third Military Medical University, Chongqing 400037, P.R. China; Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, USA
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Benameur T, Soleti R, Porro C, Andriantsitohaina R, Martínez MC. Microparticles carrying Sonic hedgehog favor neovascularization through the activation of nitric oxide pathway in mice. PLoS One 2010; 5:e12688. [PMID: 20856928 PMCID: PMC2938335 DOI: 10.1371/journal.pone.0012688] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 08/17/2010] [Indexed: 01/27/2023] Open
Abstract
Background Microparticles (MPs) are vesicles released from plasma membrane upon cell activation and during apoptosis. Human T lymphocytes undergoing activation and apoptosis generate MPs bearing morphogen Shh (MPsShh+) that are able to regulate in vitro angiogenesis. Methodology/Principal Findings Here, we investigated the ability of MPsShh+ to modulate neovascularization in a model of mouse hind limb ischemia. Mice were treated in vivo for 21 days with vehicle, MPsShh+, MPsShh+ plus cyclopamine or cyclopamine alone, an inhibitor of Shh signalling. Laser doppler analysis revealed that the recovery of the blood flow was 1.4 fold higher in MPsShh+-treated mice than in controls, and this was associated with an activation of Shh pathway in muscles and an increase in NO production in both aorta and muscles. MPsShh+-mediated effects on flow recovery and NO production were completely prevented when Shh signalling was inhibited by cyclopamine. In aorta, MPsShh+ increased activation of eNOS/Akt pathway, and VEGF expression, being inhibited by cyclopamine. By contrast, in muscles, MPsShh+ enhanced eNOS expression and phosphorylation and decreased caveolin-1 expression, but cyclopamine prevented only the effects of MPsShh+ on eNOS pathway. Quantitative RT-PCR revealed that MPsShh+ treatment increased FGF5, FGF2, VEGF A and C mRNA levels and decreased those of α5-integrin, FLT-4, HGF, IGF-1, KDR, MCP-1, MT1-MMP, MMP-2, TGFβ1, TGFβ2, TSP-1 and VCAM-1, in ischemic muscles. Conclusions/Significance These findings suggest that MPsShh+ may contribute to reparative neovascularization after ischemic injury by regulating NO pathway and genes involved in angiogenesis.
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Affiliation(s)
- Tarek Benameur
- CNRS, UMR 6214, INSERM, U771, Université d'Angers, Faculté de Médecine, Angers, France
| | - Raffaella Soleti
- CNRS, UMR 6214, INSERM, U771, Université d'Angers, Faculté de Médecine, Angers, France
| | - Chiara Porro
- Department of Biomedical Sciences, School of Medicine, University of Foggia, Foggia, Italy
| | | | - Maria Carmen Martínez
- CNRS, UMR 6214, INSERM, U771, Université d'Angers, Faculté de Médecine, Angers, France
- * E-mail:
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Bijlsma MF, Spek CA. The Hedgehog morphogen in myocardial ischemia-reperfusion injury. Exp Biol Med (Maywood) 2010; 235:447-54. [PMID: 20407076 DOI: 10.1258/ebm.2009.009303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The developmental Hedgehog (Hh) protein family is known to be pivotal in many embryonic patterning events and the number of processes in which Hh plays an essential role is expanding persistently. Recently, it has become clear that the Hh pathway is not only active in the developing embryo but also in the adult organism. For example, Hh has been suggested to salvage ischemia-induced tissue damage although endogenous Hh might be deleterious during the early phase of myocardial ischemia-reperfusion. The current review provides an overview of the history of Hh biology and discusses some novel insights on Hh cell biology. Hh function in pathophysiology as well as recent findings concerning Hh signaling in ischemia models, especially in light of cardiovascular disease, is discussed in more detail and future perspectives are proposed.
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Affiliation(s)
- Maarten F Bijlsma
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
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Tamamura M, Saito M, Kinoshita Y, Shimizu S, Satoh I, Shomori K, Dimitriadis F, Satoh K. Protective effect of edaravone, a free-radical scavenger, on ischaemia-reperfusion injury in the rat testis. BJU Int 2009; 105:870-6. [PMID: 19694712 DOI: 10.1111/j.1464-410x.2009.08798.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the effect of edaravone, a radical scavenger, on ischaemia-reperfusion (I-R) injury in the testes. MATERIALS AND METHODS Eight-week-old male Sprague-Dawley rats were allocated to one of four groups: a no-drug group subjected to induction of 30-min of ischaemia and 60-min reperfusion; two drug groups administered edaravone at 1 or 10 mg/kg intraperitoneal and then subjected to 30-min ischaemia and 60-min reperfusion; and a sham-operated control group administered edaravone at 10 mg/kg intraperitoneal. To induce testicular I-R, the right testis was exposed outside of the body and the testicular artery was clamped with a small clip for 30 min. Blood flow and nitric oxide (NO) release were monitored in real time simultaneously with a laser Doppler flowmeter and an NO-selective electrode, respectively. After death the tissue levels of NO(2)-NO(3) (a marker of NO production), malondialdehyde (a marker of lipid peroxidation), 8-hydroxydeoxyguanosine (a marker of oxidative DNA damage), myeloperoxidase (a marker of neutrophil infiltration), and heat-shock protein 70 (HSP 70) and its mRNA were measured. The testicular tissue was also analysed histologically. RESULTS Clamping the testicular artery resulted in a decrease of blood flow to 0-5% of the basal level measured before clamping. NO release was increased during clamping and gradually recovered to the basal level on removing the clip. Interestingly, the peak of NO release in rats of the no-drug group occurred at the start of reperfusion, while that in the high-dose drug group occurred several minutes later. The levels of NO(2)-NO(3), malondialdehyde, 8-hydroxydeoxyguanosine, myeloperoxidase and HSP 70 and its mRNA, and histological variables, were significantly greater in the no-drug I-R group than in the control, and these variables were ameliorated by treatment with edaravone. CONCLUSION These results indicate that edaravone reduces the oxidative stress and prevents the testicular damage induced by I-R.
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Affiliation(s)
- Mayuko Tamamura
- Department of Pathophysiological and Therapeutic Science, Tottori University Yonago, Japan
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Ellati RT, Kavoussi PK, Turner TT, Lysiak JJ. Twist and Shout: A Clinical and Experimental Review of Testicular Torsion. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.12.1159] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Riyad T. Ellati
- Department of Urology, University of Virginia Health System, USA
| | | | - Terry T. Turner
- Department of Urology, University of Virginia Health System, USA
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