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Rajasekar N, Gandhi D, Sivanantham A, Ravikumar V, Raj D, Paramasivam SG, Mukhopadhyay S, Rajasekaran S. Dietary tannic acid attenuates elastase-induced pulmonary inflammation and emphysema in mice. Inflammopharmacology 2024; 32:747-761. [PMID: 37947914 DOI: 10.1007/s10787-023-01381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/13/2023] [Indexed: 11/12/2023]
Abstract
Emphysema is one of the major components of chronic obstructive pulmonary disease (COPD), which is characterised by the destruction and enlargement of air spaces, leading to airflow limitation and dyspnoea, finally progressing to oxygen dependency. The alveolar wall destruction is due to chronic inflammation, oxidative stress, apoptosis, and proteinase/anti-proteinase imbalance. So far, there has been no effective therapy for patients with COPD. We evaluated the therapeutic efficacy of tannic acid (TA), a naturally occurring plant-derived polyphenol in the murine emphysema model. In C57BL/6 J mice, we established emphysema by intratracheal instillation of elastase (EL). Then, mice were treated with TA and evaluated 1 and 21 days post-EL instillation. After 24 h, TA treatment significantly reduced EL-induced histopathological alterations, infiltrating leukocytes, and gene expression of markers of inflammation and apoptosis. Similarly, after 21 days, TA treatment suppressed the mean linear intercept, gene expression of proteinases, and increased elastic fiber contents in the lungs when compared to the EL-alone group. Furthermore, EL induced the activation of p38 mitogen-activated protein kinase (MAPK) and nuclear factor kappa light chain enhancer of activated B cells (NF-kB) p65 pathways in the lungs was suppressed by TA treatment. In summary, TA has the potential to mitigate EL-induced inflammation, apoptosis, proteinase/anti-proteinase imbalance, and subsequent emphysema in mice.
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Affiliation(s)
- Nandhine Rajasekar
- Department of Biotechnology, BIT-Campus, Anna University, Tiruchirappalli, Tamil Nadu 620024, India
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Deepa Gandhi
- Division of Biochemistry, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, 462030, India
| | - Ayyanar Sivanantham
- Department of Biotechnology, BIT-Campus, Anna University, Tiruchirappalli, Tamil Nadu 620024, India
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA, 02118, USA
| | - Vilwanathan Ravikumar
- Department of Biochemistry, School of Life Sciences, Bharathidasan University, Tiruchirappalli, Tamil Nadu 620024, India
| | - Dharma Raj
- Division of Biostatistics and Bioinformatics, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh 462030, India
| | | | - Sramana Mukhopadhyay
- Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh 462026, India
| | - Subbiah Rajasekaran
- Division of Biochemistry, ICMR-National Institute for Research in Environmental Health, Bhopal, Madhya Pradesh, 462030, India.
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Hosseini M, Arab Z, Beheshti F, Anaeigoudari A, Shakeri F, Rajabian A. Zataria multiflora and its constituent, carvacrol, counteract sepsis-induced aortic and cardiac toxicity in rat: Involvement of nitric oxide and oxidative stress. Animal Model Exp Med 2023; 6:221-229. [PMID: 37272426 PMCID: PMC10272902 DOI: 10.1002/ame2.12323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/03/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Zataria multiflora and carvacrol showed various pharmacological properties including anti-inflammatory and anti-oxidant effects. However, up to now no studies have explored its potential benefits in ameliorating sepsis-induced aortic and cardiac injury. Thus, this study aimed to investigate the effects of Z. multiflora and carvacrol on nitric oxide (NO) and oxidative stress indicators in lipopolysaccharide (LPS)-induced aortic and cardiac injury. METHODS Adult male Wistar rats were assigned to: Control, lipopolysaccharide (LPS) (1 mg/kg, intraperitoneal (i.p.)), and Z. multiflora hydro-ethanolic extract (ZME, 50-200 mg/kg, oral)- and carvacrol (25-100 mg/kg, oral)-treated groups. LPS was injected daily for 14 days. Treatment with ZME and carvacrol started 3 days before LPS administration and treatment continued during LPS administration. At the end of the study, the levels of malondialdehyde (MDA), NO, thiols, and antioxidant enzymes were evaluated. RESULTS Our findings showed a significant reduction in the levels of superoxide dismutase (SOD), catalase (CAT), and thiols in the LPS group, which were restored by ZME and carvacrol. Furthermore, ZME and carvacrol decreased MDA and NO in cardiac and aortic tissues of LPS-injected rats. CONCLUSIONS The results suggest protective effects of ZME and carvacrol on LPS-induced cardiovascular injury via improved redox hemostasis and attenuated NO production. However, additional studies are needed to elucidate the effects of ZME and its constituents on inflammatory responses mediated by LPS.
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Affiliation(s)
- Mahmoud Hosseini
- Psychiatry and Behavioral Sciences Research CenterMashhad University of Medical SciencesMashhadIran
| | - Zohreh Arab
- Applied Biomedical Research CenterMashhad University of Medical SciencesMashhadIran
| | - Farimah Beheshti
- Neuroscience Research CenterTorbat Heydariyeh University of Medical SciencesTorbat HeydariyehIran
- Department of Physiology, School of Paramedical SciencesTorbat Heydariyeh University of Medical SciencesTorbat HeydariyehIran
| | - Akbar Anaeigoudari
- Department of Physiology, School of MedicineJiroft University of Medical SciencesJiroftIran
| | - Farzaneh Shakeri
- Natural Products and Medicinal Plants Research CenterNorth Khorasan University of Medical SciencesBojnurdIran
- Department of Physiology and Pharmacology, School of MedicineNorth Khorasan University of Medical SciencesBojnurdIran
| | - Arezoo Rajabian
- Department of Internal Medicine, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
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He D, Hu J, Li Y, Zeng X. Preventive use of beta-blockers for anthracycline-induced cardiotoxicity: A network meta-analysis. Front Cardiovasc Med 2022; 9:968534. [PMID: 36035937 PMCID: PMC9403514 DOI: 10.3389/fcvm.2022.968534] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background Anthracyclines are commonly used chemotherapeutic agents to treat malignant tumors. However, cardiotoxicity is a potentially serious adverse effect of anthracyclines. Beta-blockers may be effective in preventing anthracycline-induced cardiotoxicity (AIC). However, the lack of direct comparisons of various beta-blockers interferes with clinical decision-making. Network meta-analysis (NMA) was performed to assess the effectiveness of beta-blockers for AIC. Methods We searched PubMed, Embase, Web of Science, and the Cochrane Central Register of Clinical Trials. The last update was in May 2022. Randomized controlled trials (RCT) of beta-blockers for AIC were included. Four beta-blockers were selected for comparison based on the number of studies. NMA was conducted with STATA 14.0 software. Results A total of 10 RCTs (875 patients) met the selection criteria. NMA results showed that carvedilol was superior to bisoprolol [SMD = −0.50, 95% CI (−0.91, −0.10)] and nebivolol [SMD = −1.46, 95%CI (−2.82, −0.11)] in a delay of LVEF. The results of the cumulative probability ordering are as follows: carvedilol (83.8%) > metoprolol (71.8%) > bisoprolol (43.9%) > placebo (40.9%) > nebivolol (9.5%). Conclusion Based on the available evidence, carvedilol is the best beta-blocker for AIC, followed by metoprolol. However, additional studies with large samples should be conducted to confirm our findings.
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Affiliation(s)
- Dongsheng He
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Jun Hu
- Department of Cardiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Ying Li
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- *Correspondence: Ying Li
| | - Xiaofei Zeng
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- Xiaofei Zeng
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Eisa CS, Mohammed SS, El-Aziz HIA, Farghaly LM, Hosny S. The Effect of Selenium Nanoparticles versus Royal Jelly against Cisplatin-Induced Testicular Toxicity in Adult Male Albino Rats: A Light and Transmission Electron Microscopic Study. J Microsc Ultrastruct 2022; 10:180-196. [PMID: 36687330 PMCID: PMC9846925 DOI: 10.4103/jmau.jmau_44_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/25/2021] [Accepted: 08/19/2021] [Indexed: 01/25/2023] Open
Abstract
Background and Aim Cisplatin (Cis) is a highly effective chemotherapeutic agent. However, it produces severe testicular toxicity. It was reported that some antioxidants could overcome this toxicity. Selenium nanoparticles and royal jelly (RJ) were among these reported antioxidants. Therefore, this study was designed to compare these two antioxidants in protecting the testes against Cis-induced toxicity. Materials and Methods This study was conducted on sixty healthy adult male albino rats (weight: 200-220 g) randomized into six groups, ten animals each. Group I (control), Group II (animals received intragastric Nano Selenium), Group III (animals received intragastric RJ), Group IV (animals received an IP injection of Cis 7 mg/kg), Group V (animals received intragastric Nano Selenium, and Cis injection), and Group VI (animals received intragastric RJ and Cis injection). After 10 days, the animals were sacrificed by cervical decapitation. The testes were weighted, and specimens from the left testis were processed for histological and immunohistochemical techniques, whereas specimens from the right testes were prepared for transmission electron microscopic examination. Results Cis-treated animals had significantly reduced weight of their testes. Light microscopic examination revealed severe histopathological changes in the germinal epithelium and Leydig cells, confirmed with electron microscopic examination. There was a significant increase in the color area percentage of Caspase-3 immunostaining of the germinal epithelium and Leydig cells, compared to that of the control group. Group II and III were similar to control group. Both Groups V and VI revealed significant preservation compared to the Cis group. Conclusion Selenium nanoparticles and RJ partially improved testis from Cis-induced toxicity, However, there was no significant difference between both groups.
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Affiliation(s)
- Christina S. Eisa
- Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Sally S. Mohammed
- Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt,Address for correspondence: Dr. Sally S. Mohammed, Faculty of Medicine, Suez Canal University, Circular Road, Ismailia, Egypt. E-mail:
| | - Hoida I. Abd El-Aziz
- Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Lamia M. Farghaly
- Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Somaya Hosny
- Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Arab Z, Hosseini M, Marefati N, Beheshti F, Anaeigoudari A, Sadeghnia HR, Boskabady MH. Neuroprotective and memory enhancing effects of Zataria multiflora in lipopolysaccharide-treated rats. VETERINARY RESEARCH FORUM : AN INTERNATIONAL QUARTERLY JOURNAL 2022; 13:101-110. [PMID: 35601788 PMCID: PMC9094587 DOI: 10.30466/vrf.2020.117553.2786] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/28/2020] [Indexed: 11/27/2022]
Abstract
The study was aimed to evaluate the effects of hydro-ethanol extract Zataria multiflora on the brain tissue oxidative damage, and hippocampal interleukin-6 (IL-6) as well as learning and memory capacity in lipopolysaccharide (LPS) - challenged rats. The rats were randomized into five groups as follow: Control group: Rats were treated with saline, LPS group: Rats were treated with LPS 1.00 mg kg-1, ZM50, ZM100 and ZM200 groups in which the rats were treated with Z. multiflora extract (50.00, 100 or 200 mg kg-1 per day, respectively). The treatments including extract or vehicle were administered intraperitoneally and given three days before the behavioral tests and were continued within a6-day behavioral experiment. Injection of LPS was daily done before the behavioral tests. Finally, the brains were collected for biochemical evaluations. Although LPS administration prolonged the latency in Morris water maze and shortened the latency to enter the dark chamber in passive avoidance test, ZM extract restored these changes to approach control group values. Also, LPS increased IL-6, malondialdehyde (MDA) and nitric oxide (NO) metabolites levels and lowered thiol, superoxide dismutase (SOD) and catalase (CAT) levels in the brain, however, Z. multiflora extract reduced IL-6, MDA and NO metabolites concentrations, but increased thiol content, SOD, and CAT levels. The results of this study showed that Z. multiflora ameliorated learning and memory dysfunction in LPS - challenged rats by alleviating of inflammatory responses and brain tissue oxidative damage.
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Affiliation(s)
- Zohreh Arab
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran;
| | - Mahmoud Hosseini
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran;
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran;
| | - Narges Marefati
- Department of Physiology and Medical Physics, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran;
| | - Farimah Beheshti
- Neuroscience Research Center, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran;
- Department of Physiology, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran;
| | - Akbar Anaeigoudari
- Department of Physiology,School of Medicine, Jiroft University of Medical Sciences, Jiroft,Iran;
| | - Hamid Reza Sadeghnia
- Pharmacological Research Center of Medicinal Plants, Mashhad University of Medical Sciences, Mashhad, Iran;
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Hosseinzadeh A, Mehrzadi S, Siahpoosh A, Basir Z, Bahrami N, Goudarzi M. Gallic acid ameliorates di-(2-ethylhexyl) phthalate-induced testicular injury in adult mice. Hum Exp Toxicol 2022; 41:9603271221078867. [PMID: 35196152 DOI: 10.1177/09603271221078867] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Di-(2-ethylhexyl) phthalate (DEHP) is a well-known endocrine-disrupting compound inducing degeneration of testes. Gallic acid (GA) is a polyphenol with various pharmacological properties, including antioxidant and anti-inflammatory effects.Purpose: This research evaluated effects of different doses of GA on DEHP-induced testicular injury in adult mice.Research Design: Male mice were randomly divided into five groups and treated with agents for two weeks; group (I) received normal saline and corn oil (5 mL/kg/day, p. o.), group (II) received DEHP (2 g/kg/day, dissolved in corn oil, p. o.), groups (III, IV, and V) received DEHP + GA (25, 50, and 100 mg/kg/day, p. o.). Body and testes weights, serum testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels were evaluated. The number of sperms and sperm motility and viability were analyzed in the cauda epididymis. Histological changes, oxidative/nitrosative stress markers, and inflammatory cytokines levels were examined in testes.Results: Body and testes weights, the number of spermatogonia, primary spermatocyte and early spermatid, and late spermatid and sperm vitality, and progressive motility were significantly reduced in mice exposed to DEHP. Serum testosterone level decreased and serum LH and FSH levels increased in DEHP-exposed mice. These alterations were associated with the increased oxidative stress level and inflammatory responses in testicular tissue. Treatment with GA (50 and 100 mg/kg/day) attenuated DEHP-induced alterations in oxidative stress markers and inflammatory cytokines and reversed abnormality in sperm characteristic and number, tissue structure, and serum hormones levels.Conclusions: Results indicated that GA might be a promising agent against male gonadal toxicity induced by endocrine disrupting chemicals including DEHP.
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Affiliation(s)
- Azam Hosseinzadeh
- Razi Drug Research Center, 440827Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Mehrzadi
- Razi Drug Research Center, 440827Iran University of Medical Sciences, Tehran, Iran
| | - Amir Siahpoosh
- Medicinal Plant Research Center, 48407Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Zahra Basir
- Department of Basic Sciences, Faculty of Veterinary Medicine, 48513Shahid Chamran University of Ahvaz, Ahvaz, Iran
| | - Nosrat Bahrami
- Department of Midwifery, Faculty of Nursing and Midwifery, 393563Dezful University of Medical Sciences, Dezful, Iran
| | - Mehdi Goudarzi
- Medicinal Plant Research Center, 48407Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Arab Z, Hosseini M, Mashayekhi F, Anaeigoudari A. Zataria multiflora extract reverses lipopolysaccharide-induced anxiety and depression behaviors in rats. AVICENNA JOURNAL OF PHYTOMEDICINE 2020; 10:78-88. [PMID: 31921610 PMCID: PMC6941686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Stressors have an important role in sickness behaviors. We checked the effect of Zataria multiflora (ZM) extract against lipopolysaccharide (LPS)-induced anxiety and depression behaviors in rats. MATERIALS AND METHODS Rats were distributed in the following groups (n=10): Control, LPS (1 mg/kg), LPS-ZM50, LPS-ZM100 and LPS-ZM200. LPS was syringed intraperitoneally (ip) 2 hr before performing behavioral tests. LPS-ZM groups were treated with 50, 100 and 200 mg/kg (ip) of ZM extract 30 min before LPS administration. Open field (OF), elevated plus maze (EPM) and forced swimming (FS) tests were done. White blood cell (WBC) was counted in all groups. RESULTS In OF, pretreatment with ZM extract augmented the number of lines crossed and traveled distance in central and peripheral areas. The rats treated with ZM extract spent more time in the central zone and less time in the peripheral area compared to the LPS group. In EPM, the number of entries into the open and closed arms and stop time in the open arms in LPS-ZM groups were higher than the LPS group. The stop time in the closed arms of ZM-LPS groups was less than the LPS group. In FS test, swimming and climbing time in groups treated with ZM extract was more than the LPS group while their immobility time was less. WBC count in the LPS-ZM100 and LPS-ZM200 was lower than that of the LPS group. CONCLUSION Based on the results, pretreatment with ZM extract restituted anxiety and depression caused by LPS in rats. This effect of ZM was associated with amelioration of LPS-promoted inflammation.
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Affiliation(s)
- Zohreh Arab
- Division of Neurocognitive Sciences, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahmoud Hosseini
- Division of Neurocognitive Sciences, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Mashayekhi
- Critical Care Nursing, Faculty of Nursing and Midwifery, Jiroft University of Medical Science, Jiroft, Iran
| | - Akbar Anaeigoudari
- Department of Physiology,School of Medicine, Jiroft University of Medical Sciences, Jiroft, Iran,Corresponding Author: Tel: +983443318084, Fax: +9834318084,
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Bagherpour H, Karimpour Malekshah A, Talebpour Amiri F, Azadbakht M. Protective effect of green tea extract on the deltamethrin-induced toxicity in mice testis: An experimental study. Int J Reprod Biomed 2018; 17. [PMID: 31435613 PMCID: PMC6653493 DOI: 10.18502/ijrm.v17i5.4601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/31/2018] [Accepted: 01/26/2019] [Indexed: 01/07/2023] Open
Abstract
Background Deltamethrin (DM) is one of the environmental factors that can have destructive effects on the male fertility. Green tea (GT) as a medicinal herb, has antioxidant property. Objective The present study investigated the protective role of GT extract in improving the harmful effects of DM on the testis. Materials and Methods In this experimental study, 35 adult male mice (25–30 gr) were divided in to five groups (n = 7/each). The control group received only normal saline. Sham received 0.2 ml corn oil. Green tea group received only GT of 150 mg/kg. bw; deltamethrin group received the DM at a dose of 0.6 mg/kg. bw; GT + DM received both GT and DM. The effect of GT was assessed by measuring oxidative stress markers, sperm parameters, histological and immunohistochemical analysis. Results The results showed that the count and motility of spermatozoa, testosterone, and Malondialdehyde significantly decreased (p < 0.001) and the abnormal spermatozoa increased (p < 0.001) in DM group compared to control group. Moreover, enhanced caspase-3expression and apoptosis were observed in DM-treated mice compared to control group. Histologically, DM with a degenerative effect on testicular tissue reduced the spermatogenesis progenitor cells. The epithelial height and the diameter of the seminiferous tubules were also reduced in the DM group. Treatment with GT in the DM-treated mice significantly improved these changes. Conclusion With these findings, it was concluded that the GT treatment with antioxidant activity and anti-apoptotic property could protect the testicular injury induced by DM.
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Affiliation(s)
- Hoda Bagherpour
- Department of Anatomy, Faculty of Medicine, Molecular and Cell Biology Research Center, Mazandaran University of Medical Sciences, Sari, Iran.,Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abbasali Karimpour Malekshah
- Department of Anatomy, Faculty of Medicine, Molecular and Cell Biology Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fereshteh Talebpour Amiri
- Department of Anatomy, Faculty of Medicine, Molecular and Cell Biology Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Azadbakht
- Department of Pharmacognosy, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
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