1
|
Wang L, Yukselten Y, Nuwagaba J, Sutton RE. JAK/STAT signaling pathway affects CCR5 expression in human CD4 + T cells. Sci Adv 2024; 10:eadl0368. [PMID: 38507500 PMCID: PMC10954213 DOI: 10.1126/sciadv.adl0368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/15/2024] [Indexed: 03/22/2024]
Abstract
CCR5 serves as R5-tropic HIV co-receptor. Knocking out CCR5 in HIV patients, which has occurred <10 times, is believed important for cure. JAK/STAT inhibitors tofacitinib and ruxolitinib inhibit CCR5 expression in HIV+ viremic patients. We investigated the association of JAK/STAT signaling pathway with CCR5/CCR2 expression in human primary CD4+ T cells and confirmed its importance. Six of nine JAK/STAT inhibitors that reduced CCR5/CCR2 expression were identified. Inhibitor-treated CD4+ T cells were relatively resistant, specifically to R5-tropic HIV infection. Furthermore, single JAK2, STAT3, STAT5A, and STAT5B knockout and different combinations of JAK/STAT knockout significantly reduced CCR2/CCR5 expression of both RNA and protein levels, indicating that CCR5/CCR2 expression was positively regulated by JAK-STAT pathway in CD4+ T cells. Serum and glucocorticoid-regulated kinase 1 (SGK1) knockout affected CCR2/CCR5 gene expression, suggesting that SGK1 is involved in CCR2/CCR5 regulation. If cell surface CCR5 levels can be specifically and markedly down-regulated without adverse effects, that may have a major impact on the HIV cure agenda.
Collapse
Affiliation(s)
- Lingyun Wang
- Section of Infectious Diseases, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Yunus Yukselten
- Section of Infectious Diseases, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Julius Nuwagaba
- Section of Infectious Diseases, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Richard E. Sutton
- Section of Infectious Diseases, Department of Internal Medicine, Yale University, New Haven, CT, USA
| |
Collapse
|
2
|
Aydos OS, Yukselten Y, Ozkan T, Ozkavukcu S, Tuten Erdogan M, Sunguroglu A, Aydos K. Co-Culture of Cryopreserved Healthy Sertoli Cells with Testicular Tissue of Non-Obstructive Azoospermia (NOA) Patients in Culture Media Containing Follicle-Stimulating Hormone (FSH)/Testosterone Has No Advantage in Germ Cell Maturation. J Clin Med 2023; 12:jcm12031073. [PMID: 36769720 PMCID: PMC9917953 DOI: 10.3390/jcm12031073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/11/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Different cell culture conditions and techniques have been used to mature spermatogenic cells to increase the success of in vitro fertilization. Sertoli cells (SCs) are essential in maintaining spermatogenesis and FSH stimulation exerts its effect through direct or indirect actions on SCs. The effectiveness of FSH and testosterone added to the co-culture has been demonstrated in other studies to provide microenvironment conditions of the testicular niche and to contribute to the maturation and meiotic progression of spermatogonial stem cells (SSCs). In the present study, we investigated whether co-culture of healthy SCs with the patient's testicular tissue in the medium supplemented with FSH/testosterone provides an advantage in the differentiation and maturation of germ cells in NOA cases (N = 34). In men with obstructive azoospermia (N = 12), healthy SCs from testicular biopsies were identified and purified, then cryopreserved. The characterization of healthy SCs was done by flow cytometry (FC) and immunohistochemistry using antibodies specific for GATA4 and vimentin. FITC-conjugated annexin V/PI staining and the MTT assay were performed to compare the viability and proliferation of SCs before and after freezing. In annexin V staining, no difference was found in percentages of live and apoptotic SCs, and MTT showed that cryopreservation did not inhibit SC proliferation compared to the pre-freezing state. Then, tissue samples from NOA patients were processed in two separate environments containing FSH/testosterone and FSH/testosterone plus co-culture with thawed healthy SCs for 7 days. FC was used to measure 7th-day levels of specific markers expressed in spermatogonia (VASA), meiotic cells (CREM), and post-meiotic cells (protamine-2 and acrosin). VASA and acrosin basal levels were found to be lower in infertile patients compared to the OA group (8.2% vs. 30.6% and 12.8% vs. 30.5%, respectively; p < 0.05). Compared to pre-treatment measurements, on the 7th day in the FSH/testosterone environment, CREM levels increased by 58.8% and acrosin levels increased by 195.5% (p < 0.05). Similarly, in medium co-culture with healthy SCs, by day 7, CREM and acrosin levels increased to 92.2% and 204.8%, respectively (p < 0.05). Although VASA and protamine levels increased in both groups, they did not reach a significant level. No significant difference was found between the day 7 increase rates of CREM, VASA, acrosin and protamine-2 in either FSH/testosterone-containing medium or in medium additionally co-cultured with healthy SCs (58.8% vs. 92.2%, 120.6% vs. 79.4%, 195.5% vs. 204.8%, and 232.3% vs. 198.4%, respectively; p > 0.05). Our results suggest that the presence of the patient's own SCs for maturation of germ cells in the culture medium supplemented with FSH and testosterone is sufficient, and co-culture with healthy SCs does not have an additional advantage. In addition, the freezing-thawing process would not impair the viability and proliferation of SCs.
Collapse
Affiliation(s)
- O. Sena Aydos
- Department of Medical Biology, School of Medicine, Ankara University, Ankara 06230, Turkey
- Correspondence: (O.S.A.); (Y.Y.); Tel.: +90-3125958050 (O.S.A.)
| | - Yunus Yukselten
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT 06520, USA
- Correspondence: (O.S.A.); (Y.Y.); Tel.: +90-3125958050 (O.S.A.)
| | - Tulin Ozkan
- Department of Medical Biology, School of Medicine, Ankara University, Ankara 06230, Turkey
| | - Sinan Ozkavukcu
- Center for Assisted Reproduction, School of Medicine, Ankara University, Ankara 06230, Turkey
- Postgraduate Medicine, School of Medicine, University of Dundee, Dundee DD1 4HN, UK
| | - Meltem Tuten Erdogan
- Department of Medical Biology, School of Medicine, Ankara University, Ankara 06230, Turkey
| | - Asuman Sunguroglu
- Department of Medical Biology, School of Medicine, Ankara University, Ankara 06230, Turkey
| | - Kaan Aydos
- Department of Urology, School of Medicine, Ankara University, Ankara 06230, Turkey
| |
Collapse
|
3
|
Akcora-Yildiz D, Yukselten Y, Sunguroglu M, Ugur HC, Sunguroglu A. IL-33 induces ADAMTS5 expression and cell migration in glioblastoma multiforme. Med Oncol 2022; 39:22. [PMID: 34982269 DOI: 10.1007/s12032-021-01590-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/23/2021] [Indexed: 12/30/2022]
Abstract
Glioblastoma multiforme (GBM), characterized by a high rate of proliferation and migration capacity, is an incurable brain tumor in adults. Interleukin-33 (IL-33), a member of the IL-1 cytokine superfamily, and a disintegrin and metalloproteinase with thrombospondin motifs 5 (ADAMTS5), a family of zinc dependent metalloproteinases, are known to have essential roles in GBM migration and invasion. Previous studies have separately revealed elevated expressions of IL-33 and ADAMTS5 in GBM; however, the interaction between IL-33 and ADAMTS5 in GBM remains unclear. Here, using publically available GlioVis and GEPIA programs, we showed that mRNA expressions of IL-33 and ADAMTS5 are significantly high in GBM cells, and a positive correlation between IL-33 and ADAMTS5 was also determined in these cells. In parallel with the mRNA data of IL-33 and ADAMTS5, by Western blot analysis, protein levels were found to be elevated in GBM tissues and increased gradually with the disease progression. Primary GBM cells and low-grade glioma cells were then treated with IL-33 to examine its stimulating effect on ADAMTS5 expression. Exposure to IL-33 raised ADAMTS5 protein levels in a dose-dependent manner. Finally, the wound-healing method was performed to confirm the impact of IL-33 on migration in primary GBM cells. IL-33 promoted migration of primary GBM cells three times higher than untreated GBM cells. Thus, the current study suggests for the first time that IL-33 might have a role in playing a part in GBM progression through induction of ADAMTS5 expression and promotion of migration in GBM cells.
Collapse
Affiliation(s)
- Dilara Akcora-Yildiz
- Department of Biology, Science & Art Faculty, Mehmet Akif Ersoy University, Burdur, Turkey
| | - Yunus Yukselten
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey.,Research Laboratories for Health Science, Y Gen Biotechnology Company Ltd., Ankara, Turkey
| | - Merve Sunguroglu
- Department of Medical Biology, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Hasan Caglar Ugur
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Asuman Sunguroglu
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey.
| |
Collapse
|
4
|
Aktepe N, Yukselten Y. Induction of apoptosis in human hormone-refractory prostate cancer cell lines by using resveratrol in combination with AT-101. Andrologia 2021; 54:e14267. [PMID: 34633104 DOI: 10.1111/and.14267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/06/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to determine the appropriate doses of AT-101 and resveratrol combination in the in vitro hormone-refractory prostate cancer (PC) cell lines, in order to evaluate the cytotoxic and genotoxic effects of this combination on the proliferation of cancer cells, namely PC-3, DU-145 and LNCAP. Cytotoxicity in PC cell lines was analysed by using the XTT Cell Proliferation Assay. DNA damage was performed with the cell death assay. Apoptotic protein levels were performed by Roche Human Apoptosis Array. IC50 values were determined by XTT analysis. The strongest combined doses (100 µM resveratrol + 5µM AT-101) were found to have the strongest synergistic apoptotic and cytotoxic effects on DU-145 cells at 72 hr. While the combined use of resveratrol and AT-101 increased the expression of markers in apoptotic cell pathways on cells, a decrease in the expression of anti-apoptotic markers was detected (p ˂ 0.05). Combined applications of these compounds showed an important synergism in the hormone-refractory PC cell lines, and it was determined that after the post-translational modification, they were significantly effective on the apoptotic pathway. These results have revealed that the combination of resveratrol and AT-101 holds great expectation as a new chemotherapeutic application in the treatment of human prostate cancer.
Collapse
Affiliation(s)
- Necmettin Aktepe
- Faculty of Health, Department of Nursing, Mardin Artuklu University, Mardin, Turkey
| | - Yunus Yukselten
- School of Medicine, Department of Medical Biology, Ankara University, Ankara, Turkey.,Research Laboratories for Health Science, Y Gen Biotechnology Company Ltd., Ankara, Turkey
| |
Collapse
|
5
|
Aydos OS, Yukselten Y, Aydos D, Sunguroglu A, Aydos K. Relationship between functional Nrf2 gene promoter polymorphism and sperm DNA damage in male infertility. Syst Biol Reprod Med 2021; 67:399-412. [PMID: 34541983 DOI: 10.1080/19396368.2021.1972359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study examines the association of the -617 C > A polymorphism in the Nrf2 gene (rs6721961) with male infertility in a Turkish population and determines its functional role in spermatogenesis in correlation with the impact of different levels of DNA damage on the genotypes. A total of 100 infertile men and 100 healthy fertile men were included in the study. Nrf2 genotyping was performed with the PCR-based restriction fragment length gene polymorphism (RFLP-PCR) analysis. According to our results, the Nrf2 CC, CA, and AA genotype distribution frequencies were 58.6%, 38.4%, and 3% in the control group, respectively, and 38%, 48%, and 14% in the infertile men, respectively. The AA genotype was significantly higher in the patient group. In smokers, a significant difference was found in progressive motility values between the genotypes (p = 0.001). Also, sperm progressive motility and concentration decreased significantly in those smokers with the AA genotype; smokers carrying this genotype were also 5.75 times more likely to have oligoasthenozoospermia than those with CC (p < 0.05). There was a significant relationship between the number of cases with high sperm-DNA damage when comparing the frequency of Nrf2 AA genotype carriers with the CC genotype 16.3% vs. 6.9%, respectively (p < 0.001). These results suggest the importance of the Nrf2 gene C > A (rs 6,721,961) polymorphism in the etiology of sperm DNA damage as a risk factor for male infertility. Smokers carrying the AA genotype are more likely to impair seminal parameters through antioxidant mechanisms.Abbreviations: Polymerase chain reaction (PCR)-based restriction fragment length gene polymorphism (RFLP-PCR); reactive oxygen species (ROS); deoxyribonucleic acid (DNA); catalases (CATs); superoxide dismutase (SOD); glutathione peroxidase (GPX); glutathione-S-transferase (GST); Nuclear factor erythroid 2 (NF-E2)-related factor 2 (Nrf2); basic leucine zipper (bZIP); antioxidant response element (ARE); World Health Organization (WHO);normospermia(NS);asthenozoospermia(AS);oligozoospermia(OS);oligoasthenozoospermia (OAS); follicle stimulating hormone (FSH); ultraviolet (UV); low-melting-point agarose (LMA); normal-melting-point agarose (NMA); arbitrary units (AU); total comet score (TCS); A one-way analysis of variance (ANOVA); standard deviation (SD); N-acetyltransferase (NAT2); small non-coding RNAs (ncRNAs); microRNAs (miRNA).
Collapse
Affiliation(s)
- O Sena Aydos
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey
| | - Yunus Yukselten
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey.,Research Laboratories for Health Science, Y Gen Biotechnology Company Ltd, Ankara, Turkey
| | - Dunya Aydos
- Department of Stem Cells and Regenerative Medicine, Stem Cell Institute, Ankara University Ankara, Turkey
| | - Asuman Sunguroglu
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey
| | - Kaan Aydos
- Department of Urology, School of Medicine, Ankara University, Ankara, Turkey
| |
Collapse
|
6
|
Aydos S, Yukselten Y, Ozkan T, Ozkavukcu S, Erdogan M, Sunguroglu A, Aydos K. P–115 Supplementation of healthy Sertoli cells into culture media containing follicle stimulating hormone (FSH)/testosterone (T) has no advantage in germ cell maturation. Hum Reprod 2021. [DOI: 10.1093/humrep/deab130.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
In nonobstructive azoospermia (NOA) cases, whether supplementation of healthy Sertoli cells (SCs) has an effect on spermatogenic differentiation in culture medium containing FSH/T.
Summary answer
Expression of Crem and Acrosin increased significantly in both medium with FSH/T and medium with additional healthy SCs but there was no difference between them
What is known already
In NOA the induction of spermatogonial stem cells (SSCs) proliferation and differentiation has been demonstrated using different culture systems. SCs have vital roles in the regulation of spermatogenesis. Hormonal control of spermatogenesis is through FSH and T activity on SCs. Growth factors secreted by SCs via FSH, stimulate proliferation and colonization of SSCs. Although germ cells do not express androgen receptors, FSH receptors are localized on spermatogonia. It is not clear whether native SCs are sufficient for FSH/T added to the culture medium to be effective in induction of spermatogenesis, and whether supplementation of healthy SCs will increase this activity.
Study design, size, duration
34 NOA and 12 obstructive azoospermia (OA) cases were included. Testicular tissue samples were taken with testicular sperm extraction (TESE) in the study and control groups. In a group of fertile cases, healthy Sertoli cells were identified and purified and then cryopreserved. Tissue samples of each case prepared in standard DMEM/F12 medium were processed in 2 separate environments containing FSH/T and FSH/T plus thawed healthy SCs for 7 days.
Participants/materials, setting, methods
The characterization of healthy SCs isolated from fertile cases was done by flow cytometry (FC) and immunohistochemistry using antibodies specific for GATA4 and vimentin. FITC-conjugated annexin V/PI staining and MTT assay were performed to compare the viability and proliferation of SCs before and after freezing. FC was used to measure the 7th day levels of specific markers expressed in spermatogonia (Vasa), meiotic cells (Crem) and post-meiotic cells (Protamine–2 and Acrosin).
Main results and the role of chance
In Annexin V staining, no difference was found in percentages of live and apoptotic SCs, and MTT exhibited that cryopreservation didn’t inhibite the SCs proliferation compared to the pre-freezing state. Vasa and Acrosin basal levels were found to be lower in infertile patients compared to the control group (8.2% vs. 30.6% and 12.8% vs. 30.5%, p < 0.05). Compared to day 0 measurements, on the 7th day in FSH/T environment, Crem level increased by 58.8% and Acrosin level increased by 195.5% (p < 0.05). Similarly, in medium supplemented with healthy SCs, by day 7, the Crem and Acrosin levels were increased to 92.2% and 204.8%, respectively (p < 0.05). Although Vasa and Protamine levels increased in both groups, they did not reach a significant level. No significant difference was found between the 7th day increase rates of Crem, Vasa, Acrosin and Protamine–2 in either FSH/T-containing medium or in medium additionally supplemented with healthy SCs (58.8% vs. 92.2%, 120.6% vs. 79.4%, 195.5% vs. 204.8% and 232.3% vs. 198.4%, respectively, p > 0.05). Our results suggest that freezing-thawing process would not impair the viability and proliferation of SCs, and adding healthy SCs to the culture medium to correct impaired gene expression does not have an advantage over FSH/T.
Limitations, reasons for caution
The 7-day culture period we determined might be not sufficient for spermatogenic differentiation completion. This period could be extended in order to see further morphological differentiation may need.
Wider implications of the findings: The failure of the culture media containing FSH/T to show the expected effectiveness could be thought to be due to the SCs’ inadequate response to these hormones. Therefore, healthy SCs supplementation would be needed, but this could pose ethical issues. Our findings show that it is not necessary.
Trial registration number
214S532
Collapse
Affiliation(s)
- S Aydos
- Ankara University- School of Medicine, Department of Medical Biology, Ankara, Turkey
| | - Y Yukselten
- Ankara University- School of Medicine, Department of Medical Biology, Ankara, Turkey
| | - T Ozkan
- Ankara University- School of Medicine, Department of Medical Biology, Ankara, Turkey
| | - S Ozkavukcu
- Ankara University- School of Medicine, Department of Histology and Embryology, Ankara, Turkey
| | - M Erdogan
- Ankara University- School of Medicine, Department of Medical Biology, Ankara, Turkey
| | - A Sunguroglu
- Ankara University- School of Medicine, Department of Medical Biology, Ankara, Turkey
| | - K Aydos
- Ankara University- School of Medicine, Department of Urology, Ankara, Turkey
| |
Collapse
|
7
|
Aydos D, Aydos OS, Yukselten Y, Sunguroglu A, Aydos K. P–117 Bioinformatic analysis of NRF2 in the study of association of NRF2 variant and male infertility related to smoking status. Hum Reprod 2021. [DOI: 10.1093/humrep/deab130.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Study question
Could Nrf2 polymorphism (–617C>A; rs6721961) and oxidative stress (OS)-induced changes of signature seminal plasma (SP) miRNAs related to Nrf2 provide possible biomarkers of male infertility?
Summary answer
–617C>A SNP is associated with infertility through sperm OS DNA damage and miR–582–5p and miR–20a–5p, differentially represented between spermatozoa of smokers-non-smokers, might regulate Nrf2/ARE axis.
What is known already
As an extrinsic factor causing OS, smoking decreases male infertility by causing sperm membrane damage and DNA fragmentation. Expression of proteins related to the antioxidant defense system and phase 2 detoxifying enzymes controlled mainly by Nrf2/ARE pathway components is vital in managing OS-induced DNA damage. miRNAs, which multiple of are produced abundantly in male germ cells throughout spermatogenesis, have been detected in SP and contribute to multiple biological processes related to male reproductive events. miRNA-expression alterations may be induced in response to OS and without involving DNA sequence changes, miRNAs can provide additional mechanism of regulating the Nrf2 gene expression.
Study design, size, duration
Wild-type (WT) and SNP (–617) alleles in the Nrf2 gene were studied in 100 infertile cases and 100 controls and their associations with seminal parameters in relation to smoking status were assessed. In infertile cases, sperm DNA damage level was determined and compared among Nrf2 genotypes. Interactions between differentially expressed miRNAs (DEMIs) in response to smoking and Nrf2/ARE pathway components were visualized on a miRNA-mRNA regulatory network using CluePedia (v1.5.7) plugin of Cytoscape software (v3.8.2).
Participants/materials, setting, methods
Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was utilized to genotype the Nrf2 SNP (–617). DNA damages were analyzed by Comet assay. DEMIs were identified by a comprehensive bioinformatics analysis using the miRNA expression dataset GSE44134 downloaded from the GEO database. Predicted targets of DEMIs in smokers were identified by mirDIP portal. Known interactions between Nrf2 and its first neighbors were visualized after selecting STRING-actions, miRTarBase and miRecords validated miRNA source files from CluePedia panel.
Main results and the role of chance
There was significant difference for Nrf2 polymorphism between fertile and infertile males. The A allele was detected more frequently in the patient group; (P = 0.001). The frequencies of the C and A alleles of the Nrf2 were 62% and 38% in patients, and 78% and 44% in control group. The AA genotype was higher in the infertiles; 14% vs. 3% (P = 0.001). In smokers, sperm quality decreased significantly in AA genotype. The risk of DNA damage was highest with 224.58 AU in the AA genotype group, whereas it is the lowest with 164.56 AU in those carrying the CC genotype (P < 0.005). 21 differentially expressed miRNAs (including 7 downregulated and 14 upregulated in smokers) were identified. Among the upregulated DEMIs, miR–582–5p, miR–20a–5p, miR–573, miR–186–5p, miR–499a–5p were found to target the Nrf2 mRNA, suggesting their usage as biomarkers capable of indicating the antioxidant ability of the male reproductive system. The interrelations between Nrf2/Nrf2 direct interactors and DEMIs revealed the regulatory role of hsa-miR–20a–5p in SQSTM1/p62-Keap1-Nrf2 axis linked to selective autophagy. hsa-miR–582–5p was found to regulate the JNK/Jun/caspase–3 pathway, previously shown to be activated in response to OS, in which JUN can activate or suppress the Nrf2 expression.
Limitations, reasons for caution
Small number of cases while evaluating the effect of smoking weakens our ability to generalize the results. Including other coexisting factors and larger patient groups carrying other functional variants of Nrf2 as well as confirming the results at the protein level would further strengthen the results of the study.
Wider implications of the findings: This study is the first to report –617C>A polymorphism in the Nrf2 gene in the Turkish population and such a SNP may cause impaired fertility in men, especially in smokers, through oxidative metabolism. Considering these data may be valuable in determining risk groups.
Trial registration number
N/A
Collapse
Affiliation(s)
- D Aydos
- Ankara University Stem Cell Institute, Department of Stem Cells and Regenerative Medicine, Ankara, Turkey
| | - O S Aydos
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| | - Y Yukselten
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| | - A Sunguroglu
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| | - K Aydos
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| |
Collapse
|
8
|
Aydos D, Aydos OS, Yukselten Y, Sunguroglu A, Aydos K. P-117 Pre-selected for an award: Bioinformatic analysis of NRF2 in the study of association of NRF2 variant and male infertility related to smoking status. Hum Reprod 2021. [DOI: 10.1093/humrep/deab127.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Study question
Could Nrf2 polymorphism (-617C>A; rs6721961) and oxidative stress (OS)-induced changes of signature seminal plasma (SP) miRNAs related to Nrf2 provide possible biomarkers of male infertility?
Summary answer
-617C>A SNP is associated with infertility through sperm OS DNA damage and miR-582-5p and miR-20a-5p, differentially represented between spermatozoa of smokers-non-smokers, might regulate Nrf2/ARE axis.
What is known already
As an extrinsic factor causing OS, smoking decreases male infertility by causing sperm membrane damage and DNA fragmentation. Expression of proteins related to the antioxidant defense system and phase 2 detoxifying enzymes controlled mainly by Nrf2/ARE pathway components is vital in managing OS-induced DNA damage. miRNAs, which multiple of are produced abundantly in male germ cells throughout spermatogenesis, have been detected in SP and contribute to multiple biological processes related to male reproductive events. miRNA-expression alterations may be induced in response to OS and without involving DNA sequence changes, miRNAs can provide additional mechanism of regulating the Nrf2 gene expression.
Study design, size, duration
Wild-type (WT) and SNP (-617) alleles in the Nrf2 gene were studied in 100 infertile cases and 100 controls and their associations with seminal parameters in relation to smoking status were assessed. In infertile cases, sperm DNA damage level was determined and compared among Nrf2 genotypes. Interactions between differentially expressed miRNAs (DEMIs) in response to smoking and Nrf2/ARE pathway components were visualized on a miRNA-mRNA regulatory network using CluePedia (v1.5.7) plugin of Cytoscape software (v3.8.2).
Participants/materials, setting, methods
Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was utilized to genotype the Nrf2 SNP (-617). DNA damages were analyzed by Comet assay. DEMIs were identified by a comprehensive bioinformatics analysis using the miRNA expression dataset GSE44134 downloaded from the GEO database. Predicted targets of DEMIs in smokers were identified by mirDIP portal. Known interactions between Nrf2 and its first neighbors were visualized after selecting STRING-actions, miRTarBase and miRecords validated miRNA source files from CluePedia panel.
Main results and the role of chance
There was significant difference for Nrf2 polymorphism between fertile and infertile males. The A allele was detected more frequently in the patient group; (P = 0.001). The frequencies of the C and A alleles of the Nrf2 were 62% and 38% in patients, and 78% and 44% in control group. The AA genotype was higher in the infertiles; 14% vs. 3% (P = 0.001). In smokers, sperm quality decreased significantly in AA genotype. The risk of DNA damage was highest with 224.58 AU in the AA genotype group, whereas it is the lowest with 164.56 AU in those carrying the CC genotype (P < 0.005). 21 differentially expressed miRNAs (including 7 downregulated and 14 upregulated in smokers) were identified. Among the upregulated DEMIs, miR-582-5p, miR-20a-5p, miR-573, miR-186-5p, miR-499a-5p were found to target the Nrf2 mRNA, suggesting their usage as biomarkers capable of indicating the antioxidant ability of the male reproductive system. The interrelations between Nrf2/Nrf2 direct interactors and DEMIs revealed the regulatory role of hsa-miR-20a-5p in SQSTM1/p62-Keap1-Nrf2 axis linked to selective autophagy. hsa-miR-582-5p was found to regulate the JNK/Jun/caspase-3 pathway, previously shown to be activated in response to OS, in which JUN can activate or suppress the Nrf2 expression.
Limitations, reasons for caution
Small number of cases while evaluating the effect of smoking weakens our ability to generalize the results. Including other coexisting factors and larger patient groups carrying other functional variants of Nrf2 as well as confirming the results at the protein level would further strengthen the results of the study.
Wider implications of the findings
This study is the first to report -617C>A polymorphism in the Nrf2 gene in the Turkish population and such a SNP may cause impaired fertility in men, especially in smokers, through oxidative metabolism. Considering these data may be valuable in determining risk groups.
Trial registration number
N/A
Collapse
Affiliation(s)
- D Aydos
- Ankara University Stem Cell Institute, Department of Stem Cells and Regenerative Medicine, Ankara, Turkey
| | - O S Aydos
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| | - Y Yukselten
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| | - A Sunguroglu
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| | - K Aydos
- Ankara University Faculty of Medicine, Department of Medical Biology, Ankara, Turkey
| |
Collapse
|
9
|
Yukselten Y, Aydos OSE, Sunguroglu A, Aydos K. Investigation of CD133 and CD24 as candidate azoospermia markers and their relationship with spermatogenesis defects. Gene 2019; 706:211-221. [PMID: 31054360 DOI: 10.1016/j.gene.2019.04.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/07/2019] [Accepted: 04/09/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Yunus Yukselten
- Department of Medical Biology, School of Medicine, Ankara University, 06100 Ankara, Turkey; Research Laboratories for Health Science, Y Gen Biotechnology Company Ltd., 06110 Ankara, Turkey
| | - O Sena E Aydos
- Department of Medical Biology, School of Medicine, Ankara University, 06100 Ankara, Turkey.
| | - Asuman Sunguroglu
- Department of Medical Biology, School of Medicine, Ankara University, 06100 Ankara, Turkey
| | - Kaan Aydos
- Department of Urology, School of Medicine, Ankara University 06100, Ankara, Turkey
| |
Collapse
|
10
|
Aydos OS, Yukselten Y, Ozkavukcu S, Sunguroglu A, Aydos K. ADAMTS1 and ADAMTS5 metalloproteases produced by Sertoli cells: a potential diagnostic marker in azoospermia. Syst Biol Reprod Med 2018; 65:29-38. [PMID: 29737873 DOI: 10.1080/19396368.2018.1467512] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In this study, our aim was to detect protein levels of A Disintegrin and Metalloproteinase with Thrombospondin Motifs 1 and 5 (ADAMTS1 and ADAMTS5) proteases and to examine the effect of in vitro FSH supplementation on protease production in cultured Sertoli cells. The expression of metalloproteases, ADAMTS1, and ADAMTS5 were investigated in Sertoli cell cultures as well as in ejaculate of azoospermic men which then were compared with ejaculates of the fertile control group. A total of 15 azoospermic men, diagnosed as obstructive (OA, n = 5) and nonobstructive (NOA, n = 10) azoospermia were included in the study. ADAMTS1, ADAMTS5 and FSH receptors (FSHR) were found to be expressed 2.56, 2.10, and 2.66-fold less in Sertoli cells of NOA patients, than those of OA (p < 0.05). After rFSH was added onto Sertoli cell cultures of NOA patients, their expression did not increase significantly and did not reach to levels of control group. Evaluation of ejaculates revealed that the expression of ADAMTS1 and ADAMTS5 were insignificantly 1.03 and 1.1-fold higher in OA group (p > 0.05), respectively; however, in the NOA group, their expression were 1.70 and 1.96-fold lower, respectively, when compared with the fertile control group (p < 0.05) which was statistically significant. As a conclusion, the present study has revealed that insufficiency of ADAMTS1 and ADAMTS5 expression in Sertoli cells may have an important role in the etiology of male infertility. As expected due to low FSHR expression, rFSH response is impaired in NOA patients with relatively low ADAMTS expression response; therefore, such patients might hardly benefit from rFSH treatment. Further studies with larger cohorts may reveal ADAMTSs' potential use as a predictive marker for positive sperm retrieval in azoospermic patients who are scheduled to undergo testicular sperm extraction. Abbreviations: ADAM: A Disintegrin and Metalloproteinase; ADAMTS1 and ADAMTS5: A Disintegrin and Metalloproteinase with 10 Thrombospondin Motifs 1 and 5; ADAMTS: A Disintegrin and Metalloproteinase with Thrombospondin; ABP: androgen binding protein; CAMs: cell adhesion molecules; ECM: extracellular matrix; FSH: follicle stimulating hormone; FSHR: FSH receptors; HRP: horseradish peroxidase; MMP: matrix metalloproteinases; MP: metalloproteinases; NOA: nonobstructive azoospermia; OA: obstructive azoospermia; TIMP-1: tissue inhibitor of metalloproteinase-1.
Collapse
Affiliation(s)
- Oya Sena Aydos
- a Department of Medical Biology , School of Medicine, Ankara University , Ankara , Turkey
| | - Yunus Yukselten
- a Department of Medical Biology , School of Medicine, Ankara University , Ankara , Turkey
| | - Sinan Ozkavukcu
- b Center for Assisted Reproduction, Department of Obstetrics and Gynecology , Ankara University School of Medicine , Ankara , Turkey
| | - Asuman Sunguroglu
- a Department of Medical Biology , School of Medicine, Ankara University , Ankara , Turkey
| | - Kaan Aydos
- c Department of Urology , School of Medicine, Ankara University , Ankara , Turkey
| |
Collapse
|
11
|
Akyol S, Ugurcu V, Cakmak O, Altuntas A, Yukselten Y, Akyol O, Sunguroglu A, Demircan K. Evidence for the Control of Aggrecanases by Insulin and Glucose in Alzheimer's Disease. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20140905124459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Sumeyya Akyol
- Turgut Özal University, Faculty of Medicine, Department of Medical Biology, Ankara - Turkey
| | - Veli Ugurcu
- Dumlupınar University, Faculty of Medicine, Department of Medical Biochemistry, Kütahya - Turkey
| | - Ozlem Cakmak
- Gazi University, Faculty of Education, Department of Biology Education, Ankara - Turkey
| | - Aynur Altuntas
- Ankara Regional Office of Council of Forensic Medicine, Department of Chemistry, Ankara - Turkey
| | - Yunus Yukselten
- Ankara University, Faculty of Medicine, Department of Medical Biology, Ankara - Turkey
| | - Omer Akyol
- Hacettepe University, Medical School, Department of Medical Biochemistry, Ankara - Turkey
| | - Asuman Sunguroglu
- Ankara University, Faculty of Medicine, Department of Medical Biology, Ankara - Turkey
| | - Kadir Demircan
- Turgut Özal University, Faculty of Medicine, Department of Medical Biology, Ankara - Turkey
| |
Collapse
|
12
|
Gun-Eryilmaz O, Urman B, Yukselten Y, Boza A, Sunguroglu A. Gene expression levels of MMP 2, MMP 9, TIMP 1 and ADAMTS 1 in placentas of IVF/ICSI pregnancies. Fertil Steril 2016. [DOI: 10.1016/j.fertnstert.2016.07.993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
13
|
Heidargholizadeh S, Aydos SE, Yukselten Y, Ozkavukcu S, Sunguroglu A, Aydos K. A differential cytokine expression profile before and after rFSH treatment in Sertoli cell cultures of men with nonobstructive azoospermia. Andrologia 2016; 49. [DOI: 10.1111/and.12647] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2016] [Indexed: 12/20/2022] Open
Affiliation(s)
- S. Heidargholizadeh
- Department of Medical Biology; School of Medicine; Ankara University; Ankara Turkey
| | - S. E. Aydos
- Department of Medical Biology; School of Medicine; Ankara University; Ankara Turkey
| | - Y. Yukselten
- Department of Medical Biology; School of Medicine; Ankara University; Ankara Turkey
| | - S. Ozkavukcu
- Department of Obstetrics and Gynecology; School of Medicine; Assisted Reproduction Center; Ankara University; Ankara Turkey
| | - A. Sunguroglu
- Department of Medical Biology; School of Medicine; Ankara University; Ankara Turkey
| | - K. Aydos
- Department of Urology; School of Medicine; Ankara University; Ankara Turkey
| |
Collapse
|
14
|
Abstract
The aim of this study was to investigate the relationship of infertility with metalloproteinases ADAMTS1 and ADAMTS5, which are known to be responsible for the degradation of extracellular matrix (ECM) proteins associated with many diseases. ECM is the noncellular component that provides structural and biochemical support to the surrounding cells required for tissue morphogenesis, differentiation and homoeostasis. Sixty infertile individuals and 10 healthy semen donors were included in this study. The infertile individuals were classified as normozoospermia (NS; n = 20), oligozoospermia (OS; n = 20), azoospermia (AS; n = 20) groups. ADAMTS1 and ADAMTS5 protein levels in semen were analysed by Western blot. ADAMTS1 protein level was 3.0-, 3.3- and 1.6-fold lower in the OS, AS and NS groups, respectively, than in the control group (P < 0.001). ADAMTS5 protein level was 3.2-, 2.7- and 1.4-fold lower in the OS, AS and NS groups, respectively, than in the control group (P < 0.001). Sperm count and sperm motility showed a negative correlation with the levels of ADAMTS1 and ADAMTS5 protein expression: r = -0.477, r = -0.470; and r = -0.332, r = -0.275 respectively (P < 0.001). In conclusion, ADAMTS1 and ADAMTS5 protein expressions in semen are significantly related with sperm production. It is very important to understand molecular function and organisation of ADAMTSs which will be significant in enlightening the process of spermatogenesis in male infertility.
Collapse
Affiliation(s)
- S E Aydos
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey
| | - Y Yukselten
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey
| | - A Sunguroglu
- Department of Medical Biology, School of Medicine, Ankara University, Ankara, Turkey
| | - K Demircan
- Department of Medical Biology, School of Medicine, Turgut Ozal University, Ankara, Turkey
| | - K Aydos
- Department of Urology, School of Medicine, Ankara University, Ankara, Turkey
| |
Collapse
|
15
|
Akyol S, Cömertoğlu I, Firat R, Çakmak Ö, Yukselten Y, Erden G, Ugurcu V, Demircan K. Effect of insulin on the mRNA expression of procollagen N-proteinases in chondrosarcoma OUMS-27 cells. Oncol Lett 2015; 10:1091-1096. [PMID: 26622631 DOI: 10.3892/ol.2015.3317] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 04/14/2015] [Indexed: 12/30/2022] Open
Abstract
Chondrosarcoma is one of the most common bone tumors, and at present, there is no non-invasive treatment option for this cancer. The chondrosarcoma OUMS-27 cell line produces proteoglycan and type II, IX, and XI collagens, which constitutes cartilage tissue. A disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) proteases are a group of secreted proteases, which include the procollagen N-proteinases ADAMTS-2, -3 and -14. These procollagen N-proteinases perform a role in the processing of procollagens to collagen and the maturation of type I collagen. The present study aimed to improve the understanding of the causes of metastasis, local invasion and resistance to chemo- and radiotherapy in chondrosarcoma, as well as the effect of insulin on cancer cells. The present study was designed to reveal the effects of insulin on procollagen N-proteinases in chondrosarcoma OUMS-27 cells. The cells were cultured in Dulbecco's modified Eagle's medium (DMEM) alone or in DMEM containing 10 µg/ml insulin. The medium was changed every other day for 11 days. The cells were harvested on days 1, 3, 7 and 11, and total RNA isolation was performed immediately following harvesting. The expression levels of ADAMTS2, ADAMTS3 and ADAMTS14 mRNA were estimated by reverse transcription-quantitative polymerase chain reaction using appropriate primers. ADAMTS2 mRNA expression was found to be decreased on day 7 (P=0.028) and increased at day 11 compared with the control group (P=0.016). The increase in mRNA concentration at day 11 was significantly different compared to the concentrations on days 3 (P=0.047) and 7 (P=0.008). The expression of ADAMTS3 mRNA decreased immediately subsequent to insulin induction on day 1 compared with the control group (P=0.008). The most evident decrease in mRNA concentration was seen at day 7 subsequent to insulin induction (P=0.008). The present results demonstrated that ADAMTS2 and ADAMTS3 may perform a role in the invasion and metastasis of tumors, and may also possess proteolytic activity that results in the breakdown of the extracellular matrix (ECM). Insulin itself can modulate the biosynthesis of ECM macromolecules that are altered in diabetes through various pathways.
Collapse
Affiliation(s)
- Sumeyya Akyol
- Department of Medical Biology, Turgut Ozal University School of Medicine, Ankara, Ankara 06170, Turkey
| | - Ismail Cömertoğlu
- Department of Medical Genetics, Faculty of Medicine, Mevlana University, Selcuklu, Konya 42003, Turkey
| | - Ridvan Firat
- Division of Clinical Biochemistry Laboratory, Golbasi Hospital, Ministry of Health, Golbasi, Ankara 06830, Turkey
| | - Özlem Çakmak
- Department of Biology, Faculty of Education, Gazi University, Ankara, Ankara 06500, Turkey
| | - Yunus Yukselten
- Department of Medical Biology, Faculty of Medicine, Ankara University, Sihhiye, Ankara 06100, Turkey
| | - Gönül Erden
- Department of Clinical Biochemistry, Faculty of Medicine, Hacettepe University, Ankara, Ankara 06100, Turkey
| | - Veli Ugurcu
- Department of Medical Biochemistry, Faculty of Medicine, Dumlupinar University, Kutahya, Kutahya 43266, Turkey
| | - Kadir Demircan
- Department of Medical Biology, Turgut Ozal University School of Medicine, Ankara, Ankara 06170, Turkey
| |
Collapse
|
16
|
Demircan K, Yukselten Y, Bal M, Bunsuz M, Akcora Yildiz D, Sunguroglu A, Ugur H. The Role of IL33 in Glioblastoma Multiforme. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.lb142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Merve Bal
- Medical Biology Ankara UniversityAnkaraTurkey
| | | | - Dilara Akcora Yildiz
- Medical Biology Ankara UniversityAnkaraTurkey
- BiologyMehmet Akif UniversityBurdurTurkey
| | | | - Hasan Ugur
- NeurosurgeryAnkara UniversityANKARAPlease SelectTurkey
| |
Collapse
|
17
|
Yukselten Y, Akcora Yildiz D, Demircan K, Sunguroglu A, Ugur H. Isolation of Human Glioblastoma Multiforme Primary Cells and analysis of CD133+. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.lb135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Dilara Akcora Yildiz
- Medical Biology Ankara UniversityAnkaraTurkey
- BiologyMehmet Akif UniversityBurdurTurkey
| | | | | | - Hasan Ugur
- NeurosurgeryAnkara UniversityAnkaraTurkey
| |
Collapse
|
18
|
Aktepe N, Kocyigit A, Yukselten Y, Taskin A, Keskin C, Celik H. Increased DNA damage and oxidative stress among silver jewelry workers. Biol Trace Elem Res 2015; 164:185-91. [PMID: 25575665 DOI: 10.1007/s12011-014-0224-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 12/29/2014] [Indexed: 01/11/2023]
Abstract
Silver has long been valued as a precious metal, and it is used to make ornaments, jewelry, high-value tableware, utensils, and currency coins. Human exposures to silver and silver compounds can occur oral, dermal, or by inhalation. In this study, we investigated genotoxic and oxidative effects of silver exposure among silver jewelry workers. DNA damage in peripheral mononuclear leukocytes was measured by using the comet assay. Serum total antioxidative status (TAS), total oxidative status (TOS), total thiol contents, and ceruloplasmin levels were measured by using colorimetric methods among silver jewelry workers. Moreover, oxidative stress index (OSI) was calculated. Results were compared with non-exposed healthy subjects. The mean values of mononuclear leukocyte DNA damage were significantly higher than control subjects (p < 0.001). Serum TOS, OSI, and ceruloplasmin levels were also found to be higher in silver particles exposed group than those of non-exposed group (p < 0.001, p < 0.001, p < 0.01, respectively). However, serum TAS levels and total thiol contents of silver exposed group were found significantly lower (p < 0.05, p < 0.001, respectively). Exposure to silver particles among silver jewelry workers caused oxidative stress and accumulation of severe DNA damage.
Collapse
Affiliation(s)
- Necmettin Aktepe
- Department of Nursing, Mardin Artuklu University School of Health, Mardin, Turkey,
| | | | | | | | | | | |
Collapse
|