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ANKAFERD BLOOD STOPPER ALLEVIATES CADMIUM-INDUCED LUNG INJURY BY REDUCING MITOCHONDRIAL STRESS-RELATED APOPTOSIS VIA BAX/BCL-2 AND CYT-C/CAS-3 PATHWAYS

Yıl 2023, Cilt: 30 Sayı: 2, 225 - 233, 22.06.2023
https://doi.org/10.17343/sdutfd.1278783

Öz

As a result of environmental factors, cadmium (Cd)
taken into the body causes damage to lung tissues
through inflammation, oxidative stress, and increased
apoptosis. Ankaferd Blood Stopper (ABS), which is
used as a hemostatic agent, has antioxidant, antiinflammatory,
antibacterial, antiapoptotic, and wound
healing properties due to five different plant extracts
and components in its composition. Therefore, in our
study, we aimed to investigate the curative effect of
ABS on the toxicity of Cd on the lung.
Material and Method
Thirty two rats were used in the study, and they were
divided into 4 groups, with 8 rats in each group:
control, Kd (2.5 mg/kg single dose ip), ABS (1.5 ml/
kg single dose ip), and Kd+ABS (Kd, 2,5 mg/kg single
dose ip-ABS, 1.5 ml/kg single dose ip). Lung tissues
were evaluated histopathologically. Inflammation
was evaluated immunohistochemically with tumor
necrosis factor-α (TNF-α). Oxidative stress was
evaluated with the total oxidant level (TOS) and total
antioxidant level (TAS) using the spectrophotometric
method. Apoptosis was evaluated using RT-PCR with
relative mRNA fold changes of Bcl-2-associated X
(Bax), B-cell lymphoma 2 (Bcl-2), cytochrome c (Cyt
c), and caspase 3 genes.
Results
Histopathological findings such as congestion,
hemorrhage, and mononuclear cell infiltration were
found to increase in the Cd group. It was found that
Cd increased inflammation by increasing TNF-α,
increasing TOS and OSI, and decreasing TAS,
causing an increase in oxidative stress. (p<0.05).
It was determined that there was a significant
improvement in all these parameters after the ABS
application (p<0.05).
Conclusion
In conclusion, we suggested that ABS may be an
alternative option to protect against Cd-induced lung
toxicity, and more research should be done on this
subject.

Kaynakça

  • 1. Yesildag K, Gur C, Ileriturk M, Kandemir FM. Evaluation of oxidative stress, inflammation, apoptosis, oxidative DNA damage and metalloproteinases in the lungs of rats treated with cadmium and carvacrol. Mol Biol Rep. 2022;49(2):1201–11.
  • 2. Zwolak I. The role of selenium in arsenic and cadmium toxicity: an updated review of scientific literature. Biol Trace Elem Res. 2020;193(1):44–63.
  • 3. Zhang Y, Xu X, Sun D, Cao J, Zhang Y, Huo X. Alteration of the number and percentage of innate immune cells in preschool children from an e-waste recycling area. Ecotoxicol Environ Saf. 2017;145:615–22.
  • 4. Wang Y, Wu Y, Luo K, Liu Y, Zhou M, Yan S, et al. The protective effects of selenium on cadmium-induced oxidative stress and apoptosis via mitochondria pathway in mice kidney. Food Chem Toxicol. 2013;58:61–7.
  • 5. Rahimzadeh MR, Rahimzadeh MR, Kazemi S, Moghadamnia A. Cadmium toxicity and treatment: An update. Casp J Intern Med. 2017;8(3):135.
  • 6. Park JH, Lee BM, Kim HS. Potential protective roles of curcumin against cadmium-induced toxicity and oxidative stress. J Toxicol Environ Heal Part B. 2021;24(3):95–118.
  • 7. Rikans LE, Yamano T. Mechanisms of cadmium‐mediated acute hepatotoxicity. J Biochem Mol Toxicol. 2000;14(2):110–7.
  • 8. Chang K-C, Hsu C-C, Liu S-H, Su C-C, Yen C-C, Lee M-J, et al. Cadmium induces apoptosis in pancreatic β-cells through a mitochondria-dependent pathway: the role of oxidative stress-mediated c-Jun N-terminal kinase activation. PLoS One. 2013;8(2):e54374.
  • 9. Monteiro C, Ferreira de Oliveira JMP, Pinho F, Bastos V, Oliveira H, Peixoto F, et al. Biochemical and transcriptional analyses of cadmium-induced mitochondrial dysfunction and oxidative stress in human osteoblasts. J Toxicol Environ Heal Part A. 2018;81(15):705–17.
  • 10. Hu X, Chandler JD, Park S, Liu K, Fernandes J, Orr M, et al. Low-dose cadmium disrupts mitochondrial citric acid cycle and lipid metabolism in mouse lung. Free Radic Biol Med. 2019;131:209–17.
  • 11. Zhang J, Zhang Y, Qi X, Cui Y, Chen X, Lin H. TRAF2/ASK1/JNK Signaling Pathway Is Involved in the Lung Apoptosis of Swine Induced by Cadmium Exposure. Biol Trace Elem Res. 2022;1–9.
  • 12. Bertin G, Averbeck D. Cadmium: cellular effects, modifications of biomolecules, modulation of DNA repair and genotoxic consequences (a review). Biochimie. 2006;88(11):1549–59.
  • 13. Wu KC, Liu JJ, Klaassen CD. Nrf2 activation prevents cadmium- induced acute liver injury. Toxicol Appl Pharmacol. 2012;263(1):14–20.
  • 14. Pathak N, Khandelwal S. Influence of cadmium on murine thymocytes: potentiation of apoptosis and oxidative stress. Toxicol Lett. 2006;165(2):121–32.
  • 15. Guo AH, Kumar S, Lombard DB. Epigenetic mechanisms of cadmium-induced nephrotoxicity. Curr Opin Toxicol. 2022;100372.
  • 16. Susnow N, Zeng L, Margineantu D, Hockenbery DM. Bcl-2 family proteins as regulators of oxidative stress. In: Seminars in cancer biology. Elsevier; 2009. p. 42–9.
  • 17. Goker H, Haznedaroglu IC, Ercetin S, Kirazli S, Akman U, Ozturk Y, et al. Haemostatic actions of the folkloric medicinal plant extract Ankaferd Blood Stopper®. J Int Med Res. 2008;36(1):163–70.
  • 18. Beyazit Y, Kurt M, Kekilli M, Goker H, Haznedaroglu IC. Evaluation of hemostatic effects of Ankaferd as an alternative medicine. Altern Med Rev. 2010;15(4):329–36.
  • 19. Fisgin NT, Cayci YT, Coban AY, Ozatli D, Tanyel E, Durupinar B, et al. Antimicrobial activity of plant extract Ankaferd Blood Stopper®. Fitoterapia. 2009;80(1):48–50.
  • 20. Hasgul R, Uysal S, Haltas H, Akyol S, Yuksel Y, Gurel A, et al. Protective effects of Ankaferd blood stopper on aspirin-induced oxidative mucosal damage in a rat model of gastric injury. Toxicol Ind Health. 2014;30(10):888–95.
  • 21. Sheela ML, Ramakrishna MK, Salimath BP. Angiogenic and proliferative effects of the cytokine VEGF in Ehrlich ascites tumor cells is inhibited by Glycyrrhiza glabra. Int Immunopharmacol. 2006;6(3):494–8.
  • 22. Mumcuoglu M, Akin DF, Ezer U, Akar N. Ankaferd Blood Stopper induces apoptosis and regulates PAR1 and EPCR expression in human leukemia cells. Egypt J Med Hum Genet. 2015;16(1):19–27.
  • 23. Nenni M, Öncül S, Ercan A, Çelebier M, Süslü İ, Haznedaroğlu İC. Exposure of hepatocellular carcinoma cells to ankaferd blood stopper® alters cell death signaling networks confirmed by Oncoproteomic and genomic profiling studies. Curr Tradit Med. 2021;7(2):246–58.
  • 24. Buyuktiryaki M, Tayman C, Koyuncu I, Cakir U, Turkmenoglu TT, Cakir E, et al. Therapeutic and preventative effects of ankaferd blood stopper in an experimental necrotizing enterocolitis model. Biomed Pharmacother. 2019;110:105–10.
  • 25. Hortu I, Ozceltik G, Karadadas E, Erbas O, Yigitturk G, Ulukus M. The role of ankaferd blood stopper and oxytocin as potential therapeutic agents in endometriosis: a rat model. Curr Med Sci. 2020;40(3):556–62.
  • 26. Coşan DT, Aylin DAL, Soyocak A, Çolak E, Çiçek A, Hülyam K. Kadmiyum Toksisitesi Oluşturulan Sıçanlarda Tannik Asitin, Ağır Metal Giderimi ve Bazı Biyokimyasal Değerler Üzerine Etkisinin Araştırılması. Kocatepe Tıp Derg. 2017;18(4):146–53.
  • 27. Savran M, Ascı H, Armagan İ, Erzurumlu Y, Azırak S, Kaya Ozer M, et al. Thymoquinone could be protective against valproic acid‐induced testicular toxicity by antioxidant and anti‐inflammatory mechanisms. Andrologia. 2020;52(7):e13623.
  • 28. Erel O. A new automated colorimetric method for measuring total oxidant status. Clin Biochem. 2005;38(12):1103–11.
  • 29. Altindag O, Erel O, Soran N, Celik H, Selek S. Total oxidative/ anti-oxidative status and relation to bone mineral density in osteoporosis. Rheumatol Int. 2008;28(4):317–21.
  • 30. Yu W, Xu Z, Gao Q, Xu Y, Wang B, Dai Y. Protective role of wogonin against cadmium induced testicular toxicity: Involvement of antioxidant, anti-inflammatory and anti-apoptotic pathways. Life Sci. 2020;258:118192.
  • 31. Naidoo SVK, Bester MJ, Arbi S, Venter C, Dhanraj P, Oberholzer HM. Oral exposure to cadmium and mercury alone and in combination causes damage to the lung tissue of Sprague- Dawley rats. Environ Toxicol Pharmacol. 2019;69:86–94.
  • 32. Koşmaz K, Durhan A, Süleyman M, Ünal Y, Bostanci MT, Haskaraca TY, et al. The effect of Ankaferd blood stopper on liver damage in experimental obstructivejaundice. Turkish J Med Sci. 2021;51(3):1472–80.
  • 33. Jomova K, Valko M. Advances in metal-induced oxidative stress and human disease. Toxicology. 2011;283(2–3):65–87.
  • 34. Kannan K, Jain SK. Oxidative stress and apoptosis. Pathophysiology. 2000;7(3):153–63.
  • 35. Kostecka-Sochoń P, Onopiuk BM, Dąbrowska E. Protective effect of increased zinc supply against oxidative damage of sublingual gland in chronic exposure to cadmium: experimental study on rats. Oxid Med Cell Longev. 2018;2018:3732842.
  • 36. Miltonprabu S, Manoharan V. Hepatoprotective effect of grape seed proanthocyanidins on Cadmium-induced hepatic injury in rats: possible involvement of mitochondrial dysfunction, inflammation and apoptosis. Toxicol reports. 2016;3:63–77.
  • 37. Kiran Kumar KM, Naveen Kumar M, Patil RH, Nagesh R, Hegde SM, Kavya K, et al. Cadmium induces oxidative stress and apoptosis in lung epithelial cells. Toxicol Mech Methods. 2016;26(9):658–66.
  • 38. Koluman A, Akar N, Malkan UY, Haznedaroglu IC. Qualitative/ chemical analyses of Ankaferd hemostat and its antioxidant content in synthetic gastric fluids. Biomed Res Int. 2016;2016: 8957820.

ANKAFERD BLOOD STOPPER BAX/BCL-2 VE CYT-C/CAS-3 YOLAKLARI ARACILIĞIYLA MİTOKONDRİYAL STRESLE İLİŞKİLİ APOPTOZU AZALTARAK KADMİYUM KAYNAKLI AKCİĞER HASARINI HAFİFLETİR

Yıl 2023, Cilt: 30 Sayı: 2, 225 - 233, 22.06.2023
https://doi.org/10.17343/sdutfd.1278783

Öz

Amaç
Çevresel faktörlerin bir sonucu olarak vücuda alınan
kadmiyum (Kd) akciğer dokularında inflamasyon, oksidatif
stres ve artan apoptozis ile hasara neden olur.
Hemostatik bir ajan olarak kullanılan Ankaferd Blood
Stopper (ABS), bileşimindeki beş farklı bitki özü ve
bileşeni nedeniyle antioksidan, antienflamatuar, antibakteriyel,
antiapoptotik ve yara iyileştirici özelliklere
sahiptir. Bu nedenle çalışmamızda Kd’un akciğer üzerinde
oluşturduğu toksisite üzerine ABS’nin iyileştirici
etkisini araştırmayı amaçladık.
Gereç ve Yöntem
Çalışmada 32 rat kullanıldı ve her grupta 8 rat olmak
üzere 4 gruba ayrıldı: kontrol, Kd (2,5 mg/kg tek doz
ip), ABS (1,5 ml/kg tek doz ip) ve Kd+ABS (Kd, 2,5
mg/kg tek doz ip-ABS, 1,5 ml/kg tek doz ip). Akciğer
dokuları histopatolojik olarak değerlendirildi. İnflamasyon,
tümör nekroz faktörü-α (TNF-α) ile immünohistokimyasal
olarak değerlendirildi. Oksidatif stres,
total oksidan seviye (TOS) ve total antioksidan seviye
(TAS) ile spektrofotometrik yöntem kullanılarak değerlendirildi.
Apopitoz, Bcl-2 ile ilişkili X (Bax), B-hücreli
lenfoma 2 (Bcl-2), Sitokrom c (Sit c) ve kaspaz
3 genlerinin rölatif mRNA kat değişimleri ile RT-PCR
yöntemi kullanılarak değerlendirildi.
Bulgular
Kd grubunda, konjesyon, hemoraji ve mononükleer
hücre infiltrasyonu gibi histopatolojik bulgularda artış
bulundu. Kd’un TNF-α'yı yükselterek inflamasyonu
arttırdığı, TOS ve OSİ artırıp TAS'ı azaltarak oksidatif
stres artışına neden olduğu ayrıca Bax, Sit c
ve kaspaz 3 gen ekspresyonlarının arttırıp Bcl-2 gen
ekspresyonunu azaltarak mitokondriyal stres ile ilişkili
apoptozise neden olduğu bulundu (p<0.05). ABS uygulamasından
sonra tüm bu parametrelerde anlamlı
düzelme olduğu belirlendi (p<0.05).
Sonuç
Sonuç olarak, ABS'nin Kd kaynaklı akciğer toksisitesinden
koruyucu alternatif bir seçenek olabileceği ve
bu konuda daha fazla araştırma yapılması gerektiği
kanısındayız.

Kaynakça

  • 1. Yesildag K, Gur C, Ileriturk M, Kandemir FM. Evaluation of oxidative stress, inflammation, apoptosis, oxidative DNA damage and metalloproteinases in the lungs of rats treated with cadmium and carvacrol. Mol Biol Rep. 2022;49(2):1201–11.
  • 2. Zwolak I. The role of selenium in arsenic and cadmium toxicity: an updated review of scientific literature. Biol Trace Elem Res. 2020;193(1):44–63.
  • 3. Zhang Y, Xu X, Sun D, Cao J, Zhang Y, Huo X. Alteration of the number and percentage of innate immune cells in preschool children from an e-waste recycling area. Ecotoxicol Environ Saf. 2017;145:615–22.
  • 4. Wang Y, Wu Y, Luo K, Liu Y, Zhou M, Yan S, et al. The protective effects of selenium on cadmium-induced oxidative stress and apoptosis via mitochondria pathway in mice kidney. Food Chem Toxicol. 2013;58:61–7.
  • 5. Rahimzadeh MR, Rahimzadeh MR, Kazemi S, Moghadamnia A. Cadmium toxicity and treatment: An update. Casp J Intern Med. 2017;8(3):135.
  • 6. Park JH, Lee BM, Kim HS. Potential protective roles of curcumin against cadmium-induced toxicity and oxidative stress. J Toxicol Environ Heal Part B. 2021;24(3):95–118.
  • 7. Rikans LE, Yamano T. Mechanisms of cadmium‐mediated acute hepatotoxicity. J Biochem Mol Toxicol. 2000;14(2):110–7.
  • 8. Chang K-C, Hsu C-C, Liu S-H, Su C-C, Yen C-C, Lee M-J, et al. Cadmium induces apoptosis in pancreatic β-cells through a mitochondria-dependent pathway: the role of oxidative stress-mediated c-Jun N-terminal kinase activation. PLoS One. 2013;8(2):e54374.
  • 9. Monteiro C, Ferreira de Oliveira JMP, Pinho F, Bastos V, Oliveira H, Peixoto F, et al. Biochemical and transcriptional analyses of cadmium-induced mitochondrial dysfunction and oxidative stress in human osteoblasts. J Toxicol Environ Heal Part A. 2018;81(15):705–17.
  • 10. Hu X, Chandler JD, Park S, Liu K, Fernandes J, Orr M, et al. Low-dose cadmium disrupts mitochondrial citric acid cycle and lipid metabolism in mouse lung. Free Radic Biol Med. 2019;131:209–17.
  • 11. Zhang J, Zhang Y, Qi X, Cui Y, Chen X, Lin H. TRAF2/ASK1/JNK Signaling Pathway Is Involved in the Lung Apoptosis of Swine Induced by Cadmium Exposure. Biol Trace Elem Res. 2022;1–9.
  • 12. Bertin G, Averbeck D. Cadmium: cellular effects, modifications of biomolecules, modulation of DNA repair and genotoxic consequences (a review). Biochimie. 2006;88(11):1549–59.
  • 13. Wu KC, Liu JJ, Klaassen CD. Nrf2 activation prevents cadmium- induced acute liver injury. Toxicol Appl Pharmacol. 2012;263(1):14–20.
  • 14. Pathak N, Khandelwal S. Influence of cadmium on murine thymocytes: potentiation of apoptosis and oxidative stress. Toxicol Lett. 2006;165(2):121–32.
  • 15. Guo AH, Kumar S, Lombard DB. Epigenetic mechanisms of cadmium-induced nephrotoxicity. Curr Opin Toxicol. 2022;100372.
  • 16. Susnow N, Zeng L, Margineantu D, Hockenbery DM. Bcl-2 family proteins as regulators of oxidative stress. In: Seminars in cancer biology. Elsevier; 2009. p. 42–9.
  • 17. Goker H, Haznedaroglu IC, Ercetin S, Kirazli S, Akman U, Ozturk Y, et al. Haemostatic actions of the folkloric medicinal plant extract Ankaferd Blood Stopper®. J Int Med Res. 2008;36(1):163–70.
  • 18. Beyazit Y, Kurt M, Kekilli M, Goker H, Haznedaroglu IC. Evaluation of hemostatic effects of Ankaferd as an alternative medicine. Altern Med Rev. 2010;15(4):329–36.
  • 19. Fisgin NT, Cayci YT, Coban AY, Ozatli D, Tanyel E, Durupinar B, et al. Antimicrobial activity of plant extract Ankaferd Blood Stopper®. Fitoterapia. 2009;80(1):48–50.
  • 20. Hasgul R, Uysal S, Haltas H, Akyol S, Yuksel Y, Gurel A, et al. Protective effects of Ankaferd blood stopper on aspirin-induced oxidative mucosal damage in a rat model of gastric injury. Toxicol Ind Health. 2014;30(10):888–95.
  • 21. Sheela ML, Ramakrishna MK, Salimath BP. Angiogenic and proliferative effects of the cytokine VEGF in Ehrlich ascites tumor cells is inhibited by Glycyrrhiza glabra. Int Immunopharmacol. 2006;6(3):494–8.
  • 22. Mumcuoglu M, Akin DF, Ezer U, Akar N. Ankaferd Blood Stopper induces apoptosis and regulates PAR1 and EPCR expression in human leukemia cells. Egypt J Med Hum Genet. 2015;16(1):19–27.
  • 23. Nenni M, Öncül S, Ercan A, Çelebier M, Süslü İ, Haznedaroğlu İC. Exposure of hepatocellular carcinoma cells to ankaferd blood stopper® alters cell death signaling networks confirmed by Oncoproteomic and genomic profiling studies. Curr Tradit Med. 2021;7(2):246–58.
  • 24. Buyuktiryaki M, Tayman C, Koyuncu I, Cakir U, Turkmenoglu TT, Cakir E, et al. Therapeutic and preventative effects of ankaferd blood stopper in an experimental necrotizing enterocolitis model. Biomed Pharmacother. 2019;110:105–10.
  • 25. Hortu I, Ozceltik G, Karadadas E, Erbas O, Yigitturk G, Ulukus M. The role of ankaferd blood stopper and oxytocin as potential therapeutic agents in endometriosis: a rat model. Curr Med Sci. 2020;40(3):556–62.
  • 26. Coşan DT, Aylin DAL, Soyocak A, Çolak E, Çiçek A, Hülyam K. Kadmiyum Toksisitesi Oluşturulan Sıçanlarda Tannik Asitin, Ağır Metal Giderimi ve Bazı Biyokimyasal Değerler Üzerine Etkisinin Araştırılması. Kocatepe Tıp Derg. 2017;18(4):146–53.
  • 27. Savran M, Ascı H, Armagan İ, Erzurumlu Y, Azırak S, Kaya Ozer M, et al. Thymoquinone could be protective against valproic acid‐induced testicular toxicity by antioxidant and anti‐inflammatory mechanisms. Andrologia. 2020;52(7):e13623.
  • 28. Erel O. A new automated colorimetric method for measuring total oxidant status. Clin Biochem. 2005;38(12):1103–11.
  • 29. Altindag O, Erel O, Soran N, Celik H, Selek S. Total oxidative/ anti-oxidative status and relation to bone mineral density in osteoporosis. Rheumatol Int. 2008;28(4):317–21.
  • 30. Yu W, Xu Z, Gao Q, Xu Y, Wang B, Dai Y. Protective role of wogonin against cadmium induced testicular toxicity: Involvement of antioxidant, anti-inflammatory and anti-apoptotic pathways. Life Sci. 2020;258:118192.
  • 31. Naidoo SVK, Bester MJ, Arbi S, Venter C, Dhanraj P, Oberholzer HM. Oral exposure to cadmium and mercury alone and in combination causes damage to the lung tissue of Sprague- Dawley rats. Environ Toxicol Pharmacol. 2019;69:86–94.
  • 32. Koşmaz K, Durhan A, Süleyman M, Ünal Y, Bostanci MT, Haskaraca TY, et al. The effect of Ankaferd blood stopper on liver damage in experimental obstructivejaundice. Turkish J Med Sci. 2021;51(3):1472–80.
  • 33. Jomova K, Valko M. Advances in metal-induced oxidative stress and human disease. Toxicology. 2011;283(2–3):65–87.
  • 34. Kannan K, Jain SK. Oxidative stress and apoptosis. Pathophysiology. 2000;7(3):153–63.
  • 35. Kostecka-Sochoń P, Onopiuk BM, Dąbrowska E. Protective effect of increased zinc supply against oxidative damage of sublingual gland in chronic exposure to cadmium: experimental study on rats. Oxid Med Cell Longev. 2018;2018:3732842.
  • 36. Miltonprabu S, Manoharan V. Hepatoprotective effect of grape seed proanthocyanidins on Cadmium-induced hepatic injury in rats: possible involvement of mitochondrial dysfunction, inflammation and apoptosis. Toxicol reports. 2016;3:63–77.
  • 37. Kiran Kumar KM, Naveen Kumar M, Patil RH, Nagesh R, Hegde SM, Kavya K, et al. Cadmium induces oxidative stress and apoptosis in lung epithelial cells. Toxicol Mech Methods. 2016;26(9):658–66.
  • 38. Koluman A, Akar N, Malkan UY, Haznedaroglu IC. Qualitative/ chemical analyses of Ankaferd hemostat and its antioxidant content in synthetic gastric fluids. Biomed Res Int. 2016;2016: 8957820.
Toplam 38 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Klinik Tıp Bilimleri
Bölüm Araştırma Makaleleri
Yazarlar

Muhammet Yusuf Tepebaşı 0000-0002-1087-4874

Perihan Sezginer 0000-0002-1846-5530

Yayımlanma Tarihi 22 Haziran 2023
Gönderilme Tarihi 7 Nisan 2023
Kabul Tarihi 17 Mayıs 2023
Yayımlandığı Sayı Yıl 2023 Cilt: 30 Sayı: 2

Kaynak Göster

Vancouver Tepebaşı MY, Sezginer P. ANKAFERD BLOOD STOPPER ALLEVIATES CADMIUM-INDUCED LUNG INJURY BY REDUCING MITOCHONDRIAL STRESS-RELATED APOPTOSIS VIA BAX/BCL-2 AND CYT-C/CAS-3 PATHWAYS. SDÜ Tıp Fak Derg. 2023;30(2):225-33.

                                                                                         14791


Süleyman Demirel Üniversitesi Tıp Fakültesi Dergisi/Medical Journal of Süleyman Demirel University is licensed under Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International.