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Wylenzek F, Bühling KJ, Laakmann E. A systematic review on the impact of nutrition and possible supplementation on the deficiency of vitamin complexes, iron, omega-3-fatty acids, and lycopene in relation to increased morbidity in women after menopause. Arch Gynecol Obstet 2024; 310:2235-2245. [PMID: 38935105 PMCID: PMC11393286 DOI: 10.1007/s00404-024-07555-6] [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: 10/08/2023] [Accepted: 05/14/2024] [Indexed: 06/28/2024]
Abstract
A balanced and healthy diet during the menopausal transition and after menopause is crucial for women to reduce the risk for morbidities and chronic diseases due to deficiency of essential nutrients. PURPOSE The objective of this study was to conduct a systematic review of studies that analyzed the impact of vitamin and nutrient deficiencies in postmenopausal women in relation to increased morbidities and chronic conditions. METHODS Observational studies were searched in the databases PubMed, UpToDate, and Google Scholar. RESULTS We searched 122 studies, of which 90 were included in our analysis. The meta-analysis of the data could not be performed because of the heterogeneity of the statistical methods in the included studies. In our study, we focused on the aspects of vitamin B6, vitamin B12, vitamin D, iron, omega-3-fatty acids, and lycopene, belonging to the family of carotenoids. Postmenopausal women with deficiencies of these nutrients are more vulnerable to comorbidities such as cardiovascular and cerebrovascular events, metabolic diseases, osteoporosis, obesity, cancer and neurodegenerative diseases such as Parkinson's disease, Alzheimer's disease, depression, cognitive decline, dementia, and stroke. We concluded that women after menopause tend to have a greater probability of suffering from deficiencies in various vitamins and nutrients, and consequently have an increased risk of developing morbidities and chronic diseases. CONCLUSION In conclusion, maintaining optimum serum levels of nutrients and vitamins, either through a balanced and healthy diet consuming fresh fruits, vegetables, and fats or by taking appropriate supplementation, is essential in maintaining optimal health-related quality of life and reducing the risk for women during the menopausal transition and after menopause. Nevertheless, more recent studies need to be assessed to formulate adequate recommendations to achieve positive clinical outcomes.
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Affiliation(s)
- Friederike Wylenzek
- Department of Gynecological Endocrinology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Kai J Bühling
- Department of Gynecological Endocrinology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Elena Laakmann
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Zhang Y, Cong Y, Du J, Guo D, Huang J, Pan J, Liang Y, Zhang J, Ye Z, Liu Y, Zhou Y. Lif-deficiency promote systemic Iron metabolism disorders and increases the susceptibility of osteoblasts to ferroptosis. Bone 2024; 189:117266. [PMID: 39341481 DOI: 10.1016/j.bone.2024.117266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 09/20/2024] [Accepted: 09/25/2024] [Indexed: 10/01/2024]
Abstract
Leukemia inhibitory factor (LIF) is a multifunctional cytokine that plays a crucial role in various biological processes. However, LIF involvement in iron metabolism remains almost unexplored. This study aimed to explore the impact of LIF on systemic iron transportation and its potential role in ferroptosis in osteoblasts. We observed that the Lif-deficient (Lif-/-) mice is characterized by a reduction in bone mass and a decrease in bone mineral density compared with wild-type (WT) mice. Energy-dispersive X-ray spectroscopy revealed a marked increase in iron content on the surface of femurs from Lif-/- mice. Meanwhile, iron stores test lower iron levels in the spleens and higher levels in the femurs of Lif-/- mice. Besides, Lif-/- mice display increased levels of serum iron, total iron-binding capacity, unsaturated iron-binding capacity, and transferrin saturation and serum ferritin relative to WT mice. Hepcidin mRNA expression reduction in the liver of Lif-/- mice. It also holds true in the AML-12 hepatocyte cell line after Lif-knockdown. Immunohistochemistry and RT-PCR revealed elevated ferroportin (FPN) in duodenal cells of Lif-/- mice. Lif-deficiency decreases SLC7A11 levels in osteoblasts. In addition, overexpression of LIF downregulates CD71, DCYTB, and DMT1, thereby reducing iron uptake in iron-overloaded cells. Femur immunohistochemistry (IHC) revealed increased ACSL4 and decreased GPX4 and SLC7A11, indicating an increase in ferroptosis of osteoblasts in Lif-/- mice. Whole-transcriptome sequencing showed gene expression changes after Lif-knockdown, exhibiting a negative correlation with genes involved in long-chain fatty acid transport, mitochondrial organization, and the p38 MAPK signaling pathway. These results demonstrate that Lif-deficiency alter systemic iron metabolism and increases the susceptibility of osteoblasts to ferroptosis.
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Affiliation(s)
- Yu Zhang
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Yaqi Cong
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Juan Du
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Donghua Guo
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Jing Huang
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Junchen Pan
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Youde Liang
- The People's Hospital of Baoan Shenzhen, Shenzhen, China
| | - Jiali Zhang
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China
| | - Zhou Ye
- Applied Oral Sciences and Community Dental Care, Faculty of Dentistry, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Yi Liu
- Department of Stomatology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Edong Healthcare Group, Huangshi 435002, China.
| | - Yi Zhou
- State Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Key Laboratory of Oral Biomedicine Ministry of Education, Hubei Key Laboratory of Stomatology, School & Hospital of Stomatology, Wuhan University, Wuhan 430079, China; Center for Prosthodontics and Implant Dentistry, Optics Valley Branch, School and Hospital of Stomatology, Wuhan University, Wuhan, China.
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Papastergiou E, Rallis D, Papagianni A, Cholevas V, Katzilakis N, Siomou E, Stiakaki E, Makis A. Intact FGF23 and Markers of Iron Homeostasis, Inflammation, and Bone Mineral Metabolism in Acute Pediatric Infections. BIOLOGY 2024; 13:728. [PMID: 39336155 PMCID: PMC11428972 DOI: 10.3390/biology13090728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Revised: 09/10/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024]
Abstract
We intend to evaluate the association of intact Fibroblast Growth Factor 23 (i-FGF23), a phosphaturic hormone that contributes to anemia of inflammation, with markers of iron homeostasis, inflammation, and bone mineral metabolism in acute pediatric infections. Seventy-nine children, aged 1 month-13 years, out of which forty-two were males and thirty-seven females, participated in this study. Children with diseases and nutrient deficiencies causing anemia were excluded. Twenty-six patients had bacterial infections, twenty-six had viral infections, and twenty-seven children served as healthy controls. Complete blood count, markers of inflammation, iron and mineral metabolism, serum hepcidin, and i-FGF23 were compared between the groups. Thirty-nine percent of patients with bacterial infection and twelve percent of patients with viral infection presented characteristics of anemia of inflammation (p < 0.001). Ninety-two percent of patients with bacterial infection and eighty-one percent of patients with viral infection had functional iron deficiency (p < 0.001). Hepcidin was significantly positively correlated with the duration of fever, markers of inflammation, and negatively with iron, mineral metabolism parameters, and i-FGF23. i-FGF23 was positively correlated with iron metabolism parameters and negatively with the duration of fever, markers of inflammation, and hepcidin. Hepcidin levels increase, whereas i-FGF23 levels decrease in acute pediatric infections. Further research is required to understand the role of FGF23 in the hepcidin-ferroportin axis and for hepcidin in the diagnosis of bacterial infections and mineral metabolism.
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Affiliation(s)
- Eleni Papastergiou
- Department of Pediatrics, University Hospital of Ioannina, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
- Department of Pediatric Hematology-Oncology, University Hospital of Heraklion, Postgraduate Program “Hematology-Oncology in Childhood and Adolescence” of Medical School, University of Crete, 71003 Heraklion, Greece
| | - Dimitrios Rallis
- Neonatal Intensive Care Unit, University Hospital of Ioannina, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Afroditi Papagianni
- Laboratory of Child Health, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Vasileios Cholevas
- Laboratory of Child Health, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Nikolaos Katzilakis
- Department of Pediatric Hematology-Oncology, University Hospital of Heraklion, Postgraduate Program “Hematology-Oncology in Childhood and Adolescence” of Medical School, University of Crete, 71003 Heraklion, Greece
| | - Ekaterini Siomou
- Department of Pediatrics, University Hospital of Ioannina, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
| | - Eftichia Stiakaki
- Department of Pediatric Hematology-Oncology, University Hospital of Heraklion, Postgraduate Program “Hematology-Oncology in Childhood and Adolescence” of Medical School, University of Crete, 71003 Heraklion, Greece
| | - Alexandros Makis
- Department of Pediatrics, University Hospital of Ioannina, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
- Laboratory of Child Health, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
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Li Z, Yao X, Zhang J, Yang J, Ni J, Wang Y. Exploring the bone marrow micro environment in thalassemia patients: potential therapeutic alternatives. Front Immunol 2024; 15:1403458. [PMID: 39161767 PMCID: PMC11330836 DOI: 10.3389/fimmu.2024.1403458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/22/2024] [Indexed: 08/21/2024] Open
Abstract
Genetic mutations in the β-globin gene lead to a decrease or removal of the β-globin chain, causing the build-up of unstable alpha-hemoglobin. This condition is referred to as beta-thalassemia (BT). The present treatment strategies primarily target the correction of defective erythropoiesis, with a particular emphasis on gene therapy and hematopoietic stem cell transplantation. However, the presence of inefficient erythropoiesis in BT bone marrow (BM) is likely to disturb the previously functioning BM microenvironment. This includes accumulation of various macromolecules, damage to hematopoietic function, destruction of bone cell production and damage to osteoblast(OBs), and so on. In addition, the changes of BT BM microenvironment may have a certain correlation with the occurrence of hematological malignancies. Correction of the microenvironment can be achieved through treatments such as iron chelation, antioxidants, hypoglycemia, and biologics. Hence, This review describes damage in the BT BM microenvironment and some potential remedies.
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Affiliation(s)
- Zengzheng Li
- Department of Hematology, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Hematologic Disease, The First People’s Hospital of Yunnan Province, Kunming, Yunnan, China
- Yunnan Provincial Clinical Medical Center for Blood Diseases and Thrombosis Prevention and Treatment, Kunming, Yunnan, China
| | - Xiangmei Yao
- Department of Hematology, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Hematologic Disease, The First People’s Hospital of Yunnan Province, Kunming, Yunnan, China
- Yunnan Provincial Clinical Medical Center for Blood Diseases and Thrombosis Prevention and Treatment, Kunming, Yunnan, China
| | - Jie Zhang
- Department of Medical Genetics, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Jinghui Yang
- Department of Pediatrics, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Junxue Ni
- Hospital Office, The First People’s Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yajie Wang
- Department of Hematology, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
- Yunnan Province Clinical Research Center for Hematologic Disease, The First People’s Hospital of Yunnan Province, Kunming, Yunnan, China
- Yunnan Provincial Clinical Medical Center for Blood Diseases and Thrombosis Prevention and Treatment, Kunming, Yunnan, China
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Zhang H, Yang F, Cao Z, Xu Y, Wang M. The influence of iron on bone metabolism disorders. Osteoporos Int 2024; 35:243-253. [PMID: 37857915 DOI: 10.1007/s00198-023-06937-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 09/29/2023] [Indexed: 10/21/2023]
Abstract
Iron is a necessary trace element in the human body, and it participates in many physiological processes. Disorders of iron metabolism can cause lesions in many tissues and organs, including bone. Recently, iron has gained attention as an independent factor influencing bone metabolism disorders, especially the involvement of iron overload in osteoporosis. The aim of this review was to summarize the findings from clinical and animal model research regarding the involvement of iron in bone metabolism disorders and to elucidate the mechanisms behind iron overload and osteoporosis. Lastly, we aimed to describe the association between bone loss and iron overload. We believe that a reduction in iron accumulation can be used as an alternative treatment to assist in the treatment of osteoporosis, to improve bone mass, and to improve the quality of life of patients.
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Affiliation(s)
- Hui Zhang
- Department of Orthopedics, the Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Fan Yang
- Department of Orthopedics, the Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Zihou Cao
- Department of Orthopedics, the Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Youjia Xu
- Department of Orthopedics, the Second Affiliated Hospital of Soochow University, Suzhou, 215004, China.
| | - Mingyong Wang
- Murui Biological Technology Co., Ltd, Suzhou Industrial Park, Suzhou, China.
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6
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Liu LL, Liu ZR, Xiao YS, Xiao JH, Huang WM, Liu WY, Zhao K, Ye YJ. SPI1 exacerbates iron accumulation and promotes osteoclast formation through inhibiting the expression of Hepcidin. Mol Cell Endocrinol 2024; 580:112103. [PMID: 38450475 DOI: 10.1016/j.mce.2023.112103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Osteoporosis (OP) can be caused by an overactive osteoclastic function. Anti-osteoporosis considerable therapeutic effects in tissue repair and regeneration because bone resorption is a unique osteoclast function. In this study, we mainly explored the underlying mechanisms of osteoclasts' effects on osteoporosis. METHODS RAW264.7 cells were used and induced toward osteoclast and iron accumulation by M-CSF and RANKL administration. We investigated Hepcidin and divalent metal transporter 1 (DMT1) on iron accumulation and osteoclast formation in an ovariectomy (OVX)-induced osteoporosis. Osteoporosis was induced in mice by OVX, and treated with Hepcidin (10, 20, 40, 80 mg/kg, respectively) and overexpression of DMT1 by tail vein injection. Hepcidin, SPI1, and DMT1 were detected by immunohistochemical staining, western blot and RT-PCR. The bioinformatics assays, luciferase assays, and Chromatin Immunoprecipitation (ChIP) verified that Hepcidin was a direct SPI1 transcriptional target. Iron accumulation was detected by laser scanning confocal microscopy, Perl's iron staining and iron content assay. The formation of osteoclasts was assessed using tartrate-resistant acid phosphatase (TRAP) staining. RESULTS We found that RAW264.7 cells differentiated into osteoclasts when exposed to M-CSF and RANKL, which increased the protein levels of osteoclastogenesis-related genes, including c-Fos, MMP9, and Acp5. We also observed higher concentration of iron accumulation when M-CSF and RANKL were administered. However, Hepcidin inhibited the osteoclast differentiation cells and decreased intracellular iron concentration primary osteoclasts derived from RAW264.7. Spi-1 proto-oncogene (SPI1) transcriptionally repressed the expression of Hepcidin, increased DMT1, facilitated the differentiation and iron accumulation of mouse osteoclasts. Overexpression of SPI1 significantly declined luciferase activity of HAMP promoter and increased the enrichment of HAMP promoter. Furthermore, our results showed that Hepcidin inhibited osteoclast differentiation and iron accumulation in mouse osteoclasts and OVX mice. CONCLUSION Therefore, the study revealed that SPI1 could inhibit Hepcidin expression contribute to iron accumulation and osteoclast formation via DMT1 signaling activation in mouse with OVX.
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Affiliation(s)
- Lu-Lin Liu
- Department of Orthopedics, The First Affiliated Hospital of Gannan Medical University, China
| | - Zhong-Rui Liu
- The First Clinical Medical College of Gannan Medical University, China
| | - Yao-Sheng Xiao
- Department of Orthopedics, The First Affiliated Hospital of Gannan Medical University, China
| | - Jian-Hua Xiao
- Department of Orthopedics, The First Affiliated Hospital of Gannan Medical University, China
| | - Wei-Min Huang
- Department of Orthopedics, The First Affiliated Hospital of Gannan Medical University, China
| | - Wu-Yang Liu
- Department of Orthopedics, The First Affiliated Hospital of Gannan Medical University, China
| | - Kai Zhao
- Department of Orthopedics, The First Affiliated Hospital of Gannan Medical University, China.
| | - Yong-Jun Ye
- Department of Orthopedics, The First Affiliated Hospital of Gannan Medical University, China.
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7
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Wang S, Liu Y, Lou C, Cai C, Ren W, Liu J, Gong M, Shang P, Zhang H. Moderate static magnetic field promotes fracture healing and regulates iron metabolism in mice. Biomed Eng Online 2023; 22:107. [PMID: 37968671 PMCID: PMC10647027 DOI: 10.1186/s12938-023-01170-3] [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: 06/27/2023] [Accepted: 10/31/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Fractures are the most common orthopedic diseases. It is known that static magnetic fields (SMFs) can contribute to the maintenance of bone health. However, the effect and mechanism of SMFs on fracture is still unclear. This study is aim to investigate the effect of moderate static magnetic fields (MMFs) on bone structure and metabolism during fracture healing. METHODS Eight-week-old male C57BL/6J mice were subjected to a unilateral open transverse tibial fracture, and following treatment under geomagnetic field (GMF) or MMF. The micro-computed tomography (Micro-CT) and three-point bending were employed to evaluate the microarchitecture and mechanical properties. Endochondral ossification and bone remodeling were evaluated by bone histomorphometric and serum biochemical assay. In addition, the atomic absorption spectroscopy and ELISA were utilized to examine the influence of MMF exposure on iron metabolism in mice. RESULTS MMF exposure increased bone mineral density (BMD), bone volume per tissue volume (BV/TV), mechanical properties, and proportion of mineralized bone matrix of the callus during fracture healing. MMF exposure reduced the proportion of cartilage in the callus area during fracture healing. Meanwhile, MMF exposure increased the number of osteoblasts in callus on the 14th day, and reduced the number of osteoclasts on the 28th day of fracture healing. Furthermore, MMF exposure increased PINP and OCN levels, and reduced the TRAP-5b and β-CTX levels in serum. It was also observed that MMF exposure reduced the iron content in the liver and callus, as well as serum ferritin levels while elevating the serum hepcidin concentration. CONCLUSIONS MMF exposure could accelerate fracture healing via promote the endochondral ossification and bone formation while regulating systemic iron metabolism during fracture healing. This study suggests that MMF may have the potential to become a form of physical therapy for fractures.
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Affiliation(s)
- Shenghang Wang
- Department of Spine Surgery, People's Hospital of Longhua, Affiliated Hospital of Southern Medical University, No.38 Jinglong Construction Road, Shenzhen, China
- School of Life Sciences, Northwestern Polytechnical University, Xi'an, China
| | - Yuetong Liu
- School of Life Sciences, Northwestern Polytechnical University, Xi'an, China
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, No. 45, Gaoxin South 9th Road, Nanshan District, Shenzhen, 518057, China
| | - Chenge Lou
- School of Life Sciences, Northwestern Polytechnical University, Xi'an, China
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, No. 45, Gaoxin South 9th Road, Nanshan District, Shenzhen, 518057, China
| | - Chao Cai
- School of Life Sciences, Northwestern Polytechnical University, Xi'an, China
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, No. 45, Gaoxin South 9th Road, Nanshan District, Shenzhen, 518057, China
| | - Weihao Ren
- School of Life Sciences, Northwestern Polytechnical University, Xi'an, China
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, No. 45, Gaoxin South 9th Road, Nanshan District, Shenzhen, 518057, China
| | - Junyu Liu
- School of Life Sciences, Northwestern Polytechnical University, Xi'an, China
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, No. 45, Gaoxin South 9th Road, Nanshan District, Shenzhen, 518057, China
| | - Ming Gong
- Department of Spine Surgery, People's Hospital of Longhua, Affiliated Hospital of Southern Medical University, No.38 Jinglong Construction Road, Shenzhen, China
| | - Peng Shang
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, No. 45, Gaoxin South 9th Road, Nanshan District, Shenzhen, 518057, China.
| | - Hao Zhang
- Department of Spine Surgery, People's Hospital of Longhua, Affiliated Hospital of Southern Medical University, No.38 Jinglong Construction Road, Shenzhen, China.
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Skalny AV, Aschner M, Silina EV, Stupin VA, Zaitsev ON, Sotnikova TI, Tazina SI, Zhang F, Guo X, Tinkov AA. The Role of Trace Elements and Minerals in Osteoporosis: A Review of Epidemiological and Laboratory Findings. Biomolecules 2023; 13:1006. [PMID: 37371586 DOI: 10.3390/biom13061006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
The objective of the present study was to review recent epidemiological and clinical data on the association between selected minerals and trace elements and osteoporosis, as well as to discuss the molecular mechanisms underlying these associations. We have performed a search in the PubMed-Medline and Google Scholar databases using the MeSH terms "osteoporosis", "osteogenesis", "osteoblast", "osteoclast", and "osteocyte" in association with the names of particular trace elements and minerals through 21 March 2023. The data demonstrate that physiological and nutritional levels of trace elements and minerals promote osteogenic differentiation through the up-regulation of BMP-2 and Wnt/β-catenin signaling, as well as other pathways. miRNA and epigenetic effects were also involved in the regulation of the osteogenic effects of trace minerals. The antiresorptive effect of trace elements and minerals was associated with the inhibition of osteoclastogenesis. At the same time, the effect of trace elements and minerals on bone health appeared to be dose-dependent with low doses promoting an osteogenic effect, whereas high doses exerted opposite effects which promoted bone resorption and impaired bone formation. Concomitant with the results of the laboratory studies, several clinical trials and epidemiological studies demonstrated that supplementation with Zn, Mg, F, and Sr may improve bone quality, thus inducing antiosteoporotic effects.
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Affiliation(s)
- Anatoly V Skalny
- Laboratory of Ecobiomonitoring and Quality Control, Yaroslavl State University, 150003 Yaroslavl, Russia
- Center of Bioelementology and Human Ecology, Institute of Biodesign and Modeling of Complex Systems, Department of Therapy of the Institute of Postgraduate Education, IM Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Ekaterina V Silina
- Center of Bioelementology and Human Ecology, Institute of Biodesign and Modeling of Complex Systems, Department of Therapy of the Institute of Postgraduate Education, IM Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
| | - Victor A Stupin
- Department of Hospital Surgery No. 1, Pirogov Russian National Research Medical University, 117997 Moscow, Russia
| | - Oleg N Zaitsev
- Department of Physical Education, Yaroslavl State Technical University, 150023 Yaroslavl, Russia
| | - Tatiana I Sotnikova
- Center of Bioelementology and Human Ecology, Institute of Biodesign and Modeling of Complex Systems, Department of Therapy of the Institute of Postgraduate Education, IM Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
- City Clinical Hospital n. a. S.P. Botkin of the Moscow City Health Department, 125284 Moscow, Russia
| | - Serafima Ia Tazina
- Center of Bioelementology and Human Ecology, Institute of Biodesign and Modeling of Complex Systems, Department of Therapy of the Institute of Postgraduate Education, IM Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
| | - Feng Zhang
- Key Laboratory of Trace Elements and Endemic Diseases, National Health and Family Planning Commission, Health Science Center, School of Public Health, Xi'an Jiaotong University, Xi'an 710061, China
| | - Xiong Guo
- Key Laboratory of Trace Elements and Endemic Diseases, National Health and Family Planning Commission, Health Science Center, School of Public Health, Xi'an Jiaotong University, Xi'an 710061, China
| | - Alexey A Tinkov
- Laboratory of Ecobiomonitoring and Quality Control, Yaroslavl State University, 150003 Yaroslavl, Russia
- Center of Bioelementology and Human Ecology, Institute of Biodesign and Modeling of Complex Systems, Department of Therapy of the Institute of Postgraduate Education, IM Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
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Zhang C, Li H, Li J, Hu J, Yang K, Tao L. Oxidative stress: A common pathological state in a high-risk population for osteoporosis. Biomed Pharmacother 2023; 163:114834. [PMID: 37163779 DOI: 10.1016/j.biopha.2023.114834] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023] Open
Abstract
Osteoporosis is becoming a major concern in the field of public health. The process of bone loss is insidious and does not directly induce obvious symptoms. Complications indicate an irreversible decrease in bone mass. The high-risk populations of osteoporosis, including postmenopausal women, elderly men, diabetic patients and obese individuals need regular bone mineral density testing and appropriate preventive treatment. However, the primary changes in these populations are different, increasing the difficulty of effective treatment of osteoporosis. Determining the core pathogenesis of osteoporosis helps improve the efficiency and efficacy of treatment among these populations. Oxidative stress is a common pathological state secondary to estrogen deficiency, aging, hyperglycemia and hyperlipemia. In this review, we divided oxidative stress into the direct effect of reactive oxygen species (ROS) and the reduction of antioxidant enzyme activity to discuss their roles in the development of osteoporosis. ROS initiated mitochondrial apoptotic signaling and suppressed osteogenic marker expression to weaken osteogenesis. MAPK and NF-κB signaling pathways mediated the positive effect of ROS on osteoclast differentiation. Antioxidant enzymes not only eliminate the negative effects of ROS, but also directly participate in the regulation of bone metabolism. Additionally, we also described the roles of proinflammatory factors and HIF-1α under the pathophysiological changes of inflammation and hypoxia, which provided a supplement of oxidative stress-induced osteoporosis. In conclusion, our review showed that oxidative stress was a common pathological state in a high-risk population for osteoporosis. Targeted oxidative stress treatment would greatly optimize the therapeutic schedule of various osteoporosis treatments.
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Affiliation(s)
- Chi Zhang
- Department of Orthopedics, First Hospital of China Medical University, No.155 Nanjing North Street, Shenyang, China
| | - Hao Li
- Department of Orthopedics, First Hospital of China Medical University, No.155 Nanjing North Street, Shenyang, China
| | - Jie Li
- Department of Orthopedics, First Hospital of China Medical University, No.155 Nanjing North Street, Shenyang, China
| | - Jiajin Hu
- Health Sciences Institute, China Medical University, Shenyang 110122, China
| | - Keda Yang
- Department of Orthopedics, First Hospital of China Medical University, No.155 Nanjing North Street, Shenyang, China.
| | - Lin Tao
- Department of Orthopedics, First Hospital of China Medical University, No.155 Nanjing North Street, Shenyang, China.
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10
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Xie L, Fang B, Zhang C. The role of ferroptosis in metabolic diseases. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2023; 1870:119480. [PMID: 37127193 DOI: 10.1016/j.bbamcr.2023.119480] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/03/2023]
Abstract
The annual incidence of metabolic diseases such as diabetes, non-alcoholic fatty liver disease (NAFLD), osteoporosis, and atherosclerosis (AS) is increasing, resulting in a heavy burden on human health and the social economy. Ferroptosis is a novel form of programmed cell death driven by iron-dependent lipid peroxidation, which was discovered in recent years. Emerging evidence has suggested that ferroptosis contributes to the development of metabolic diseases. Here, we summarize the mechanisms and molecular signaling pathways involved in ferroptosis. Then we discuss the role of ferroptosis in metabolic diseases. Finally, we analyze the potential of targeting ferroptosis as a promising therapeutic approach for metabolic diseases.
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Affiliation(s)
- Ling Xie
- Department of Nephrology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430072, Hubei, China
| | - Bin Fang
- Department of Nephrology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430072, Hubei, China
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430072, Hubei, China.
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11
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Yu L, Li X, He M, Wang Q, Chen C, Li F, Li B, Li L. Antioxidant Carboxymethyl Chitosan Carbon Dots with Calcium Doping Achieve Ultra-Low Calcium Concentration for Iron-Induced Osteoporosis Treatment by Effectively Enhancing Calcium Bioavailability in Zebrafish. Antioxidants (Basel) 2023; 12:antiox12030583. [PMID: 36978831 PMCID: PMC10045075 DOI: 10.3390/antiox12030583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Iron overloads osteoporosis mainly occurs to postmenopausal women and people requiring repeated blood transfusions. Iron overload increases the activity of osteoclasts and decreases the activity of osteoblasts, leading to the occurrence of osteoporosis. Conventional treatment options include calcium supplements and iron chelators. However, simple calcium supplementation is not effective, and it does not have a good therapeutic effect. Oxidative stress is one of the triggers for osteoporosis. Therefore, the study focuses on the antioxidant aspect of osteoporosis treatment. The present work revealed that antioxidant carboxymethyl chitosan-based carbon dots (AOCDs) can effectively treat iron overload osteoporosis. More interestingly, the functional modification of AOCDs by doping calcium gluconate (AOCDs:Ca) is superior to the use of any single component. AOCDs:Ca have the dual function of antioxidant and calcium supplement. AOCDs:Ca effectively improve the bioavailability of calcium and achieve ultra-low concentration calcium supplement for the treatment of iron-induced osteoporosis in zebrafish.
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Affiliation(s)
- Lidong Yu
- School of Life Science and Technology, Harbin Institute of Technology, Harbin 150080, China
- School of Physics, Harbin Institute of Technology, Harbin 150080, China
| | - Xueting Li
- School of Life Science and Technology, Harbin Institute of Technology, Harbin 150080, China
| | - Mingyue He
- School of Life Science and Technology, Harbin Institute of Technology, Harbin 150080, China
| | - Qingchen Wang
- School of Life Science and Technology, Harbin Institute of Technology, Harbin 150080, China
| | - Ce Chen
- School of Life Science and Technology, Harbin Institute of Technology, Harbin 150080, China
| | - Fangshun Li
- School of Life Science and Technology, Harbin Institute of Technology, Harbin 150080, China
| | - Bingsheng Li
- Key Laboratory of UV Light Emitting Materials and Technology of Ministry of Education, Northeast Normal University, Changchun 130024, China
| | - Li Li
- School of Physics, Harbin Institute of Technology, Harbin 150080, China
- Correspondence:
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12
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Salminen AV, Clemens S, García-Borreguero D, Ghorayeb I, Li Y, Manconi M, Ondo W, Rye D, Siegel JM, Silvani A, Winkelman JW, Allen RP, Ferré S. Consensus guidelines on the construct validity of rodent models of restless legs syndrome. Dis Model Mech 2022; 15:dmm049615. [PMID: 35946581 PMCID: PMC9393041 DOI: 10.1242/dmm.049615] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/10/2022] [Indexed: 12/16/2022] Open
Abstract
Our understanding of the causes and natural course of restless legs syndrome (RLS) is incomplete. The lack of objective diagnostic biomarkers remains a challenge for clinical research and for the development of valid animal models. As a task force of preclinical and clinical scientists, we have previously defined face validity parameters for rodent models of RLS. In this article, we establish new guidelines for the construct validity of RLS rodent models. To do so, we first determined and agreed on the risk, and triggering factors and pathophysiological mechanisms that influence RLS expressivity. We then selected 20 items considered to have sufficient support in the literature, which we grouped by sex and genetic factors, iron-related mechanisms, electrophysiological mechanisms, dopaminergic mechanisms, exposure to medications active in the central nervous system, and others. These factors and biological mechanisms were then translated into rodent bioequivalents deemed to be most appropriate for a rodent model of RLS. We also identified parameters by which to assess and quantify these bioequivalents. Investigating these factors, both individually and in combination, will help to identify their specific roles in the expression of rodent RLS-like phenotypes, which should provide significant translational implications for the diagnosis and treatment of RLS.
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Affiliation(s)
- Aaro V. Salminen
- Institute of Neurogenomics, Helmholtz Zentrum München GmbH - German Research Center for Environmental Health, 85764 Neuherberg, Germany
- Institute of Human Genetics, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Stefan Clemens
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA
| | | | - Imad Ghorayeb
- Département de Neurophysiologie Clinique, Pôle Neurosciences Cliniques, CHU de Bordeaux, 33076 Bordeaux, France
- Université de Bordeaux, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, UMR 5287, 33076 Bordeaux, France
- CNRS, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, UMR 5287, 33076 Bordeaux, France
| | - Yuqing Li
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Mauro Manconi
- Sleep Medicine Unit, Regional Hospital of Lugano, Neurocenter of Southern Switzerland, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Department of Neurology, University Hospital Inselspital, 3010 Bern, Switzerland
| | - William Ondo
- Houston Methodist Hospital Neurological Institute, Weill Cornell Medical School, Houston, TX 77070, USA
| | - David Rye
- Department of Neurology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jerome M. Siegel
- Neuropsychiatric Institute and Brain Research Institute, University of California, Los Angeles, CA 90095, USA
- Neurobiology Research, Veterans Administration Greater Los Angeles Healthcare System, North Hills, CA 91343, USA
| | - Alessandro Silvani
- Department of Biomedical and Neuromotor Sciences Alma Mater Studiorum, Università di Bologna, 48121 Ravenna Campus, Ravenna, Italy
| | - John W. Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Richard P. Allen
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21224, USA
| | - Sergi Ferré
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD 21224, USA
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Hu J, Dusenge MA, Ye Q, Zhao YQ, Tan L, Feng Y, Zhao J, Gao ZR, Zhang SH, Chen Y, Zhou YH, Guo Y, Feng YZ. Role of NOD2 and hepcidin in inflammatory periapical periodontitis. BMC Oral Health 2022; 22:263. [PMID: 35764993 PMCID: PMC9241313 DOI: 10.1186/s12903-022-02286-z] [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: 03/27/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022] Open
Abstract
The immunological response occurring during periapical inflammation includes expression of nucleotide binding oligomerization domain containing 2 and hepcidin. Nucleotide binding oligomerization domain containing 2 deficiency increases infiltration of inflammatory cells close to alveolar bone. Hepcidin has an important role in iron metabolism affecting bone metabolism.We investigated the role of nucleotide binding oligomerization domain containing 2 and hepcidin in inflammatory periapical periodontitis. Periapical periodontitis was induced in rats and confirmed by micro-computed tomography. Nucleotide binding oligomerization domain 2 and hepcidin were evaluated through immunohistochemistry. Bioinformatics analysis was undertaken usingthe Kyoto Encyclopedia of Genes and Genomes and Gene Ontology databases. Micro-computer tomography revealed alveolar bone resorption in the periapical region and furcation area of mandibular molars in rats of the periapical periodontitis group. Immunohistochemistry showed increased expressionof nucleotide binding oligomerization domain containing 2 and hepcidin around root apices in rats of the periapical periodontitis group. Bioinformatics analysis of differentially expressed genes in inflamed and non-inflamed tissues revealed enrichment in the NOD-like receptor signaling pathway. Our data suggest that nucleotide binding oligomization domain contain2 and hepcidin have important roles in periapical periodontitis severity because they can reduce alveolar bone loss.They could elicit new perspectives for development of novel strategies for periapical periodontitis treatment.
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Affiliation(s)
- Jing Hu
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Marie Aimee Dusenge
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Qin Ye
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Ya-Qiong Zhao
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Li Tan
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Yao Feng
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Jie Zhao
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Zheng-Rong Gao
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Shao-Hui Zhang
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Yun Chen
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Ying-Hui Zhou
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Yue Guo
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
| | - Yun-Zhi Feng
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
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14
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Adding liver R2* quantification to proton density fat fraction MRI of vertebral bone marrow improves the prediction of osteoporosis. Eur Radiol 2022; 32:7108-7116. [PMID: 35610386 DOI: 10.1007/s00330-022-08861-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/28/2022] [Accepted: 05/03/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To assess the predictive value of the combination of bone marrow (BM) proton density fat fraction (PDFF) and liver R2* for osteopenia and osteoporosis and the additional role of liver R2*. METHODS A total of 107 healthy women were included between June 2019 and January 2021. Each participant underwent dual-energy X-ray absorptiometry (DXA) and chemical shift-encoded 3.0-T MRI. PDFF measurements were performed for each lumbar vertebral body, and R2* measurements were performed in liver segments. Agreement among measurements was assessed by Bland-Altman analysis. Receiver operating characteristic (ROC) curves were generated to select optimised cut-offs for BM PDFF and liver R2*. Univariable and multivariable logistic regressions were performed. The C statistic and continuous net reclassification improvement (NRI) were adopted to explore the incremental predictive ability of liver R2*. RESULTS Bone mass decreased in 42 cases (39.3%) and nonbone mass decreased in 65 cases (60.7%). There were significant differences among the age groups, menopausal status groups, PDFF > 45.0% groups, and R2* > 67.7 groups. Each measurement had good reproducibility. The odds ratios (95% CIs) were 4.05 (1.22-13.43) for PDFF and 4.34 (1.41-13.35) for R2*. The C statistic (95% CI) without R2* was 0.888 (0.827-0.950), and with R2* was 0.900 (0.841-0.960). The NRI resulting from the combination of PDFF and R2* was 75.6% (p < 0.01). CONCLUSION The predictive improvement over the use of BM PDFF and other traditional risk factors demonstrates the potential of liver R2* as a biomarker for osteopenia and osteoporosis in healthy women. KEY POINTS • Liver R2* is a biomarker for the assessment of osteopenia and osteoporosis. • Liver R2* improved the ability to predict osteopenia and osteoporosis. • The intra- and interobserver measurements showed high agreement.
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15
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Identification of Common Pathogenic Pathways Involved in Hemochromatosis Arthritis and Calcium Pyrophosphate Deposition Disease: a Review. Curr Rheumatol Rep 2022; 24:40-45. [PMID: 35143028 DOI: 10.1007/s11926-022-01054-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Arthritis is a common clinical manifestation of hereditary hemochromatosis (HH), and HH is one of a handful of conditions linked to calcium pyrophosphate deposition (CPPD) in joints. The connection between these two types of arthritis has not yet been fully elucidated. In light of new pathogenic pathways recently implicated in CPPD involving bone, we reviewed the literature on the etiology of hemochromatosis arthropathy (HHA) seeking shared pathogenic mechanisms. RESULTS Clinical observations reinforce striking similarities between HHA and CPPD even in the absence of CPP crystals. They share a similar joint distribution, low grade synovial inflammation, and generalized bone loss. Excess iron damages chondrocytes and bone cells in vitro. While direct effects of iron on cartilage are not consistently seen in animal models of HH, there is decreased osteoblast alkaline phosphatase activity, and increased osteoclastogenesis. These abnormalities are also seen in CPPD. Joint repair processes may also be impaired in both CPPD and HHA. CONCLUSIONS Possible shared pathogenic pathways relate more to bone and abnormal damage/repair mechanisms than direct damage to articular cartilage. While additional work is necessary to fully understand the pathogenesis of arthritis in HH and to firmly establish causal links with CPPD, this review provides some plausible hypotheses explaining the overlap of these two forms of arthritis.
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16
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Xu G, Li X, Zhu Z, Wang H, Bai X. Iron Overload Induces Apoptosis and Cytoprotective Autophagy Regulated by ROS Generation in Mc3t3-E1 Cells. Biol Trace Elem Res 2021; 199:3781-3792. [PMID: 33405076 DOI: 10.1007/s12011-020-02508-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022]
Abstract
Iron overload has been found very common in diseases such as hereditary hemochromatosis, thalassemia, and sickle cell disease and in healthy postmenopausal women. Recent studies have shown that iron overload is considered an independent risk factor for osteoporosis. Studies have demonstrated that iron overload could induce apoptosis and inhibit viability in osteoblasts. However, the underlying mechanism still remains poorly understood. The purpose of the present study is to investigate possible mechanism of iron overload-induced apoptosis, and the roles autophagy and reactive oxygen species (ROS) played under iron overload conditions. Ferric ammonium citrate (FAC) (100-1600 μM) was utilized as iron donor to induce iron overload conditions. Intracellular iron concentration was measured using Iron Assay Kit. The viability was assessed by CCK-8 assay. Cell apoptosis was examined using Annexin V-FITC/PI staining with a flow cytometry, and levels of Bax, Bcl-2, cleaved caspase-3, and cleaved PARP were evaluated with Western blot. Cell autophagy was detected by evaluating LC3 with immunofluorescence and Western blot. The expressions of Beclin-1 and P62 were also assessed with Western blot. The intracellular ROS level was evaluated using a DCFH-DA probe with a flow cytometry, and NADPH oxidase 4 (Nox4) expressions were assessed with Western blot. Our results showed that FAC increased intracellular iron concentration and significantly inhibited cell viability. Furthermore, iron overload induced apoptosis and autophagy in osteoblast cells. What's more, pretreatment with autophagy inhibitor chloroquine (CQ) enhanced iron overload-induced osteoblast apoptosis via the activation of caspases. Moreover, iron overload increased ROS production and Nox4 expression. Inhibition of autophagy increased ROS production, and scavenging of ROS by antioxidant N-Acetyl-L-cysteine (NAC) inhibited caspases activity and rescued iron overload-induced apoptosis. These results suggested that autophagy exerted cytoprotective effect, and scavenging excessive intracellular ROS could be a novel approach for the treatment of iron overload-induced osteoporosis.
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Affiliation(s)
- Guanpeng Xu
- Department of Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Xi Li
- Department of Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Zhiyong Zhu
- Department of Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Huisheng Wang
- Department of Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Xizhuang Bai
- Department of Sports Medicine and Joint Surgery, The People's Hospital of China Medical University, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.
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17
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Mehta KJ. Role of iron and iron-related proteins in mesenchymal stem cells: Cellular and clinical aspects. J Cell Physiol 2021; 236:7266-7289. [PMID: 33821487 DOI: 10.1002/jcp.30383] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022]
Abstract
Mesenchymal stem cells (MSCs) are located in various tissues where these cells show niche-dependent multilineage differentiation and secrete immunomodulatory molecules to support numerous physiological processes. Due to their regenerative and reparative properties, MSCs are extremely valuable for cell-based therapy in tackling several pathological conditions including COVID-19. Iron is essential for MSC processes but iron-loading, which is common in several chronic conditions, hinders normal MSC functionality. This not only aggravates disease pathology but can also affect allogeneic and autologous MSC therapy. Thus, understanding MSCs from an iron perspective is of clinical significance. Accordingly, this review highlights the roles of iron and iron-related proteins in MSC physiology. It describes the contribution of iron and endogenous iron-related effectors like hepcidin, ferroportin, transferrin receptor, lactoferrin, lipocalin-2, bone morphogenetic proteins and hypoxia inducible factors in MSC biology. It summarises the excess-iron-induced alterations in MSC components, processes and discusses signalling pathways involving ROS, PI3K/AKT, MAPK, p53, AMPK/MFF/DRP1 and Wnt. Additionally, it evaluates the endogenous and exogenous saviours of MSCs against iron-toxicity. Lastly, it elaborates on the involvement of MSCs in the pathology of clinical conditions of iron-excess, namely, hereditary hemochromatosis, diabetes, β-thalassaemia and myelodysplastic syndromes. This unique review integrates the distinct fields of iron regulation and MSC physiology. Through an iron-perspective, it describes both mechanistic and clinical aspects of MSCs and proposes an iron-linked MSC-contribution to physiology, pathology and therapeutics. It advances the understanding of MSC biology and may aid in identifying signalling pathways, molecular targets and compounds for formulating adjunctive iron-based therapies for excess-iron conditions, and thereby inform regenerative medicine.
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Affiliation(s)
- Kosha J Mehta
- Faculty of Life Sciences and Medicine, Centre for Education, King's College London, London, UK
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18
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Zhang H, Wang A, Shen G, Wang X, Liu G, Yang F, Chen B, Wang M, Xu Y. Hepcidin-induced reduction in iron content and PGC-1β expression negatively regulates osteoclast differentiation to play a protective role in postmenopausal osteoporosis. Aging (Albany NY) 2021; 13:11296-11314. [PMID: 33820875 PMCID: PMC8109081 DOI: 10.18632/aging.202817] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
As a necessary trace element, iron is involved in many physiological processes. Clinical and basic studies have found that disturbances in iron metabolism, especially iron overload, might lead to bone loss and even be involved in postmenopausal osteoporosis. Hepcidin is a key regulator of iron homeostasis. However, the exact role of hepcidin in bone metabolism and the underlying mechanism remain unknown. In this study, we found that in postmenopausal osteoporosis cohort, the concentration of hepcidin in the serum was significantly reduced and positively correlated with bone mineral density. Ovariectomized (OVX) mice were then used to construct an osteoporosis model. Hepcidin overexpression in these mice significantly improved bone mass and rescued the phenotype of bone loss. Additionally, overexpression of hepcidin in OVX mice greatly reduced the number and differentiation of osteoclasts in vivo and in vitro. This study found that overexpression of hepcidin significantly inhibited ROS production, mitochondrial biogenesis, and PGC-1β expression. These data showed that hepcidin protected osteoporosis by reducing iron levels in bone tissue, and in conjunction with PGC-1β, reduced ROS production and the number of mitochondria, thus inhibiting osteoclast differentiation and bone absorption. Hepcidin could provide new targets for the clinical treatment of postmenopausal osteoporosis.
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Affiliation(s)
- Hui Zhang
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Institute of Osteoporosis Diagnosis and Treatments of Soochow University, Suzhou 215004, China
| | - Aifei Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Institute of Osteoporosis Diagnosis and Treatments of Soochow University, Suzhou 215004, China
| | - Guangsi Shen
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
| | - Xiao Wang
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Institute of Osteoporosis Diagnosis and Treatments of Soochow University, Suzhou 215004, China
| | - Gongwen Liu
- Department of Orthopaedics, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou 215004, China
| | - Fan Yang
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Institute of Osteoporosis Diagnosis and Treatments of Soochow University, Suzhou 215004, China
| | - Bin Chen
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Osteoporosis Clinical Center, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Institute of Osteoporosis Diagnosis and Treatments of Soochow University, Suzhou 215004, China
| | - Mingyong Wang
- Institute of Osteoporosis Diagnosis and Treatments of Soochow University, Suzhou 215004, China
| | - Youjia Xu
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Osteoporosis Clinical Center, The Second Affiliated Hospital of Soochow University, Suzhou 215004, China
- Institute of Osteoporosis Diagnosis and Treatments of Soochow University, Suzhou 215004, China
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19
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Zhang S, Sun L, Zhang J, Liu S, Han J, Liu Y. Adverse Impact of Heavy Metals on Bone Cells and Bone Metabolism Dependently and Independently through Anemia. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 7:2000383. [PMID: 33042736 PMCID: PMC7539179 DOI: 10.1002/advs.202000383] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 06/21/2020] [Indexed: 05/05/2023]
Abstract
Mounting evidence is revealing that heavy metals can incur disordered bone homeostasis, leading to the development of degenerative bone diseases, including osteoporosis, osteoarthritis, degenerative disk disease, and osteomalacia. Meanwhile, heavy metal-induced anemia has been found to be intertwined with degenerative bone diseases. However, the relationship and interplay among these adverse outcomes remain elusive. Thus, it is of importance to shed light on the modes of action (MOAs) and adverse outcome pathways (AOPs) responsible for degenerative bone diseases and anemia under exposure to heavy metals. In the current Review, the epidemiological and experimental findings are recapitulated to interrogate the contributions of heavy metals to degenerative bone disease development which may be attributable dependently and independently to anemia. A few likely mechanisms are postulated for anemia-independent degenerative bone diseases, including dysregulated osteogenesis and osteoblastogenesis, imbalanced bone formation and resorption, and disturbed homeostasis of essential trace elements. By contrast, remodeled bone microarchitecture, inhibited erythropoietin production, and disordered iron homeostasis are speculated to account for anemia-associated degenerative bone disorders upon heavy metal exposure. Together, this Review aims to elaborate available literature to fill in the knowledge gaps in understanding the detrimental effects of heavy metals on bone cells and bone homeostasis through different perspectives.
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Affiliation(s)
- Shuping Zhang
- The First Affiliated Hospital of Shandong First Medical UniversityJinanShandong250014China
- Biomedical Sciences College & Shandong Medicinal Biotechnology CentreShandong First Medical University & Shandong Academy of Medical SciencesJinanShandong250062China
| | - Li Sun
- The First Affiliated Hospital of Shandong First Medical UniversityJinanShandong250014China
| | - Jie Zhang
- The First Affiliated Hospital of Shandong First Medical UniversityJinanShandong250014China
- Biomedical Sciences College & Shandong Medicinal Biotechnology CentreShandong First Medical University & Shandong Academy of Medical SciencesJinanShandong250062China
| | - Sijin Liu
- State Key Laboratory of Environmental Chemistry and EcotoxicologyResearch Center for Eco‐Environmental SciencesChinese Academy of SciencesBeijing100085China
| | - Jinxiang Han
- Biomedical Sciences College & Shandong Medicinal Biotechnology CentreShandong First Medical University & Shandong Academy of Medical SciencesJinanShandong250062China
| | - Yajun Liu
- Beijing Jishuitan HospitalPeking University Health Science CenterBeijing100035China
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Abstract
INTRODUCTION Iron overload, a state with excessive iron storage in the body, is a common complication in thalassemia patients which leads to multiple organ dysfunctions including the bone. Iron overload-induced bone disease is one of the most common and severe complications of thalassemia including osteoporosis. Currently, osteoporosis is still frequently found in thalassemia even with widely available iron chelation therapy. STUDY SELECTION Relevant publications published before December 2019 in PubMed database were reviewed. Both pre-clinical studies and clinical trials were obtained using iron overload, thalassemia, osteoporosis, osteoblast, and osteoclast as keywords. RESULTS Increased ROS production is a hallmark of iron overload-induced impaired bone remodeling. At the cellular level, oxidative stress affects bone remodeling by both osteoblast inhibition and osteoclast activation via many signaling pathways. In thalassemia patients, it has been shown that bone resorption was increased while bone formation was concurrently reduced. CONCLUSION In this review, reports on the cellular mechanisms of iron overload-associated bone remodeling are comprehensively summarized and presented to provide current understanding this pathological condition. Moreover, current treatments and potential interventions for attenuating bone remodeling in iron overload are also summarized to pave ways for the future discoveries of novel agents that alleviate this condition.
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Sato H, Takai C, Kazama JJ, Wakamatsu A, Hasegawa E, Kobayashi D, Kondo N, Nakatsue T, Abe A, Ito S, Ishikawa H, Kuroda T, Suzuki Y, Narita I. Serum hepcidin level, iron metabolism and osteoporosis in patients with rheumatoid arthritis. Sci Rep 2020; 10:9882. [PMID: 32555299 PMCID: PMC7303107 DOI: 10.1038/s41598-020-66945-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/27/2020] [Indexed: 12/14/2022] Open
Abstract
Hepcidin, a major regulator of iron metabolism and homeostasis, is regulated by inflammation. Recent studies have suggested that hepcidin and iron metabolism are involved in osteoporosis, and the aim of this study was to determine whether serum hepcidin levels are correlated with the degree of osteoporosis in patients with rheumatoid arthritis (RA). A total of 262 patients with RA (67.5 ± 11.4 years; 77.5% female) were enrolled. Serum iron, ferritin, and hepcidin levels were positively correlated each other. Multiple regression analyses revealed that the serum iron level was positively correlated with femoral T and Z scores, whereas the serum hepcidin level was not. Serum hepcidin level was correlated with the serum 25-hydroxy vitamin D level, which was in turn positively related to the femoral Z score. Serum hepcidin and serum iron were indirectly and directly related to osteoporosis in patients with RA.
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Affiliation(s)
- Hiroe Sato
- Niigata University Health Administration Center, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan. .,Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan.
| | - Chinatsu Takai
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University, 960-1295, 1 Hikariga-oka, Fukushima City, Japan
| | - Ayako Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - Eriko Hasegawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - Naoki Kondo
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - Takeshi Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
| | - Asami Abe
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - Satoshi Ito
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - Hajime Ishikawa
- Department of Rheumatology, Niigata Rheumatic Center, 1-2-8 Honcho, Shibata City, 957-0054, Japan
| | - Takeshi Kuroda
- Niigata University Health Administration Center, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan
| | - Yoshiki Suzuki
- Niigata University Health Administration Center, 2-8050 Ikarashi, Nishi-ku, Niigata City, 950-2181, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-ku, Niigata City, 951-8510, Japan
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Zhang J, Zheng L, Wang Z, Pei H, Hu W, Nie J, Shang P, Li B, Hei TK, Zhou G. Lowering iron level protects against bone loss in focally irradiated and contralateral femurs through distinct mechanisms. Bone 2019; 120:50-60. [PMID: 30304704 DOI: 10.1016/j.bone.2018.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/21/2018] [Accepted: 10/06/2018] [Indexed: 12/20/2022]
Abstract
Radiation therapy leads to increased risk of late-onset fragility and bone fracture due to the loss of bone mass. On the other hand, iron overloading causes osteoporosis by enhancing bone resorption. It has been shown that total body irradiation increases iron level, but whether the systemic bone loss is related to the changes in iron level and hepcidin regulation following bone irradiation remains unknown. To investigate the potential link between them, we first created an animal model of radiation-induced systemic bone loss by targeting the mid-shaft femur with a single 2 Gy dose of X-rays. We found that mid-shaft femur focal irradiation led to structural deterioration in the distal region of the trabecular bone with increased osteoclasts surface and expressions of bone resorption markers in both irradiated and contralateral femurs relative to non-irradiated controls. Following irradiation, reduced hepcidin activity of the liver contributed to elevated iron levels in the serum and liver. By injecting hepcidin or deferoxamine (an iron chelator) to reduce iron level, deterioration of trabecular bone microarchitecture in irradiated mice was abrogated. The ability of iron chelation to inhibit radiation-induced osteoclast differentiation was observed in vitro as well. We further showed that ionizing radiation (IR) directly stimulated osteoclast differentiation and bone resorption in bone marrow cells isolated not from contralateral femurs but from directly irradiated femurs. These results suggest that increased iron levels after focal radiation is at least one of the main reasons for systemic bone loss. Furthermore, bone loss in directly irradiated bones is not only due to the elevated iron level, but also from increased osteoclast differentiation. In contrast, the bone loss in the contralateral femurs is mainly due to the elevated iron level induced by IR alone. These novel findings provide proof-of-principle evidence for the use of iron chelation or hepcidin as therapeutic treatments for IR-induced osteoporosis.
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Affiliation(s)
- Jian Zhang
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China
| | - Lijun Zheng
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China
| | - Ziyang Wang
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China
| | - Hailong Pei
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China
| | - Wentao Hu
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China
| | - Jing Nie
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China
| | - Peng Shang
- Key Laboratory for Space Bioscience and Biotechnology, Institute of Special Environmental Biophysics, School of Life Sciences, Northwestern Polytechnical University, Xi'an, China; Research & Development Institute in Shenzhen, Northwestern Polytechnical University, Shenzhen, China
| | - Bingyan Li
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Department of Nutrition and Food Hygiene, School of Public Health, Medical College of Soochow University, Suzhou, China
| | - Tom K Hei
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China; Center for Radiological Research, College of Physician and Surgeons, Columbia University, New York, USA.
| | - Guangming Zhou
- State Key Laboratory of Radiation Medicine and Protection, School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China; Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Suzhou, China.
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23
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Çifci A, Özkan M. Iron physopathology and approach to iron deficiency anemia: new treatment strategies. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2018. [DOI: 10.32322/jhsm.430073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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