Protective effects of Acetobacter ghanensis against gliadin toxicity in intestinal epithelial cells with immunoregulatory and gluten-digestive properties.


Journal

European journal of nutrition
ISSN: 1436-6215
Titre abrégé: Eur J Nutr
Pays: Germany
ID NLM: 100888704

Informations de publication

Date de publication:
Mar 2023
Historique:
received: 14 03 2022
accepted: 22 09 2022
pubmed: 30 9 2022
medline: 25 2 2023
entrez: 29 9 2022
Statut: ppublish

Résumé

The aim of this study was to establish whether Acetobacter ghanensis, the probiotic characteristics of which were evaluated previously, attenuates gliadin-induced toxicity in intestinal epithelial cells with gluten-digestive and immunoregulatory properties. A co-culture model of human intestinal epithelial cell (Caco-2) monolayers on top of peripheral blood mononuclear cells (PBMCs) obtained from patients with celiac disease (CD) was established. The gluten-digestive properties of A. ghanensis were determined by checking bacterial growth in a medium containing gluten as the main nitrogen source. The mRNA levels of genes encoding TJ-associated proteins were measured by quantitative real-time PCR (qRT-PCR). The concentrations of IL-6 and TNFα were determined by enzyme-linked immunosorbent assay (ELISA). We found that PT-gliadin disrupted intestinal barrier integrity by modulating the expression of TJ-associated genes encoding zonulin (increased by ~ 60%), zonula occludens-1 (ZO-1) (decreased by ~ 22%), and occludin (decreased by ~ 28%) in Caco-2 cells. Furthermore, PT-gliadin treatment in Caco-2 cells was associated with increased concentrations of IL-6 (~ 1.6-fold) and TNFα (~ twofold) from PBMCs. These modulatory effects of PT-gliadin, however, were suppressed when Caco-2 cells were subjected to A. ghanensis in the presence of PT-gliadin. As a factor underlying these protective effects, we showed that A. ghanensis could digest gluten peptides. To our knowledge, the current study is the first to demonstrate that A. ghanensis improves intestinal barrier functions by attenuating the modulatory effects of PT-gliadin with immunoregulatory and gluten-digestive properties.

Identifiants

pubmed: 36175797
doi: 10.1007/s00394-022-03015-6
pii: 10.1007/s00394-022-03015-6
doi:

Substances chimiques

Glutens 8002-80-0
Gliadin 9007-90-3
Tumor Necrosis Factor-alpha 0
Interleukin-6 0

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

605-614

Subventions

Organisme : Türkiye Bilimsel ve Teknolojik Araştirma Kurumu
ID : 218S759

Informations de copyright

© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.

Références

Schuppan D, Junker Y, Barisani D (2009) Celiac disease: from pathogenesis to novel therapies. Gastroenterology 137(6):1912–1933. https://doi.org/10.1053/j.gastro.2009.09.008
doi: 10.1053/j.gastro.2009.09.008 pubmed: 19766641
Lammers KM, Lu R, Brownley J, Lu B, Gerard C, Thomas K, Rallabhandi P, Shea-Donohue T, Tamiz A, Alkan S, Netzel-Arnett S, Antalis T, Vogel SN, Fasano A (2008) Gliadin induces an increase in intestinal permeability and zonulin release by binding to the chemokine receptor CXCR3. Gastroenterology 135(1):194-204.e193. https://doi.org/10.1053/j.gastro.2008.03.023
doi: 10.1053/j.gastro.2008.03.023 pubmed: 18485912
Khaleghi S, Ju JM, Lamba A, Murray JA (2016) The potential utility of tight junction regulation in celiac disease: focus on larazotide acetate. Therap Adv Gastroenterol 9(1):37–49. https://doi.org/10.1177/1756283X15616576
doi: 10.1177/1756283X15616576 pubmed: 26770266 pmcid: 4699279
Di Sabatino A, Vanoli A, Giuffrida P, Luinetti O, Solcia E, Corazza GR (2012) The function of tissue transglutaminase in celiac disease. Autoimmun Rev 11(10):746–753. https://doi.org/10.1016/j.autrev.2012.01.007
doi: 10.1016/j.autrev.2012.01.007 pubmed: 22326684
van de Wal Y, Kooy Y, van Veelen P, Peña S, Mearin L, Papadopoulos G, Koning F (1998) Selective deamidation by tissue transglutaminase strongly enhances gliadin-specific T cell reactivity. J Immunol 161(4):1585–1588
doi: 10.4049/jimmunol.161.4.1585 pubmed: 9712018
Kim CY, Quarsten H, Bergseng E, Khosla C, Sollid LM (2004) Structural basis for HLA-DQ2-mediated presentation of gluten epitopes in celiac disease. Proc Natl Acad Sci USA 101(12):4175–4179. https://doi.org/10.1073/pnas.0306885101
doi: 10.1073/pnas.0306885101 pubmed: 15020763 pmcid: 384714
Quarsten H, Molberg O, Fugger L, McAdam SN, Sollid LM (1999) HLA binding and T cell recognition of a tissue transglutaminase-modified gliadin epitope. Eur J Immunol 29(8):2506–2514. https://doi.org/10.1002/(SICI)1521-4141(199908)29:08%3c2506::AID-IMMU2506%3e3.0.CO;2-9
doi: 10.1002/(SICI)1521-4141(199908)29:08<2506::AID-IMMU2506>3.0.CO;2-9 pubmed: 10458765
Nilsen EM, Jahnsen FL, Lundin KE, Johansen FE, Fausa O, Sollid LM, Jahnsen J, Scott H, Brandtzaeg P (1998) Gluten induces an intestinal cytokine response strongly dominated by interferon gamma in patients with celiac disease. Gastroenterology 115(3):551–563. https://doi.org/10.1016/s0016-5085(98)70134-9
doi: 10.1016/s0016-5085(98)70134-9 pubmed: 9721152
Hin H, Bird G, Fisher P, Mahy N, Jewell D (1999) Coeliac disease in primary care: case finding study. BMJ 318(7177):164–167
doi: 10.1136/bmj.318.7177.164 pubmed: 9888912 pmcid: 27697
Haines ML, Anderson RP, Gibson PR (2008) Systematic review: the evidence base for long-term management of coeliac disease. Aliment Pharmacol Ther 28(9):1042–1066. https://doi.org/10.1111/j.1365-2036.2008.03820.x
doi: 10.1111/j.1365-2036.2008.03820.x pubmed: 18671779
Mack DR (2005) Probiotics-mixed messages. Can Fam Physician 51:1455–1457
pubmed: 16353824 pmcid: 1479485
De Angelis M, Rizzello CG, Fasano A, Clemente MG, De Simone C, Silano M, De Vincenzi M, Losito I, Gobbetti M (2006) VSL#3 probiotic preparation has the capacity to hydrolyze gliadin polypeptides responsible for Celiac Sprue. Biochim Biophys Acta 1762(1):80–93. https://doi.org/10.1016/j.bbadis.2005.09.008
doi: 10.1016/j.bbadis.2005.09.008 pubmed: 16311022
Sarno M, Lania G, Cuomo M, Nigro F, Passannanti F, Budelli A, Fasano F, Troncone R, Auricchio S, Barone MV, Nigro R, Nanayakkara M (2014) Lactobacillus paracasei CBA L74 interferes with gliadin peptides entrance in Caco-2 cells. Int J Food Sci Nutr 65(8):953–959. https://doi.org/10.3109/09637486.2014.940283
doi: 10.3109/09637486.2014.940283 pubmed: 25030417
D’Arienzo R, Stefanile R, Maurano F, Mazzarella G, Ricca E, Troncone R, Auricchio S, Rossi M (2011) Immunomodulatory effects of Lactobacillus casei administration in a mouse model of gliadin-sensitive enteropathy. Scand J Immunol 74(4):335–341. https://doi.org/10.1111/j.1365-3083.2011.02582.x
doi: 10.1111/j.1365-3083.2011.02582.x pubmed: 21615450
Lindfors K, Blomqvist T, Juuti-Uusitalo K, Stenman S, Venäläinen J, Mäki M, Kaukinen K (2008) Live probiotic Bifidobacterium lactis bacteria inhibit the toxic effects induced by wheat gliadin in epithelial cell culture. Clin Exp Immunol 152(3):552–558. https://doi.org/10.1111/j.1365-2249.2008.03635.x
doi: 10.1111/j.1365-2249.2008.03635.x pubmed: 18422736 pmcid: 2453197
Husby S, Koletzko S, Korponay-Szabó IR, Mearin ML, Phillips A, Shamir R, Troncone R, Giersiepen K, Branski D, Catassi C, Lelgeman M, Mäki M, Ribes-Koninckx C, Ventura A, Zimmer KP, Diagnosis EWGoCD, Committee EG, European Society for Pediatric Gastroenterology Hp, and Nutrition (2012) European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr 54(1):136–160. https://doi.org/10.1097/MPG.0b013e31821a23d0
doi: 10.1097/MPG.0b013e31821a23d0
Caminero A, Herrán AR, Nistal E, Pérez-Andrés J, Vaquero L, Vivas S, Ruiz de Morales JM, Albillos SM, Casqueiro J (2014) Diversity of the cultivable human gut microbiome involved in gluten metabolism: isolation of microorganisms with potential interest for coeliac disease. FEMS Microbiol Ecol 88(2):309–319. https://doi.org/10.1111/1574-6941.12295
doi: 10.1111/1574-6941.12295 pubmed: 24499426
Gujral N, Suh JW, Sunwoo HH (2015) Effect of anti-gliadin IgY antibody on epithelial intestinal integrity and inflammatory response induced by gliadin. BMC Immunol 16:41. https://doi.org/10.1186/s12865-015-0104-1
doi: 10.1186/s12865-015-0104-1 pubmed: 26156219 pmcid: 4495697
Parlesak A, Haller D, Brinz S, Baeuerlein A, Bode C (2004) Modulation of cytokine release by differentiated CACO-2 cells in a compartmentalized coculture model with mononuclear leucocytes and nonpathogenic bacteria. Scand J Immunol 60(5):477–485. https://doi.org/10.1111/j.0300-9475.2004.01495.x
doi: 10.1111/j.0300-9475.2004.01495.x pubmed: 15541040
Evcan E, Gulec S (2020) The development of lentil derived protein-iron complexes and their effects on iron deficiency anemia in vitro. Food Funct 11(5):4185–4192. https://doi.org/10.1039/d0fo00384k
doi: 10.1039/d0fo00384k pubmed: 32352142
Gulec S, Collins JF (2014) Silencing the Menkes copper-transporting ATPase (Atp7a) gene in rat intestinal epithelial (IEC-6) cells increases iron flux via transcriptional induction of ferroportin 1 (Fpn1). J Nutr 144(1):12–19. https://doi.org/10.3945/jn.113.183160
doi: 10.3945/jn.113.183160 pubmed: 24174620
Herrán AR, Pérez-Andrés J, Caminero A, Nistal E, Vivas S, Ruiz de Morales JM, Casqueiro J (2017) Gluten-degrading bacteria are present in the human small intestine of healthy volunteers and celiac patients. Res Microbiol 168(7):673–684. https://doi.org/10.1016/j.resmic.2017.04.008
doi: 10.1016/j.resmic.2017.04.008 pubmed: 28526528
Greco L, Gobbetti M, Auricchio R, Di Mase R, Landolfo F, Paparo F, Di Cagno R, De Angelis M, Rizzello CG, Cassone A, Terrone G, Timpone L, D’Aniello M, Maglio M, Troncone R, Auricchio S (2011) Safety for patients with celiac disease of baked goods made of wheat flour hydrolyzed during food processing. Clin Gastroenterol Hepatol 9(1):24–29. https://doi.org/10.1016/j.cgh.2010.09.025
doi: 10.1016/j.cgh.2010.09.025 pubmed: 20951830
Francavilla R, De Angelis M, Rizzello CG, Cavallo N, Dal Bello F, Gobbetti M (2017) Selected probiotic Lactobacilli have the capacity to hydrolyze gluten peptides during simulated gastrointestinal digestion. Appl Environ Microbiol. https://doi.org/10.1128/AEM.00376-17
doi: 10.1128/AEM.00376-17 pubmed: 28500039 pmcid: 5494637
Silano M, Vincentini O, Luciani A, Felli C, Caserta S, Esposito S, Villella VR, Pettoello-Mantovani M, Guido S, Maiuri L (2012) Early tissue transglutaminase-mediated response underlies K562(S)-cell gliadin-dependent agglutination. Pediatr Res 71(5):532–538. https://doi.org/10.1038/pr.2012.4
doi: 10.1038/pr.2012.4 pubmed: 22314661
Anderson RC, Cookson AL, McNabb WC, Park Z, McCann MJ, Kelly WJ, Roy NC (2010) Lactobacillus plantarum MB452 enhances the function of the intestinal barrier by increasing the expression levels of genes involved in tight junction formation. BMC Microbiol 10:316. https://doi.org/10.1186/1471-2180-10-316
doi: 10.1186/1471-2180-10-316 pubmed: 21143932 pmcid: 3004893
Orlando A, Linsalata M, Notarnicola M, Tutino V, Russo F (2014) Lactobacillus GG restoration of the gliadin induced epithelial barrier disruption: the role of cellular polyamines. BMC Microbiol 14:19. https://doi.org/10.1186/1471-2180-14-19
doi: 10.1186/1471-2180-14-19 pubmed: 24483336 pmcid: 3911798
Fasano A (2011) Zonulin and its regulation of intestinal barrier function: the biological door to inflammation, autoimmunity, and cancer. Physiol Rev 91(1):151–175. https://doi.org/10.1152/physrev.00003.2008
doi: 10.1152/physrev.00003.2008 pubmed: 21248165
Drago S, El Asmar R, Di Pierro M, Grazia Clemente M, Tripathi A, Sapone A, Thakar M, Iacono G, Carroccio A, D’Agate C, Not T, Zampini L, Catassi C, Fasano A (2006) Gliadin, zonulin and gut permeability: effects on celiac and non-celiac intestinal mucosa and intestinal cell lines. Scand J Gastroenterol 41(4):408–419. https://doi.org/10.1080/00365520500235334
doi: 10.1080/00365520500235334 pubmed: 16635908
Clemente MG, De Virgiliis S, Kang JS, Macatagney R, Musu MP, Di Pierro MR, Drago S, Congia M, Fasano A (2003) Early effects of gliadin on enterocyte intracellular signalling involved in intestinal barrier function. Gut 52(2):218–223
doi: 10.1136/gut.52.2.218 pubmed: 12524403 pmcid: 1774976
Orlando A, Linsalata M, Bianco G, Notarnicola M, D’Attoma B, Scavo MP, Tafaro A, Russo F (2018) GG protects the epithelial barrier of Wistar rats from the pepsin-trypsin-digested gliadin (PTG)-induced enteropathy. Nutrients. https://doi.org/10.3390/nu10111698
doi: 10.3390/nu10111698 pubmed: 30577684 pmcid: 6356415
Giorgi A, Cerrone R, Capobianco D, Filardo S, Mancini P, Zanni F, Fanelli S, Mastromarino P, Mosca L (2020) A probiotic preparation hydrolyzes gliadin and protects intestinal cells from the toxicity of pro-inflammatory peptides. Nutrients. https://doi.org/10.3390/nu12020495
doi: 10.3390/nu12020495 pubmed: 33261215 pmcid: 7760942
Bruce SE, Bjarnason I, Peters TJ (1985) Human jejunal transglutaminase: demonstration of activity, enzyme kinetics and substrate specificity with special relation to gliadin and coeliac disease. Clin Sci (Lond) 68(5):573–579
doi: 10.1042/cs0680573 pubmed: 2858282
D’Argenio G, Sorrentini I, Ciacci C, Spagnuolo S, Ventriglia R, de Chiara A, Mazzacca G (1989) Human serum transglutaminase and coeliac disease: correlation between serum and mucosal activity in an experimental model of rat small bowel enteropathy. Gut 30(7):950–954
doi: 10.1136/gut.30.7.950 pubmed: 2569434 pmcid: 1434281
Werkstetter KJ, Korponay-Szabó IR, Popp A, Villanacci V, Salemme M, Heilig G, Lillevang ST, Mearin ML, Ribes-Koninckx C, Thomas A, Troncone R, Filipiak B, Mäki M, Gyimesi J, Najafi M, Dolinšek J, Dydensborg Sander S, Auricchio R, Papadopoulou A, Vécsei A, Szitanyi P, Donat E, Nenna R, Alliet P, Penagini F, Garnier-Lengliné H, Castillejo G, Kurppa K, Shamir R, Hauer AC, Smets F, Corujeira S, van Winckel M, Buderus S, Chong S, Husby S, Koletzko S, group Ps (2017) Accuracy in diagnosis of celiac disease without biopsies in clinical practice. Gastroenterology 153(4):924–935. https://doi.org/10.1053/j.gastro.2017.06.002
doi: 10.1053/j.gastro.2017.06.002 pubmed: 28624578
Monguzzi E, Marabini L, Elli L, Vaira V, Ferrero S, Ferretti F, Branchi F, Gaudioso G, Scricciolo A, Lombardo V, Doneda L, Roncoroni L (2019) Gliadin effect on the oxidative balance and DNA damage: an in-vitro, ex-vivo study. Dig Liver Dis 51(1):47–54. https://doi.org/10.1016/j.dld.2018.06.020
doi: 10.1016/j.dld.2018.06.020 pubmed: 30055963
Caputo I, Secondo A, Lepretti M, Paolella G, Auricchio S, Barone MV, Esposito C (2012) Gliadin peptides induce tissue transglutaminase activation and ER-stress through Ca2+ mobilization in Caco-2 cells. PLoS ONE 7(9):e45209. https://doi.org/10.1371/journal.pone.0045209
doi: 10.1371/journal.pone.0045209 pubmed: 23049776 pmcid: 3458012
Smecuol E, Hwang HJ, Sugai E, Corso L, Cherñavsky AC, Bellavite FP, González A, Vodánovich F, Moreno ML, Vázquez H, Lozano G, Niveloni S, Mazure R, Meddings J, Mauriño E, Bai JC (2013) Exploratory, randomized, double-blind, placebo-controlled study on the effects of Bifidobacterium infantis natren life start strain super strain in active celiac disease. J Clin Gastroenterol 47(2):139–147. https://doi.org/10.1097/MCG.0b013e31827759ac
doi: 10.1097/MCG.0b013e31827759ac pubmed: 23314670
van Heel DA (2006) Interleukin 15: its role in intestinal inflammation. Gut 55(4):444–445. https://doi.org/10.1136/gut.2005.079335
doi: 10.1136/gut.2005.079335 pubmed: 16531523 pmcid: 1856192
Mention JJ, Ben Ahmed M, Bègue B, Barbe U, Verkarre V, Asnafi V, Colombel JF, Cugnenc PH, Ruemmele FM, McIntyre E, Brousse N, Cellier C, Cerf-Bensussan N (2003) Interleukin 15: a key to disrupted intraepithelial lymphocyte homeostasis and lymphomagenesis in celiac disease. Gastroenterology 125(3):730–745
doi: 10.1016/S0016-5085(03)01047-3 pubmed: 12949719
Papista C, Gerakopoulos V, Kourelis A, Sounidaki M, Kontana A, Berthelot L, Moura IC, Monteiro RC, Yiangou M (2012) Gluten induces coeliac-like disease in sensitised mice involving IgA, CD71 and transglutaminase 2 interactions that are prevented by probiotics. Lab Invest 92(4):625–635. https://doi.org/10.1038/labinvest.2012.13
doi: 10.1038/labinvest.2012.13 pubmed: 22330344
Sánchez-Guillén MC, Argüello-García R, Garduño G, Valadez-Salazar A, Martínez-García MC, Muñoz O, Ortega-Pierres MG (1990) Study of human Entamoeba histolytica infection by zymodeme, indirect hemagglutination and electroimmunotransfer blot assays. Arch Invest Med (Mex) 21(Suppl 1):209–215
pubmed: 2136487
Vincentini O, Maialetti F, Gonnelli E, Silano M (2015) Gliadin-dependent cytokine production in a bidimensional cellular model of celiac intestinal mucosa. Clin Exp Med 15(4):447–454. https://doi.org/10.1007/s10238-014-0325-2
doi: 10.1007/s10238-014-0325-2 pubmed: 25447031
Lammers KM, Khandelwal S, Chaudhry F, Kryszak D, Puppa EL, Casolaro V, Fasano A (2011) Identification of a novel immunomodulatory gliadin peptide that causes interleukin-8 release in a chemokine receptor CXCR3-dependent manner only in patients with coeliac disease. Immunology 132(3):432–440. https://doi.org/10.1111/j.1365-2567.2010.03378.x
doi: 10.1111/j.1365-2567.2010.03378.x pubmed: 21091908 pmcid: 3044909
O’Keeffe J, Mills K, Jackson J, Feighery C (1999) T cell proliferation, MHC class II restriction and cytokine products of gliadin-stimulated peripheral blood mononuclear cells (PBMC). Clin Exp Immunol 117(2):269–276. https://doi.org/10.1046/j.1365-2249.1999.00973.x
doi: 10.1046/j.1365-2249.1999.00973.x pubmed: 10444257 pmcid: 1905335
Laparra JM, Olivares M, Gallina O, Sanz Y (2012) Bifidobacterium longum CECT 7347 modulates immune responses in a gliadin-induced enteropathy animal model. PLoS ONE 7(2):e30744. https://doi.org/10.1371/journal.pone.0030744
doi: 10.1371/journal.pone.0030744 pubmed: 22348021 pmcid: 3277586
Carrasco-Pozo C, Morales P, Gotteland M (2013) Polyphenols protect the epithelial barrier function of Caco-2 cells exposed to indomethacin through the modulation of occludin and zonula occludens-1 expression. J Agric Food Chem 61(22):5291–5297. https://doi.org/10.1021/jf400150p
doi: 10.1021/jf400150p pubmed: 23668856
Boztepe T, Gulec S (2018) Investigation of the influence of high glucose on molecular and genetic responses: an. Genes Nutr 13:11. https://doi.org/10.1186/s12263-018-0602-x
doi: 10.1186/s12263-018-0602-x pubmed: 29736189 pmcid: 5928582
Ohura K, Nishiyama H, Saco S, Kurokawa K, Imai T (2016) Establishment and characterization of a novel Caco-2 Subclone with a similar low expression level of human carboxylesterase 1 to human small intestine. Drug Metab Dispos 44(12):1890–1898. https://doi.org/10.1124/dmd.116.072736
doi: 10.1124/dmd.116.072736 pubmed: 27638507
Nabli H, Tuller E, Sharpe-Timms KL (2010) Haptoglobin expression in endometrioid adenocarcinoma of the uterus. Reprod Sci 17(1):47–55. https://doi.org/10.1177/1933719109346331
doi: 10.1177/1933719109346331 pubmed: 19801537
Maiuri L, Ciacci C, Auricchio S, Brown V, Quaratino S, Londei M (2000) Interleukin 15 mediates epithelial changes in celiac disease. Gastroenterology 119(4):996–1006. https://doi.org/10.1053/gast.2000.18149
doi: 10.1053/gast.2000.18149 pubmed: 11040186

Auteurs

Caglar Doguer (C)

Department of Nutrition and Dietetics, Tekirdağ Namık Kemal University, Tekirdağ, 59030, Turkey. cdoguer@nku.edu.tr.

Hande Akalan (H)

Department of Biology, Tekirdağ Namık Kemal University, Tekirdağ, 59030, Turkey.

Nazan Tokatlı Demirok (N)

Department of Nutrition and Dietetics, Tekirdağ Namık Kemal University, Tekirdağ, 59030, Turkey.

Berna Erdal (B)

Department of Medical Microbiology, Tekirdağ Namık Kemal University, Tekirdağ, 59030, Turkey.

Rafet Mete (R)

Department of Medicine, Tekirdağ Namık Kemal University, Tekirdağ, 59030, Turkey.

Turker Bilgen (T)

Department of Nutrition and Dietetics, Tekirdağ Namık Kemal University, Tekirdağ, 59030, Turkey.

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female
Humans United States Aged Cross-Sectional Studies Medicare Part C
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH