Molecular interactions between metformin and D-limonene inhibit proliferation and promote apoptosis in breast and liver cancer cells.


Journal

BMC complementary medicine and therapies
ISSN: 2662-7671
Titre abrégé: BMC Complement Med Ther
Pays: England
ID NLM: 101761232

Informations de publication

Date de publication:
06 May 2024
Historique:
received: 19 06 2023
accepted: 22 03 2024
medline: 7 5 2024
pubmed: 7 5 2024
entrez: 6 5 2024
Statut: epublish

Résumé

Cancer is a fatal disease that severely affects humans. Designing new anticancer strategies and understanding the mechanism of action of anticancer agents is imperative. In this study, we evaluated the utility of metformin and D-limonene, alone or in combination, as potential anticancer therapeutics using the human liver and breast cancer cell lines HepG2 and MCF-7. An integrated systems pharmacology approach is presented for illustrating the molecular interactions between metformin and D-limonene. We applied a systems-based analysis to introduce a drug-target-pathway network that clarifies different mechanisms of treatment. The combination treatment of metformin and D-limonene induced apoptosis in both cell lines compared with single drug treatments, as indicated by flow cytometric and gene expression analysis. The mRNA expression of Bax and P53 genes were significantly upregulated while Bcl-2, iNOS, and Cox-2 were significantly downregulated in all treatment groups compared with normal cells. The percentages of late apoptotic HepG2 and MCF-7 cells were higher in all treatment groups, particularly in the combination treatment group. Calculations for the combination index (CI) revealed a synergistic effect between both drugs for HepG2 cells (CI = 0.14) and MCF-7 cells (CI = 0.22). Our data show that metformin, D-limonene, and their combinations exerted significant antitumor effects on the cancer cell lines by inducing apoptosis and modulating the expression of apoptotic genes.

Sections du résumé

BACKGROUND BACKGROUND
Cancer is a fatal disease that severely affects humans. Designing new anticancer strategies and understanding the mechanism of action of anticancer agents is imperative.
HYPOTHESIS/PURPOSE OBJECTIVE
In this study, we evaluated the utility of metformin and D-limonene, alone or in combination, as potential anticancer therapeutics using the human liver and breast cancer cell lines HepG2 and MCF-7.
STUDY DESIGN METHODS
An integrated systems pharmacology approach is presented for illustrating the molecular interactions between metformin and D-limonene.
METHODS METHODS
We applied a systems-based analysis to introduce a drug-target-pathway network that clarifies different mechanisms of treatment. The combination treatment of metformin and D-limonene induced apoptosis in both cell lines compared with single drug treatments, as indicated by flow cytometric and gene expression analysis.
RESULTS RESULTS
The mRNA expression of Bax and P53 genes were significantly upregulated while Bcl-2, iNOS, and Cox-2 were significantly downregulated in all treatment groups compared with normal cells. The percentages of late apoptotic HepG2 and MCF-7 cells were higher in all treatment groups, particularly in the combination treatment group. Calculations for the combination index (CI) revealed a synergistic effect between both drugs for HepG2 cells (CI = 0.14) and MCF-7 cells (CI = 0.22).
CONCLUSION CONCLUSIONS
Our data show that metformin, D-limonene, and their combinations exerted significant antitumor effects on the cancer cell lines by inducing apoptosis and modulating the expression of apoptotic genes.

Identifiants

pubmed: 38711049
doi: 10.1186/s12906-024-04453-x
pii: 10.1186/s12906-024-04453-x
doi:

Substances chimiques

Metformin 9100L32L2N
Limonene 9MC3I34447
Terpenes 0
Antineoplastic Agents 0
Cyclohexenes 0

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

185

Subventions

Organisme : Deanship of Scientific Research at King Khalid University
ID : RGP2/291/44

Informations de copyright

© 2024. The Author(s).

Références

Arafa MA, Rabah DM, Farhat KH. Rising cancer rates in the Arab World: now is the time for action. East Mediterr Health J. 2020;26(6):638–40.
pubmed: 32621496 doi: 10.26719/emhj.20.073
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–49.
pubmed: 33538338 doi: 10.3322/caac.21660
Sun Y-S, Zhao Z, Yang Z-N, Xu F, Lu H-J, Zhu Z-Y, Shi W, Jiang J, Yao P-P, Zhu H-P. Risk factors and preventions of breast cancer. Int J Biol Sci. 2017;13(11):1387.
pubmed: 29209143 pmcid: 5715522 doi: 10.7150/ijbs.21635
Naeem M, Hayat M, Qamar SA, Mehmood T, Munir A, Ahmad G, Hussain A. Risk factors, genetic mutations and prevention of breast cancer. Int J Biosci. 2019;14(4):492–6.
Hum NR, Sebastian A, Martin KA, Rios-Arce ND, Gilmore SF, Gravano DM, Wheeler EK, Coleman MA, Loots GG. IL-17A Increases Doxorubicin Efficacy in Triple Negative Breast Cancer. Front Oncol. 2022;12:928474.
pubmed: 35924165 pmcid: 9340269 doi: 10.3389/fonc.2022.928474
Charafe-Jauffret E, Ginestier C, Monville F, Finetti P, Adelaïde J, Cervera N, Fekairi S, Xerri L, Jacquemier J, Birnbaum D. Gene expression profiling of breast cell lines identifies potential new basal markers. Oncogene. 2006;25(15):2273–84.
pubmed: 16288205 doi: 10.1038/sj.onc.1209254
Riaz M, van Jaarsveld MT, Hollestelle A. Prager-van der Smissen WJ, Heine AA, Boersma AW, Liu J, Helmijr J, Ozturk B, Smid M: miRNA expression profiling of 51 human breast cancer cell lines reveals subtype and driver mutation-specific miRNAs. Breast Cancer Res. 2013;15:1–17.
doi: 10.1186/bcr3415
Farshad H, Zarghi A., Kobarfard F, Zendehdel R, Nakhjavani M, Arfaiee S, Zebardast T, et al. Remarks in Successful Cellular Investigations for Fighting Breast Cancer Using Novel Synthetic Compounds. In: Breast Cancer - Focusing Tumor Microenvironment, Stem Cells and Metastasis; Gunduz M, Gunduz E, editors. InTech Open Access Publisher Croatia; ISBN: 978-953-307-766-6, EBOOK (PDF) ISBN: 978-953-51-6604-7. 2011:85–102. https://doi.org/10.5772/23005 .
Ozakyol A. Global epidemiology of hepatocellular carcinoma (HCC epidemiology). J Gastrointest Cancer. 2017;48(3):238–40.
pubmed: 28626852 doi: 10.1007/s12029-017-9959-0
Toyoda H, Kumada T, Tada T, Kiriyama S, Tanikawa M, Hisanaga Y, Kanamori A, Kitabatake S, Ito T. Risk factors of hepatocellular carcinoma development in non-cirrhotic patients with sustained virologic response for chronic hepatitis C virus infection. J Gastroenterol Hepatol. 2015;30(7):1183–9.
pubmed: 25678094 doi: 10.1111/jgh.12915
Dhanasekaran R, Limaye A, Cabrera R. Hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis, and therapeutics. Hepatic medicine: evidence and research. 2012;4:19.
pubmed: 24367230
Adnan M. Bioactive potential of essential oil extracted from the leaves of Eucalyptus globulus (Myrtaceae). J Pharmacogn Phytochem. 2019;8(1):213–6.
Bailey CJ. Metformin: historical overview. Diabetologia. 2017;60(9):1566–76.
pubmed: 28776081 doi: 10.1007/s00125-017-4318-z
Agius L, Ford BE, Chachra SS. The metformin mechanism on gluconeogenesis and AMPK activation: the metabolite perspective. Int J Mol Sci. 2020;21(9):3240.
pubmed: 32375255 pmcid: 7247334 doi: 10.3390/ijms21093240
Salim EI, Elsebakhy S, Hessien M. Repurposing of atorvastatin and metformin denotes their individual and combined antiproliferative effects in non-small cell lung cancer. Fundam Clin Pharmacol. 2024. https://doi.org/10.1111/fcp.12981 .
El-Sisi A, Sokar S, El-Sayad M, Moussa E, Salim E. Anticancer effect of metformin against 2-amino-1-methyl-6-phenylimidazo [4, 5-b] pyridine-induced rat mammary carcinogenesis is through AMPK pathway and modulation of oxidative stress markers. Hum Exp Toxicol. 2019;38(6):703–12.
pubmed: 30924377 doi: 10.1177/0960327119839192
Chen TC, Cho H-Y, Wang W, Barath M, Sharma N, Hofman FM, Schönthal AH. A novel temozolomide–perillyl alcohol conjugate exhibits superior activity against breast cancer cells in vitro and intracranial triple-negative tumor growth in vivo. Mol Cancer Ther. 2014;13(5):1181–93.
pubmed: 24623736 doi: 10.1158/1535-7163.MCT-13-0882
Bhattacharjee B, Chatterjee J. Identification of proapoptopic, anti-inflammatory, anti-proliferative, anti-invasive and anti-angiogenic targets of essential oils in cardamom by dual reverse virtual screening and binding pose analysis. Asian Pac J Cancer Prev. 2013;14(6):3735–42.
pubmed: 23886174 doi: 10.7314/APJCP.2013.14.6.3735
Manassero CA, Girotti JR, Mijailovsky S. García de Bravo M, Polo M: In vitro comparative analysis of antiproliferative activity of essential oil from mandarin peel and its principal component limonene. Nat Prod Res. 2013;27(16):1475–8.
pubmed: 22943501 doi: 10.1080/14786419.2012.718775
Sonboli A, Esmaeili MA, Gholipour A, Kanani MR. Composition, cytotoxicity and antioxidant activity of the essential oil of Dracocephalum surmandinum from Iran. Nat Prod Commun. 2010;5(2):1934578X1000500234.
Shahen M, Shar AH, Abd Abomohra E-F, Guo Z, Wang Y. Recent Trends in Systems Biology of miRNAs and RNAi in Dengue Fever: Diagnosis and Treatment. Int J Appl Res Vet Med. 2018;16(1):81–7.
Smoot ME, Ono K, Ruscheinski J, Wang P-L, Ideker T. Cytoscape 2.8: new features for data integration and network visualization. Bioinformatics. 2011;27(3):431–2.
pubmed: 21149340 doi: 10.1093/bioinformatics/btq675
Shannon P, Markiel A, Ozier O, Baliga NS, Wang JT, Ramage D, Amin N, Schwikowski B, Ideker T. Cytoscape: a software environment for integrated models of biomolecular interaction networks. Genome Res. 2003;13(11):2498–504.
pubmed: 14597658 pmcid: 403769 doi: 10.1101/gr.1239303
Xu Q, Qu F, Pelkonen O: Network Pharmacology and Traditional Chinese Medicine: INTECH Open Access Publisher; 2012.
Hossain MA, Rahman MH, Sultana H, Ahsan A, Rayhan SI, Hasan MI, Sohel M, Somadder PD, Moni MA. An integrated in-silico Pharmaco-BioInformatics approaches to identify synergistic effects of COVID-19 to HIV patients. Comput Biol Med. 2023;155:106656.
pubmed: 36805222 pmcid: 9911982 doi: 10.1016/j.compbiomed.2023.106656
Klopfenstein D, Zhang L, Pedersen BS, Ramírez F, Vesztrocy AW, Naldi A, Mungall CJ, Yunes JM, Botvinnik O, Weigel M. GOATOOLS: A Python library for Gene Ontology analyses. Sci Rep. 2018;8(1):1–17.
doi: 10.1038/s41598-018-28948-z
Mosmann T: Rapid colorimetric assay for cellular growth and survival: application to proliferation and cytotoxicity assays J Immunol Methods. 1983;65: 55–63. Planta Med 1998, 64:212–215.
Salim EI, Mosbah AM, Elhussiny F, Hanafy NA, Abdou Y. Preparation and characterization of cetuximab-loaded egg serum albumin nanoparticles and their uses as a drug delivery system against Caco-2 colon cancer cells. Cancer Nanotechnology. 2023;14(1):1–20.
doi: 10.1186/s12645-022-00153-8
Chou T-C: The combination index (CI< 1) as the definition of synergism and of synergy claims. In., vol. 7: Elsevier; 2018: 49–50.
Van Engeland M, Nieland LJ, Ramaekers FC, Schutte B, Reutelingsperger CP. Annexin V-affinity assay: a review on an apoptosis detection system based on phosphatidylserine exposure. Cytometry. 1998;31(1):1–9.
pubmed: 9450519 doi: 10.1002/(SICI)1097-0320(19980101)31:1<1::AID-CYTO1>3.0.CO;2-R
Darzynkiewicz Z, Huang X, Zhao H Analysis of cellular DNA content by flow cytometry. Curr Protoc Immunol. 2017;119(1):5.7.1-5.7.20.
pubmed: 29091264 doi: 10.1002/cpim.36
Sammar M, Abu-Farich B, Rayan I, Falah M, Rayan A. Correlation between cytotoxicity in cancer cells and free radical-scavenging activity: In vitro evaluation of 57 medicinal and edible plant extracts. Oncol Lett. 2019;18(6):6563–71.
pubmed: 31819777 pmcid: 6896308
Beutler E. Improved method for the determination of blood glutathione. J lab clin Med. 1963;61:882–8.
pubmed: 13967893
Kuang J, Yan X, Genders AJ, Granata C, Bishop DJ. An overview of technical considerations when using quantitative real-time PCR analysis of gene expression in human exercise research. PLoS ONE. 2018;13(5):e0196438.
pubmed: 29746477 pmcid: 5944930 doi: 10.1371/journal.pone.0196438
Basudhar D, Glynn SA, Greer M, Somasundaram V, No JH, Scheiblin DA, Garrido P, Heinz WF, Ryan AE, Weiss JM. Coexpression of NOS2 and COX2 accelerates tumor growth and reduces survival in estrogen receptor-negative breast cancer. Proc Natl Acad Sci. 2017;114(49):13030–5.
pubmed: 29087320 pmcid: 5724261 doi: 10.1073/pnas.1709119114
Salim E, El-Sisi AE, Sokar S, El-Sayad M, Moussa E. Metformin potentiates the chemotherapeutic effects of doxorubicin on 2-amino-1-methyl-6-phenylimidazo[4,5b] pyridine-induced Mammary Carcinoma in rats. Fundam Clin Pharmacol. 2021;(4):700–13. https://doi.org/10.1111/fcp.12604 .
Wang J, Wang Y, Han L, Shahen M, Hu C, Li F. Multi-Omics Integration Reveals a Competitive Endogenous RNAs Network for the Identification of Progression Biomarkers and the Stratification of Patients Diagnosed With Nephroblastoma. Front Oncol. 2020;10:444.
pubmed: 32318341 pmcid: 7154083 doi: 10.3389/fonc.2020.00444
Zhao B, Luo J, Yu T, Zhou L, Lv H, Shang P. Anticancer mechanisms of metformin: A review of the current evidence. Life Sci. 2020;254:117717.
pubmed: 32339541 doi: 10.1016/j.lfs.2020.117717
Hajizadeh MR, Maleki H, Barani M, Fahmidehkar MA, Mahmoodi M, Torkzadeh-Mahani M. In vitro cytotoxicity assay of D-limonene niosomes: an efficient nano-carrier for enhancing solubility of plant-extracted agents. Research in pharmaceutical sciences. 2019;14(5):448.
pubmed: 31798662 pmcid: 6827193 doi: 10.4103/1735-5362.268206
Das BK, Knott RM, Gadad PC. Metformin and asarone inhibit HepG2 cell proliferation in a high glucose environment by regulating AMPK and Akt signaling pathway. Future journal of pharmaceutical sciences. 2021;7(1):1–10.
doi: 10.1186/s43094-021-00193-8
Kuang Y, Hu B, Feng G, Xiang M, Deng Y, Tan M, Li J, Song J. Metformin prevents against oxidative stress-induced senescence in human periodontal ligament cells. Biogerontology. 2020;21(1):13–27.
pubmed: 31559522 doi: 10.1007/s10522-019-09838-x
Mahmoud EA-M, Al-Askalany SA, Hanafy EA. Antioxidant antibacterial and cytotoxic effect of Cymbopogon citratus Mentha longifolia and Artemisia absinthium essential oils. Egypt J Chem. 2022;65(2):287–96.
Zhang HH, Zhang Y, Cheng YN, Gong FL, Cao ZQ, Yu LG, Guo XL. Metformin incombination with curcumin inhibits the growth, metastasis, and angiogenesis of hepatocellular carcinoma in vitro and in vivo. Mol Carcinog. 2018;57(1):44–56.
pubmed: 28833603 doi: 10.1002/mc.22718
Isleem RM, Alzaharna MM, Sharif FA. Synergistic anticancer effect of combining metformin with olive (Olea europaea L.) leaf crude extract on the human breast cancer cell line MCF-7. J Med Plants. 2020;8(2):30–7.
Kaur R, Arora P. Combinations of Plant Extracts and Drugs for Synergistic Anti-Cancer Activity-A Review. J Pharm Sci Res. 2020;12(4):536–44.
Hamlaoui I, Bencheraiet R, Bensegueni R, Bencharif M. Experimental and theoretical study on DPPH radical scavenging mechanism of some chalcone quinoline derivatives. J Mol Struct. 2018;1156:385–9.
doi: 10.1016/j.molstruc.2017.11.118
Hacioglu C, Kar F, Kara Y, Yucel E, Donmez DB, Sentürk H, Kanbak G. Comparative effects of metformin and Cistus laurifolius L. extract in streptozotocin-induced diabetic rat model: oxidative, inflammatory, apoptotic, and histopathological analyzes. Environ Sci Pollut Res Int. 2021;28(41):57888–57901. https://doi.org/10.1007/s11356-021-14780-y .
Induri SNR, Kansara P, Thomas SC, Xu F, Saxena D, Li X. The Gut Microbiome, Metformin, and Aging. Annu Rev Pharmacol Toxicol. 2021;62:85–108.
pubmed: 34449247 doi: 10.1146/annurev-pharmtox-051920-093829
Anandakumar P, Kamaraj S, Vanitha MK. D-limonene: A multifunctional compound with potent therapeutic effects. J Food Biochem. 2021;45(1):e13566.
pubmed: 33289132 doi: 10.1111/jfbc.13566
Adhikary A, Das S, Bhattacharjee M: Terpenoids in Cancer Treatment. In: Terpenoids Against Human Diseases. edn.: CRC Press; 2019: 177–185.
Yu X, Lin H, Wang Y, Lv W, Zhang S, Qian Y, Deng X, Feng N, Yu H, Qian B. D-limonene exhibits antitumor activity by inducing autophagy and apoptosis in lung cancer. Onco Targets Ther. 1833;2018:11.
Hadad S, Hardie D, Appleyard V, Thompson A. Effects of metformin on breast cancer cell proliferation, the AMPK pathway and the cell cycle. Clin Transl Oncol. 2014;16(8):746–52.
pubmed: 24338509 doi: 10.1007/s12094-013-1144-8
Xiong Y, Lu Q-J, Zhao J, Wu G-Y. Metformin inhibits growth of hepatocellular carcinoma cells by inducing apoptosis via mitochondrion-mediated pathway. Asian Pac J Cancer Prev. 2012;13(7):3275–9.
pubmed: 22994747 doi: 10.7314/APJCP.2012.13.7.3275
Qu Z, Zhang Y, Liao M, Chen Y, Zhao J, Pan Y. In vitro and in vivo antitumoral action of metformin on hepatocellular carcinoma. Hepatol Res. 2012;42(9):922–33.
pubmed: 22524458 doi: 10.1111/j.1872-034X.2012.01007.x
Proshkina E, Plyusnin S, Babak T, Lashmanova E, Maganova F, Koval L, Platonova E, Shaposhnikov M, Moskalev A. Terpenoids as potential geroprotectors Antioxidants. 2020;9(6):529.
pubmed: 32560451
Hafidh R, Faridah A, Abdulamir A, Fatemeh J, Fatimah AB, Zamberi S. A review: cancer research of natural products in Asia. International Journal of Cancer Research (USA). 2009;5(2):69–82.
doi: 10.3923/ijcr.2009.69.82
Falah RR, Talib WH, Shbailat SJ. Combination of metformin and curcumin targets breast cancer in mice by angiogenesis inhibition, immune system modulation and induction of p53 independent apoptosis. Therapeutic advances in medical oncology. 2017;9(4):235–52.
pubmed: 28491145 pmcid: 5405996 doi: 10.1177/1758834016687482
Ye Z, Liang Z, Mi Q, Guo Y. Limonene terpenoid obstructs human bladder cancer cell (T24 cell line) growth by inducing cellular apoptosis, caspase activation, G2/M phase cell cycle arrest and stops cancer metastasis. J BUON Off J Balk Union Oncol. 2020;25:280–5.
Hafidh RR, Hussein ZS, MalAllah QM, Abdulamir SA, Abu Bakar F. A High-throughput Quantitative Expression Analysis of Cancer-related Genes in Human HepG2 Cells in Response to Limonene, a Potential Anticancer Agent. Curr Cancer Drug Targets. 2018;18(8):807–15.
pubmed: 29141549 doi: 10.2174/1568009617666171114144236
Yin C, Knudson CM, Korsmeyer SJ, Van Dyke T. Bax suppresses tumorigenesis and stimulates apoptosis in vivo. Nature. 1997;385(6617):637–40.
pubmed: 9024662 doi: 10.1038/385637a0
Forrester K, Ambs S, Lupold SE, Kapust RB, Spillare EA, Weinberg WC, Felley-Bosco E, Wang XW, Geller DA, Tzeng E. Nitric oxide-induced p53 accumulation and regulation of inducible nitric oxide synthase expression by wild-type p53. Proc Natl Acad Sci. 1996;93(6):2442–7.
pubmed: 8637893 pmcid: 39816 doi: 10.1073/pnas.93.6.2442
Singh B, Berry JA, Shoher A, Ramakrishnan V, Lucci A. COX-2 overexpression increases motility and invasion of breast cancer cells. Int J Oncol. 2005;26(5):1393–9.
pubmed: 15809733
Leng J, Han C, Demetris AJ, Michalopoulos GK, Wu T. Cyclooxygenase-2 promotes hepatocellular carcinoma cell growth through Akt activation: evidence for Akt inhibition in celecoxib-induced apoptosis. Hepatology. 2003;38(3):756–68.
pubmed: 12939602 doi: 10.1053/jhep.2003.50380
Sobolewski C, Cerella C, Dicato M, Ghibelli L, Diederich M. The role of cyclooxygenase-2 in cell proliferation and cell death in human malignancies. Int J Cell Biol. 2010;2010:215158.
pubmed: 20339581 pmcid: 2841246 doi: 10.1155/2010/215158

Auteurs

Elsayed I Salim (EI)

Department of Zoology, Research Lab of Molecular Carcinogenesis, Faculty of Science, Tanta University, Tanta, 31527, Egypt. elsayed.salim@science.tanta.edu.eg.

Mona M Alabasy (MM)

Department of Zoology, Research Lab of Molecular Carcinogenesis, Faculty of Science, Tanta University, Tanta, 31527, Egypt.

Eman M El Nashar (EME)

Department of Anatomy, College of Medicine, King Khalid University, Abha, 62529, Saudi Arabia.

Norah S Al-Zahrani (NS)

Department of Clinical Biochemistry, College of Medicine, King Khalid University, Abha, 62529, Saudi Arabia.

Mohammed A Alzahrani (MA)

Internal Medicine Department, College of Medicine, King Khalid University, Abha, 62529, Saudi Arabia.

Zihu Guo (Z)

College of Life Science, Center of Bioinformatics, Northwest A and F University, Yangling, Shaanxi, 712100, China.

Doha M Beltagy (DM)

Biochemistry Department, Faculty of Science, Damanhour University, Damanhour, Egypt.

Mohamed Shahen (M)

Department of Zoology, Research Lab of Molecular Carcinogenesis, Faculty of Science, Tanta University, Tanta, 31527, Egypt. Mshahen@science.tanta.edu.eg.

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