TY - JOUR T1 - Wnt/Beta-katenin Sinyal Yolunun Preimplantasyon, İmplantasyon, Desidualizasyon ve Plasentasyondaki Kritik Rolü AU - Dönmez, Hanife Güler AU - Beksac, M.sinan PY - 2025 DA - May Y2 - 2025 DO - 10.63716/guffd.1617231 JF - Gazi Üniversitesi Fen Fakültesi Dergisi JO - GÜFFD PB - Gazi Üniversitesi WT - DergiPark SN - 2757-5543 SP - 74 EP - 84 VL - 6 IS - 1 LA - tr AB - Embriyo ve maternal faktörler arasındaki sıkı ilişki sağlıklı bir gebelik süreci için oldukça önemlidir. Bu noktada uterus, sağlıklı bir embriyonun gelişimine devam etmesi ya da ortadan kaldırılması için embriyoyu indüklerken, embriyo endometriyuma tutunmaya, endometriyum içine yayılmaya ve maternal immünolojik etkilere karşı hayatta kalmaya çalışmaktadır. İmplantasyon, desidual reaksiyon ve plasentasyon olayları çok sayıda sinyal yolunun birbirleri ile etkileştiği kompleks bir süreçle kontrol edilmektedir. Wnt/beta-katenin sinyal yolu da bu gelişimsel olaylarda rol oynadığı belirlenen evrimsel olarak korunmuş bir sinyal yoludur. Son bulgular, Wnt/beta-katenin sinyalindeki anormalliklerin implantasyon başarısızlığı, anormal plasenta gelişimi ve preeklampsi gibi üreme bozukluklarına katkıda bulunabileceğini göstermektedir. Bu sebeple derlememizde erişkin ve embriyonik dönemde hücre proliferasyonu, farklılaşması, adezyonu ve hücre göçü gibi çeşitli biyolojik süreçlerdeki etkisi olan Wnt/beta-katenin sinyal yolunun preimplantasyon, implantasyon, desidual reaksiyon ve plasentasyondaki rolünün literatür bilgileri eşliğinde açıklanması ve ortaya konulması amaçlanmıştır. Böylece bu derleme, Wnt/beta-Katenin sinyal yolunun üreme sürecindeki kritik rolünü daha iyi anlamamıza katkı sağlayarak, bu yoldaki bozukluklarla ilişkili komplikasyonların tanı ve tedavisinde yeni stratejilerin geliştirilmesine ışık tutmayı amaçlamaktadır. KW - İmplantasyon KW - Desidualizasyon KW - Plasentasyon KW - Wnt/beta-katenin sinyal yolu CR - Klaus, A., and Birchmeier, W. (2008). Wnt signalling and its impact on development and cancer. Nature Reviews Cancer, 8(5), 387–398. https://doi.org/10.1038/nrc2389 CR - Nusse, R., and Clevers, H. (2017). Wnt/β-Catenin signaling, disease, and emerging therapeutic modalities. Cell, 169, 985–999. https://doi.org/10.1016/J.CELL.2017.05.016 CR - Cadigan, K. M., and Waterman, M. L. (2012). TCF/LEFs and Wnt signaling in the nucleus. Cold Spring Harbor Perspectives in Biology, 4(11), a007906. https://doi.org/10.1101/cshperspect.a007906 CR - Shitashige, M., Hirohashi, S., and Yamada, T. (2008). Wnt signaling inside the nucleus. Cancer Science, 99(4), 631–637. https://doi.org/10.1111/j.1349-7006.2007.00716.x CR - Liu, J., Xiao, Q., Xiao, J., Niu, C., Li, Y., Zhang, X., Zhou, Z., Shu, G., and Yin, G. (2022). Wnt/β-catenin signalling: function, biological mechanisms, and therapeutic opportunities. Signal Transduction and Targeted Therapy, 7(1), 3. https://doi.org/10.1038/s41392-021-00762-6 CR - de Winter, T. J. J., and Nusse, R. (2021). Running against the Wnt: How Wnt/β-Catenin suppresses adipogenesis. Frontiers in Cell and Developmental Biology, 9, 627429. https://doi.org/10.3389/fcell.2021.6274297. CR - Olsen, J. J., Pohl, S. Ö., Deshmukh, A., Visweswaran, M., Ward, N. C., Arfuso, F., Agostino, M., and Dharmarajan, A. (2017). The role of Wnt signalling in angiogenesis. The Clinical Biochemist Reviews, 38(3), 131–142. CR - Donmez, H. G., Demirezen, S., and Beksac, M. S. (2016). The relationship between beta-catenin and apoptosis: A cytological and immunocytochemical examination. Tissue & Cell, 48(3), 160–167. https://doi.org/10.1016/j.tice.2016.04.001 CR - Chong, J. M., Uren, A., Rubin, J. S., and Speicher, D. W. (2002). Disulfide bond assignments of secreted Frizzled-related protein-1 provide insights about Frizzled homology and netrin modules. The Journal of Biological Chemistry, 277(7), 5134–5144. https://doi.org/10.1074/jbc.M108533200 CR - Li, N., Wei, L., Liu, X., Bai, H., Ye, Y., Li, D., Li, N., Baxa, U., Wang, Q., Lv, L., Chen, Y., Feng, M., Lee, B., Gao, W., and Ho, M. (2019). A Frizzled-Like Cysteine-Rich Domain in Glypican-3 mediates Wnt binding and regulates hepatocellular carcinoma tumor growth in mice. Hepatology, 70(4), 1231–1245. https://doi.org/10.1002/hep.30646 CR - Zhang, X., MacDonald, B. T., Gao, H., Shamashkin, M., Coyle, A. J., Martinez, R. V., and He, X. (2016). Characterization of Tiki, a new family of Wnt-specific metalloproteases. The Journal of Biological Chemistry, 291(5), 2435–2443. https://doi.org/10.1074/jbc.M115.677807 CR - Kakugawa, S., Langton, P. F., Zebisch, M., Howell, S., Chang, T. H., Liu, Y., Feizi, T., Bineva, G., O'Reilly, N., Snijders, A. P., Jones, E. Y., and Vincent, J. P. (2015). Notum deacylates Wnt proteins to suppress signalling activity. Nature, 519(7542), 187–192. https://doi.org/10.1038/nature14259 CR - Zhang, B., and Ma, J. X. (2010). Wnt pathway antagonists and angiogenesis. Protein & Cell, 1(10), 898–906. https://doi.org/10.1007/s13238-010-0112-0 CR - Bovolenta, P., Esteve, P., Ruiz, J. M., Cisneros, E., and Lopez-Rios, J. (2008). Beyond Wnt inhibition: new functions of secreted Frizzled-related proteins in development and disease. Journal of Cell Science, 121(Pt 6), 737–746. https://doi.org/10.1242/jcs.026096 CR - Kawano, Y., and Kypta, R. (2003). Secreted antagonists of the Wnt signalling pathway. Journal of Cell Science, 116(Pt 13), 2627–2634. https://doi.org/10.1242/jcs.00623 CR - Schmidt, O., Brückner, M., and Bernkopf, D. B. (2025). AXIN2 promotes degradation of AXIN1 through tankyrase in colorectal cancer cells. The FEBS journal, 292(5), 1019–1033. https://doi.org/10.1111/febs.17226 CR - Xu, X., Zhang, M., Xu, F., and Jiang, S. (2020). Wnt signaling in breast cancer: biological mechanisms, challenges and opportunities. Molecular Cancer, 19(1), 165. https://doi.org/10.1186/s12943-020-01276-5 CR - Ely, K. A., Bischoff, L. A., and Weiss, V. L. (2018). Wnt signaling in thyroid homeostasis and carcinogenesis. Genes, 9(4), 204. https://doi.org/10.3390/genes9040204 CR - Han, R., Yang, J., Zhu, Y., and Gan, R. (2024). Wnt signaling in gastric cancer: current progress and future prospects. Frontiers in Oncology, 14, 1410513. https://doi.org/10.3389/fonc.2024.1410513 CR - Ruan, Y., Kim, H. N., Ogana, H., and Kim, Y. M. (2020). Wnt Signaling in leukemia and its bone marrow microenvironment. International Journal of Molecular Sciences, 21(17), 6247. https://doi.org/10.3390/ijms21176247 CR - Niemann, S., Zhao, C., Pascu, F., Stahl, U., Aulepp, U., Niswander, L., Weber, J. L., and Müller, U. (2004). Homozygous WNT3 mutation causes tetra-amelia in a large consanguineous family. American Journal of Human Genetics, 74(3), 558–563. https://doi.org/10.1086/382196 CR - Shin D. W. (2022). The molecular mechanism of natural products activating Wnt/β-Catenin Signaling Pathway for improving hair loss. Life, 12(11), 1856. https://doi.org/10.3390/life12111856 CR - Zhao, S. J., Jia, H., Xu, X. L., Bu, W. B., Zhang, Q., Chen, X., Ji, J., and Sun, J. F. (2021). Identification of the role of Wnt/β-Catenin Pathway through integrated analyses and in vivo experiments in vitiligo. Clinical, Cosmetic and Investigational Dermatology, 14, 1089–1103. https://doi.org/10.2147/CCID.S319061 CR - Sun, Q., Rabbani, P., Takeo, M., Lee, S. H., Lim, C. H., Noel, E. S., Taketo, M. M., Myung, P., Millar, S., and Ito, M. (2018). Dissecting Wnt signaling for melanocyte regulation during wound healing. The Journal of Investigative Dermatology, 138(7), 1591–1600. https://doi.org/10.1016/j.jid.2018.01.030 CR - Lai, J., Yang, H., Huang, J., and He, L. (2024). Investigating the impact of Wnt pathway-related genes on biomarker and diagnostic model development for osteoporosis in postmenopausal females. Scientific Reports, 14(1), 2880. https://doi.org/10.1038/s41598-024-52429-1 CR - Libro, R., Bramanti, P., and Mazzon, E. (2016). The role of the Wnt canonical signaling in neurodegenerative diseases. Life Sciences, 158, 78–88. https://doi.org/10.1016/j.lfs.2016.06.024 CR - Zhang, Z., Wang, X., Zhang, L., Shi, Y., Wang, J., and Yan, H. (2017). Wnt/β-catenin signaling pathway in trophoblasts and abnormal activation in preeclampsia (Review). Molecular Medicine Reports, 16(2), 1007–1013. https://doi.org/10.3892/mmr.2017.6718 CR - Chen, L., Wang, J., Fan, X., Zhang, Y., Zhoua, M., Li, X., and Wang, L. (2021). LASP2 inhibits trophoblast cell migration and invasion in preeclampsia through inactivation of the Wnt/β-catenin signaling pathway. Journal of Receptor and Signal Transduction Research, 41(1), 67–73. https://doi.org/10.1080/10799893.2020.1787444 CR - Pollheimer, J., Loregger, T., Sonderegger, S., Saleh, L., Bauer, S., Bilban, M., Czerwenka, K., Husslein, P., and Knöfler, M. (2006). Activation of the canonical wingless/T-cell factor signaling pathway promotes invasive differentiation of human trophoblast. The American Journal of Pathology, 168(4), 1134–1147. https://doi.org/10.2353/ajpath.2006.050686 CR - Chronopoulou, E., Koika, V., Tsiveriotis, K., Stefanidis, K., Kalogeropoulos, S., Georgopoulos, N., Adonakis, G., and Kaponis, A. (2022). Wnt4, Wnt6 and β-catenin expression in human placental tissue - is there a link with first trimester miscarriage? Results from a pilot study. Reproductive Biology and Endocrinology, 20(1), 51. https://doi.org/10.1186/s12958-022-00923-4 CR - Li, N., Li, S., Wang, Y., Wang, J., Wang, K., Liu, X., Li, Y., and Liu, J. (2017). Decreased expression of WNT2 in villi of unexplained recurrent spontaneous abortion patients may cause trophoblast cell dysfunction via downregulated Wnt/β-catenin signaling pathway. Cell Biology International, 41(8), 898–907. https://doi.org/10.1002/cbin.10807 CR - Schulz, K. N., and Harrison, M. M. (2019). Mechanisms regulating zygotic genome activation. Nature Reviews Genetics, 20(4), 221–234. https://doi.org/10.1038/s41576-018-0087-x CR - Bettegowda, A., Smith, G. W. (2007). Mechanisms of maternal mRNA regulation: implications for mammalian early embryonic development. Frontiers in Bioscience, 12, 3713–3726. https://doi.org/10.2741/2346 CR - Kemp, C. R., Hendrickx, M., Willems, E., Wawrzak, D., Metioui, M., and Leyns, L. (2007). The roles of Wnt signaling in early mouse development and embryonic stem cells. Functional Development and Embryolology, 1, 1–13. CR - Tepekoy, F., Akkoyunlu, G., and Demir, R. (2015). The role of Wnt signaling members in the uterus and embryo during pre-implantation and implantation. Journal of Assisted Reproduction and Genetics, 32(3), 337–346. https://doi.org/10.1007/s10815-014-0409-7 CR - Harwood, B. N., Cross, S. K., Radford, E. E., Haac, B. E., and De Vries, W. N. (2008). Members of the WNT signaling pathways are widely expressed in mouse ovaries, oocytes, and cleavage stage embryos. Developmental Dynamics, 237(4), 1099–1111. https://doi.org/10.1002/dvdy.21491 CR - Mohamed, O. A., Clarke, H. J., and Dufort, D. (2004). Beta-catenin signaling marks the prospective site of primitive streak formation in the mouse embryo. Developmental Dynamics, 231(2), 416–424. https://doi.org/10.1002/dvdy.20135 CR - Xie, H., Tranguch, S., Jia, X., Zhang, H., Das, S. K., Dey, S. K., Kuo, C. J., and Wang, H. (2008). Inactivation of nuclear Wnt-beta-catenin signaling limits blastocyst competency for implantation. Development, 135(4), 717–727. https://doi.org/10.1242/dev.015339 CR - ten Berge, D., Kurek, D., Blauwkamp, T., Koole, W., Maas, A., Eroglu, E., Siu, R. K., and Nusse, R. (2011). Embryonic stem cells require Wnt proteins to prevent differentiation to epiblast stem cells. Nature Cell Biology, 13(9), 1070–1075. https://doi.org/10.1038/ncb2314 CR - De Vries, W. N., Evsikov, A. V., Haac, B. E., Fancher, K. S., Holbrook, A. E., Kemler, R., Solter, D., and Knowles, B. B. (2004). Maternal beta-catenin and E-cadherin in mouse development. Development, 131(18), 4435–4445. https://doi.org/10.1242/dev.01316 CR - Krivega, M., Essahib, W., and Van de Velde, H. (2015). WNT3 and membrane-associated β-catenin regulate trophectoderm lineage differentiation in human blastocysts. Molecular Human Reproduction, 21(9), 711–722. https://doi.org/10.1093/molehr/gav036 CR - Huelsken, J., Vogel, R., Brinkmann, V., Erdmann, B., Birchmeier, C., and Birchmeier, W. (2000). Requirement for beta-catenin in anterior-posterior axis formation in mice. The Journal of Cell Biology, 148(3), 567–578. https://doi.org/10.1083/jcb.148.3.567 CR - Kelly, O. G., Pinson, K. I., and Skarnes, W. C. (2004). The Wnt co-receptors Lrp5 and Lrp6 are essential for gastrulation in mice. Development, 131(12), 2803–2815. https://doi.org/10.1242/dev.01137 CR - Large, M. J., and DeMayo, F. J. (2012). The regulation of embryo implantation and endometrial decidualization by progesterone receptor signaling. Molecular and Cellular Endocrinology, 358(2), 155–165. https://doi.org/10.1016/j.mce.2011.07.027 CR - Shibata, S., Endo, S., Nagai, L. A. E., H Kobayashi, E., Oike, A., Kobayashi, N., Kitamura, A., Hori, T., Nashimoto, Y., Nakato, R., Hamada, H., Kaji, H., Kikutake, C., Suyama, M., Saito, M., Yaegashi, N., Okae, H., and Arima, T. (2024). Modeling embryo-endometrial interface recapitulating human embryo implantation. Science Advances, 10(8), eadi4819. https://doi.org/10.1126/sciadv.adi4819 CR - Wang, H., and Dey, S. K. (2006). Roadmap to embryo implantation: clues from mouse models. Nature Reviews Genetics, 7(3), 185–199. https://doi.org/10.1038/nrg1808 CR - Yoshinaga K. (2018). A historical review of blastocyst implantation research. Biology of Reproduction, 99(1), 175–195. https://doi.org/10.1093/biolre/ioy093 CR - Edwards R. G. (1988). Human uterine endocrinology and the implantation window. Annals of the New York Academy of Sciences, 541, 445–454. https://doi.org/10.1111/j.1749-6632.1988.tb22281.x CR - Gupta, S. K., Malhotra, S. S., Malik, A., Verma, S., and Chaudhary, P. (2016). Cell signaling pathways involved during invasion and syncytialization of trophoblast cells. American Journal of Reproductive Immunology, 75(3), 361–371. https://doi.org/10.1111/aji.12436 CR - Mohamed, O. A., Jonnaert, M., Labelle-Dumais, C., Kuroda, K., Clarke, H. J., and Dufort, D. (2005). Uterine Wnt/beta-catenin signaling is required for implantation. Proceedings of the National Academy of Sciences of the United States of America, 102(24), 8579–8584. https://doi.org/10.1073/pnas.0500612102 CR - de Jaime-Soguero, A., Abreu de Oliveira, W. A., and Lluis, F. (2018). The pleiotropic effects of the Canonical Wnt Pathway in early development and pluripotency. Genes, 9(2), 93. https://doi.org/10.3390/genes9020093 CR - Fritz, R., Jain, C., and Armant, D. R. (2014). Cell signaling in trophoblast-uterine communication. The International Journal of Developmental Biology, 58(2-4), 261–271. https://doi.org/10.1387/ijdb.140011da CR - Catalano, R. D., Critchley, H. O., Heikinheimo, O., Baird, D. T., Hapangama, D., Sherwin, J. R., Charnock-Jones, D. S., Smith, S. K., and Sharkey, A. M. (2007). Mifepristone induced progesterone withdrawal reveals novel regulatory pathways in human endometrium. Molecular Human Reproduction, 13(9), 641–654. https://doi.org/10.1093/molehr/gam021 CR - Hayashi, K., Erikson, D. W., Tilford, S. A., Bany, B. M., Maclean, J. A., 2nd, Rucker, E. B., 3rd, Johnson, G. A., and Spencer, T. E. (2009). Wnt genes in the mouse uterus: potential regulation of implantation. Biology of Reproduction, 80(5), 989–1000. https://doi.org/10.1095/biolreprod.108.075416 CR - Okada, H., Tsuzuki, T., and Murata, H. (2018). Decidualization of the human endometrium. Reproductive Medicine and Biology, 17(3), 220–227. https://doi.org/10.1002/rmb2.12088 CR - Garrido-Gomez, T., Dominguez, F., Quiñonero, A., Diaz-Gimeno, P., Kapidzic, M., Gormley, M., Ona, K., Padilla-Iserte, P., McMaster, M., Genbacev, O., Perales, A., and Fisher, S. J., Simón, C. (2017). Defective decidualization during and after severe preeclampsia reveals a possible maternal contribution to the etiology. Proceedings of the National Academy of Sciences of the United States of America, 114(40), E8468–E8477. https://doi.org/10.1073/pnas.1706546114 CR - Gellersen, B., and Brosens, J. J. (2014). Cyclic decidualization of the human endometrium in reproductive health and failure. Endocrine Reviews, 35(6), 851–905. https://doi.org/10.1210/er.2014-1045 CR - Large, M. J., and DeMayo, F. J. (2012). The regulation of embryo implantation and endometrial decidualization by progesterone receptor signaling. Molecular and Cellular Endocrinology, 358(2), 155–165. https://doi.org/10.1016/j.mce.2011.07.027 CR - Tulac, S., Overgaard, M. T., Hamilton, A. E., Jumbe, N. L., Suchanek, E., and Giudice, L. C. (2006). Dickkopf-1, an inhibitor of Wnt signaling, is regulated by progesterone in human endometrial stromal cells. The Journal of Clinical Endocrinology and Metabolism, 91(4), 1453–1461. https://doi.org/10.1210/jc.2005-0769 CR - Franco, H. L., Dai, D., Lee, K. Y., Rubel, C. A., Roop, D., Boerboom, D., Jeong, J. W., Lydon, J. P., Bagchi, I. C., Bagchi, M. K., and DeMayo, F. J. (2011). WNT4 is a key regulator of normal postnatal uterine development and progesterone signaling during embryo implantation and decidualization in the mouse. FASEB Journal, 25(4), 1176–1187. https://doi.org/10.1096/fj.10-175349 CR - Hess, A. P., Hamilton, A. E., Talbi, S., Dosiou, C., Nyegaard, M., Nayak, N., Genbecev-Krtolica, O., Mavrogianis, P., Ferrer, K., Kruessel, J., Fazleabas, A. T., Fisher, S. J., and Giudice, L. C. (2007). Decidual stromal cell response to paracrine signals from the trophoblast: amplification of immune and angiogenic modulators. Biology of Reproduction, 76(1), 102–117. https://doi.org/10.1095/biolreprod.106.054791 CR - Wang, Y., Hanifi-Moghaddam, P., Hanekamp, E. E., Kloosterboer, H. J., Franken, P., Veldscholte, J., van Doorn, H. C., Ewing, P. C., Kim, J. J., Grootegoed, J. A., Burger, C. W., Fodde, R., and Blok, L. J. (2009). Progesterone inhibition of Wnt/beta-catenin signaling in normal endometrium and endometrial cancer. Clinical Cancer Research, 15(18), 5784–5793. https://doi.org/10.1158/1078-0432.CCR-09-0814 CR - Tulac, S., Nayak, N. R., Kao, L. C., Van Waes, M., Huang, J., Lobo, S., Germeyer, A., Lessey, B. A., Taylor, R. N., Suchanek, E., and Giudice, L. C. (2003). Identification, characterization, and regulation of the canonical Wnt signaling pathway in human endometrium. The Journal of Clinical Endocrinology and Metabolism, 88(8), 3860–3866. https://doi.org/10.1210/jc.2003-030494 CR - Bui, T. D., Zhang, L., Rees, M. C., Bicknell, R., and Harris, A. L. (1997). Expression and hormone regulation of Wnt2, 3, 4, 5a, 7a, 7b and 10b in normal human endometrium and endometrial carcinoma. British Journal of Cancer, 75(8), 1131–1136. https://doi.org/10.1038/bjc.1997.195 CR - Chavatte-Palmer, P., and Tarrade, A. (2016). Placentation in different mammalian species. Annales D'endocrinologie, 77(2), 67–74. https://doi.org/10.1016/j.ando.2016.04.006 CR - Knöfler, M., and Pollheimer, J. (2013). Human placental trophoblast invasion and differentiation: a particular focus on Wnt signaling. Frontiers in Genetics, 4, 190. https://doi.org/10.3389/fgene.2013.00190 CR - Sonderegger, S., Haslinger, P., Sabri, A., Leisser, C., Otten, J. V., Fiala, C., and Knöfler, M. (2010). Wingless (Wnt)-3A induces trophoblast migration and matrix metalloproteinase-2 secretion through canonical Wnt signaling and protein kinase B/AKT activation. Endocrinology, 151(1), 211–220. https://doi.org/10.1210/en.2009-0557 CR - Sonderegger, S., Husslein, H., Leisser, C., and Knöfler, M. (2007). Complex expression pattern of Wnt ligands and frizzled receptors in human placenta and its trophoblast subtypes. Placenta, 28 Suppl A(Suppl A), S97–S102. https://doi.org/10.1016/j.placenta.2006.11.003 CR - Novakovic, B., Rakyan, V., Ng, H. K., Manuelpillai, U., Dewi, C., Wong, N. C., Morley, R., Down, T., Beck, S., Craig, J. M., and Saffery, R. (2008). Specific tumour-associated methylation in normal human term placenta and first-trimester cytotrophoblasts. Molecular Human Reproduction, 14(9), 547–554. https://doi.org/10.1093/molehr/gan046 CR - Monkley, S. J., Delaney, S. J., Pennisi, D. J., Christiansen, J. H., and Wainwright, B. J. (1996). Targeted disruption of the Wnt2 gene results in placentation defects. Development, 122(11), 3343–3353. https://doi.org/10.1242/dev.122.11.3343 CR - Herr, F., Horndasch, M., Howe, D., Baal, N., Goyal, P., Fischer, S., Zygmunt, M., and Preissner, K. T. (2014). Human placenta-derived Wnt-5a induces the expression of ICAM-1 and VCAM-1 in CD133(+)CD34(+)-hematopoietic progenitor cells. Reproductive Biology, 14(4), 262–275. https://doi.org/10.1016/j.repbio.2014.08.001 CR - Newman, A. C., and Hughes, C. C. (2012). Macrophages and angiogenesis: a role for Wnt signaling. Vascular Cell, 4(1), 13. https://doi.org/10.1186/2045-824X-4-13 UR - https://doi.org/10.63716/guffd.1617231 L1 - https://dergipark.org.tr/tr/download/article-file/4509493 ER -