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通讯作者:

赵婷婷,E-mail:zhaotiti@njmu.edu.cn

中图分类号:Q78

文献标识码:A

文章编号:1007-4368(2023)08-1055-06

DOI:10.7655/NYDXBNS20230803

参考文献 1
SPASSOV D S,JURECIC R.The PUF family of RNA ⁃ binding proteins:does evolutionarily conserved structure equal conserved function[J].IUBMB Life,2003,55(7):359-366
参考文献 2
LIN K,ZHANG S,SHI Q,et al.Essential requirement of mammalian Pumilio family in embryonic development.[J].Mol Biol Cell,2018,29(24):2922-2932
参考文献 3
CHEN D,ZHENG W,LIN A,et al.Pumilio 1 suppresses multiple activators of p53 to safeguard spermatogenesis [J].Curr Biol,2012,22(5):420-425
参考文献 4
LIN K,QIANG W,ZHU M,et al.Mammalian Pum1 and Pum2 control body size via translational regulation of the cellcycle inhibitor Cdkn1b[J].Cell Rep,2019,26(9):2434-2450.e6
参考文献 5
GENNARINO V A,PALMER E E,MCDONELL L M,et al.A mild PUM1 mutation is associated with adult ⁃onset ataxia,whereas haploinsufficiency causes developmental delay and seizures[J].Cell,2018,172(5):924-936
参考文献 6
GENNARINO V A,SINGH R K,WHITE J J,et al.Pum⁃ ilio1 haploinsufficiency leads to SCA1⁃like neurodegener⁃ ation by increasing wild ⁃ type Ataxin1 levels[J].Cell,2015,160(6):1087-1098
参考文献 7
SILVA I L Z,KOHATA A A,SHIGUNOV P.Modulation and function of Pumilio proteins in cancer[J].Semin Can⁃ cer Biol,2022,86(3):298-309
参考文献 8
GUAN X,CHEN S,LIU Y,et al.PUM1 promotes ovarian cancer proliferation,migration and invasion[J].Biochem Biophys Res Commun,2018,497:313-318
参考文献 9
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参考文献 10
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参考文献 11
SHI P,ZHANG J,LI X,et al.Long non ⁃ coding RNA NORAD inhibition upregulates microRNA ⁃ 323a ⁃ 3p to suppress tumorigenesis and development of breast cancer through the PUM1/eIF2 axis[J].Cell Cycle,2021,20:1295-1307
参考文献 12
LIU Q,XIN C,CHEN Y,et al.PUM1 Is Overexpressed in colon cancer cells with acquired resistance to cetuximab [J].Front Cell Dev Biol,2021,9:696558
参考文献 13
DING Y,YUAN X,GU W.Circular RNA RBM33 contrib⁃ utes to cervical cancer progression via modulation of the miR ⁃758⁃3p/PUM2 axis[J].J Mol Histol,2021,52:173-185
参考文献 14
LI Q,LI C,CHEN J,et al.High expression of long non⁃ coding RNA NORAD indicates a poor prognosis and pro⁃ motes clinical progression and metastasis in bladder can⁃ cer[J].Urol Oncol,2018,36(310):e315-e322
参考文献 15
JANECKI D M,SAJEK M,SMIALEK M J,et al.SPIN1 is a proto⁃oncogene and SPIN3 is a tumor suppressor in hu⁃ man seminoma[J].Oncotarget,2018,9:32466-32477
参考文献 16
DUAN W,NIAN L,QIAO J,et al.LncRNA TUG1 aggra⁃ vates the progression of cervical cancer by binding PUM2 [J].Eur Rev Med Pharmacol Sci,2019,23:8211-8218
参考文献 17
TAO W,MA J,ZHENG J,et al.Silencing SCAMP1⁃TV2 inhibited the malignant biological behaviors of breast can⁃ cer cells by interaction with PUM2 to facilitate INSM1 mRNA degradation[J].Front Oncol,2020,10(613):1-13
参考文献 18
BATISTA A F,SCHROEDER,M K,KHAN K,et al,Glob⁃ al complement C3 lowering in adult mice protects hippo⁃ campal synaptic function[J].Alzheimer’s Dement,2021,17(Suppl 3):e057867
目录contents

    摘要

    目的:为探究出生后Pumilio家族的功能及其缺失对个体的影响,构建Pumilio1(Pum1)和Pumilio2(Pum2)双基因诱导性敲除的小鼠模型。方法:通过小鼠交配实验得到R26-ERT2 Cre/+Pum1flox/flox Pum2-/-小鼠,并将同窝雄鼠设为对照组和实验组。分别对实验组3周和成年小鼠注射他莫昔芬,在DNA、RNA和蛋白水平表征主要脏器中Pum1的敲除效果;并表征精子发生过程中的病理变化、细胞增殖及凋亡情况。结果:实验组3周和成年雄鼠的胸腺和睾丸组织中Pum1表达水平极低,敲除效率均高于50%,Pum1和Pum2双基因诱导性敲除小鼠模型构建成功。在注射他莫昔芬结束的第21天,3周雄鼠胸腺、脾脏和睾丸的重量明显下降,睾丸病理HE染色实验显示精子形成障碍,TUNEL和BrdU染色后计数结果显示睾丸中生精细胞凋亡增加、增殖减慢。成年小鼠在注射他莫昔芬恢复后,Pum1在胸腺、心、肝、睾丸中的表达仍有降低,但睾丸病理HE染色显示精子发生未见异常。结论:该模型的建立首次展示Pumilio家族蛋白作为未来药物靶标的潜能,为深入研究Pumilio的功能及作为肿瘤治疗靶蛋白的研究奠定了理论基础。

    Abstract

    Objective:To determine the roles of Pumilio family in the postnatal development,we established the Pumilio1/Pumilio2 (Pum1 and Pum2)inducible knockout mouse model. Methods:Pum1flox/flox Pum2-/- mice were mated with R26 - ERT2Cre/Cre mice to obtain R26-ERT2Cre/+Pum1flox/flox Pum2-/- mice. The experiment group(three week old mice and adult mice)was injected with tamoxifen, while the control group was injected with the same amount of peanut oil. The knockout efficiency of Pum1 at DNA,RNA and protein levels of multiple organs in mice was determined. The histology of the testis as well as cell proliferation and apoptosis of the testicular cells were examined. Results:The Pumilio1 RNA and protein of thymus and testis were knocked down significantly. The knock down efficiency of Pum1 varies from tissues to tissues but reaching a minimum of 50%. The mouse model of Pum1 and Pum2 gene induced knockout was successfully constructed. The weight of thymus,spleen and testis of male mice in the 3-week experiment group decreased significantly,supporting the critical role of PUM in postnatal organ growth. The hematoxylin and eosin(HE),TUNEL and BrdU staining of testis pathology showed disrupted spermatogenesis,increased apoptosis and decreased proliferation of spermatogenic cells in 3 - week experiment group testis. Although,the Pum1 of each organ in adult group was knocked down at different levels,the spermatogenesis of adult experimental group was not significantly affected. Conclusion:This inducible Pumilio knockout model provides a new tool to study the roles of Pumilio in postnatal and adult mice,and supports the future development of Pumilio as potential drug targets for diseases involving Pumilio-mediated translational control.

    关键词

    Pumilio诱导性敲除他莫昔芬生殖小鼠

  • Pumilio家族蛋白是一类高度保守的RNA结合蛋白,在哺乳动物中存在 Pumilio1(Pum1)和 Pum⁃ ilio2(Pum2)两种Pumilio蛋白,它们在结构上高度相似,并且在靶标及功能上存在冗余[1]。Pum1、Pum2蛋白参与胚胎发育[2]、生殖细胞发育[3]、细胞周期进展[4]、神经反应[5] 和记忆形成[6] 等生理过程,尤其与神经退行性疾病、癌症等人类疾病的发生发展有着重要的联系。目前研究报道,Pumlilio通过不同途径调控多种肿瘤的发生发展[7],Pum1 在卵巢癌、前列腺癌、胰腺癌和结肠癌中高表达,通过多种调控轴来影响肿瘤的增殖、转移和侵袭等[8-12];Pum2在子宫颈癌、乳腺癌和膀胱癌中的高表达预示着更短的生存期[13-15], Pum1和/或Pum2在肿瘤细胞中的降低,可影响相应的肿瘤抑制因子,进而影响肿瘤的生长[16-17]。因此, Pumilio是否可以作为肿瘤治疗靶标蛋白的关键,是其缺失对生命机体的影响大小。由于Pumilio对于细胞的早期分化以及原肠胚形成过程至关重要,Pumilio 双敲小鼠在胚胎期8.5 d死亡[3],出生后Pumilio对个体影响及功能研究显得尤为重要。

  • 本研究利用 R26 ⁃ CreERT2 小鼠与 Pum1flox/flox Pum2-/-小鼠进行交配获得基因型为 R26⁃ERT2 Cre/+ Pum1flox/flox Pum2-/-的雄鼠,注射他莫昔芬建立了诱导性全身Pumilio基因敲除小鼠模型,通过PCR、West⁃ ern blot和RT⁃PCR技术表征各组织敲除效果,以及对重要器官重量、睾丸病理改变、生殖细胞增殖和凋亡等结果进行分析,探索他莫昔芬诱导的小鼠各器官中 Pum1 敲除情况和雄性生殖系统受到的影响,为深入研究Pumilio在出生后的功能和肿瘤治疗提供了重要依据及关键的研究工具。

  • 1 材料和方法

  • 1.1 材料

  • R26⁃CreERT2 小鼠购自美国麻省理工大学的Tyler Jack实验室。Pum1诱导性敲除小鼠是在Pum1基因的第9和第10号外显子的两端插入loxp序列,Pum2敲除小鼠是在第10和第11外显子之间插入β⁃geo基因造成基因缺陷。小鼠饲养于南京医科大学医药动物实验中心生殖医学国家重点实验室模式动物研究基地SPF级动物房,室温控制在20~22℃,湿度 50%~70%,光照周期 12 h/12 h。饲养过程中保持充足食物和水,垫料每周更换 1 次。繁殖采用 1 只雄鼠和2只雌鼠同笼的方式进行。实验动物使用获得南京医科大学实验动物福利伦理审查委员会同意(IACUC⁃1903052⁃1)。

  • 1.2 方法

  • 1.2.1 基因型鉴定

  • 收取各组织后,剪下少量器官组织溶于50 mmol/L NaOH 溶液,沸水浴 30 min。冷却后加入 20 μL 1 mol/L的Tris⁃HCl(pH8.0)于涡旋仪混匀,12 000 r/min 离心 5 min,取上清液进行 PCR 扩增。目的片段的扩增序列和凝胶成像的产物大小见表1。

  • 1.2.2 BrdU实验

  • 将切片按以下顺序和时间处理:①切片脱蜡和水化;②去除内源性过氧化氢酶,3% H2O2 浸泡 10 min。ddH2O洗3次,每次5 min;③胰蛋白酶消化液37℃ 8 min,ddH2O 2 min×3次,37℃ ddH2O 5 min; ④2N HCl37℃ 30 min;⑤0.1 mol/L Borax 10 min, ddH2O 2 min×3;⑥50 mmol/L Tris⁃HCl(pH=7.6) 5 min×2,ddH2O 2 min×3;⑦封闭、抗体孵育、显色、苏木素染色、脱水、封片。

  • 1.2.3 Western blot检测小鼠主要脏器的敲除效率

  • 取小鼠脑、胸腺、心、肝、脾、睾丸各约10 mg,分别加入约200 μL RIPA强裂解液,匀浆后冰上裂解,每 10 min 漩涡震 1 次,共 3 次,冰上静置 20 min, 4℃,20 000 g 离心 30 min 后取上清液即总蛋白。浓度为10%的单一胶分离蛋白,湿转到硝酸纤维素膜 (nitrocellulose filter membrane,NC)上,用含6%脱脂奶粉的TBST封闭1 h,然后加入抗PUM1(1∶500)抗体在 4℃孵育过夜。次日用TBST液洗3次,每次10 min,加入二抗后室温孵育1 h,ECL化学发光仪曝光。

  • 表1 小鼠基因型测定引物序列

  • Table1 Sequences of primers used for genotyping

  • 1.2.4 Real⁃time PCR法测定

  • 采用 TRIzol 方法抽提 RNA,用 TaKaRa 逆转录试剂盒进行单链 cDNA 的合成(20 μL 体系; 37℃ 15 min;95℃ 5 s),在 Real⁃time PCR仪器系统上(条件95℃ 3min;95℃ 15 s;65℃ 30 s;95℃ 15 s; 40个循环)进行扩增,检测Pum1基因的表达水平,把GAPDH作为内参,利用2-ΔΔCt值进行分析。

  • 1.2.5 诱导敲除小鼠构建

  • 将成年雄性 Pum1flox/flox Pum2-/-小鼠与雌性 R26⁃ CreERT2 小鼠交配获得杂合子小鼠,进一步用雄性杂合子与Pum1flox/flox Pum2-/-雌鼠交配得到R26⁃CreERT2 Pum1flox/flox Pum2-/-小鼠,本研究选择此基因型的小鼠作为对象(图1A)。实验前将 10 mg 他莫昔芬在无菌环境下溶于1 mL花生油,将同批出生的多只3周和 8 周龄 R26⁃CreERT2 Pum1flox/flox Pum2-/-小鼠,采用单纯随机法分为对照组和实验组,实验组注射 100 mg/kg 体重的他莫昔芬,对照组注射等量的花生油,3 周小鼠持续注射5 d,8 周小鼠持续注射7 d (图1B)。

  • 1.3 统计学方法

  • 所有实验数据均采用GraphPad Prism软件进行统计分析,计量资料采用均数±标准差(x-±s)进行描述,指标间的比较采用成组 Student’s t 检验分析, P <0.05为差异有统计学意义。

  • 图1 小鼠交配策略及他莫昔芬注射方案

  • Figure1 The strategy of mouse breeding and tamoxifen injection

  • 2 结果

  • 2.1 3周小鼠诱导敲除Pumilio后睾丸重量减小,无长形精子产生

  • 3 周 R26⁃CreERT2 Pum1flox/flox Pum2-/-实验组小鼠每天注射100 mg/kg他莫昔芬花生油溶液,对照组小鼠注射等量的花生油,连续注射5 d,在注射结束的第 3 天和第 21 天收取小鼠各组织。PCR 琼脂糖凝胶电泳如图所示(图2A),下方的条带(453 bp)代表含有2个loxp位点的等位基因,其上方为敲除条带 (557 bp)。对比左侧的对照组小鼠条带,右侧两泳道为两只不同敲除组的结果,在他莫昔芬注射后,敲除组出现了敲除条带。Western blot 结果显示胸腺、心脏、肝脏和睾丸组织的Pum1蛋白水平分别下降了48%、62%、24%和46%(图2B);Real⁃time PCR 显示小脑、胸腺、肝脏和睾丸的Pum1表达量分别下降了62%、89%、76%和54%(图2C)。结合睾丸组织的Pum1免疫组化,能够看到注射他莫昔芬后,小鼠睾丸组织Pum1蛋白含量明显下降(图3A)。在他莫昔芬注射结束的第3天对小鼠体重称量和取材后发现,实验组的小鼠大脑、心脏、肺、肝脏、脾脏、肾脏的器官重量和对照组差别无统计学意义(P >0.05),而胸腺、脾脏和睾丸的重量明显下降(P <0.05,图2D),并且小鼠睾丸体重比也明显下降(图2E)。

  • 为了探究他莫昔芬诱导敲除 Pum1 对个体生殖器官的影响,对他莫昔芬注射结束第21天的小鼠 (6 周)睾丸进行固定组织切片,HE染色发现实验组小鼠精子形成发生障碍,睾丸中无长形精子,部分生殖细胞丢失(图3B)。为了进一步探究精子发生障碍的原因,从对照组和实验组小鼠的睾丸中分别取3个不连续截面,通过BrdU和TUNEL实验对睾丸内的生精细胞进行了增殖和凋亡检测,同时对每个截面中的 BrdU/TUNEL 阳性细胞数目计数发现,实验组 BrdU 阳性细胞比例与对照组相比显著降低,实验组睾丸生殖细胞凋亡数量与对照组相比显著增加(图3C、D)。

  • 2.2 成年小鼠Pumilio诱导敲除后未见明显异常

  • 成年R26⁃CreERT2 Pum1flox/flox Pum2-/-小鼠实验组进行每天注射他莫昔芬(100 mg/kg)花生油,对照组注射等量的花生油,连续注射 7 d,注射结束第 35 天小鼠各组织器官取材,PCR琼脂糖凝胶电泳和 Western blot结果显示,胸腺、心脏、肝脏、脾脏、睾丸的 Pum1 敲除效率约为 50%,脑组织敲除率依旧较低(图4A、B)。对睾丸的病理组织切片免疫组化和 HE染色没有发现明显的精子发生异常(图4C、D)。

  • 3 讨论

  • 哺乳动物中 Pumilio 蛋白 Pum1 和 Pum2 在功能上存在着冗余,Pum2-/-小鼠除了体积和器官减小,并无其他明显表型[5],因此本研究利用R26⁃CreERT2 诱导敲除模型对出生后Pum2-/-小鼠进行Pum1诱导性敲除,直接探究Pumilio缺失对出生后小鼠体型及功能的影响。实验组3周龄小鼠大脑、心脏、肝脏、肺、肾脏的器官重量无明显异常,而胸腺、脾脏和睾丸的重量明显下降。睾丸中的Pum1敲除效率约为50 %,睾丸病理切片显示实验组小鼠精子形成障碍,无长形精子形成,且睾丸生精细胞凋亡增多、增殖减慢。在实验组成年小鼠中,Pumilio仍然得到了有效敲除,但小鼠及小鼠的精子发生未见明显异常。说明成年小鼠 Pum1 和 Pum2 的双敲未引起个体明显异常,为Pumilio作为肿瘤治疗靶蛋白的研究奠定了实验基础。

  • 图2 3周小鼠他莫昔芬注射结束后PUM1的敲除效率及主要器官重量变化

  • Figure2 The knockout efficiency of PUM1 and organ weight of 3 week⁃old mice were presented after the tamoxifen injec⁃ tion

  • 图3 3周小鼠他莫昔芬注射21 d后的小鼠精子发生障碍并且细胞凋亡增多、增殖减慢

  • Figure3 The3 weeks old mice21 days after tamoxifen injection exhibited a abnormal spermatogenesis and an increasing apoptotic and decreased proliferation cells

  • 图4 成年小鼠注射他莫昔芬后PUM1仍有敲降效果但不影响精子形成

  • Figure4 PUM1 knock down effect at molecular levels and testis histology was presented by genotyping,Western blot,PUM immunohistochemistry and hematoxylin⁃eosin staining

  • Pumilio 通过不同途径调控多种肿瘤的发生发展,Pum1 和/或 Pum2 在肿瘤细胞中的降低,可影响肿瘤的生长,因此降低体内Pumilio表达水平来治疗肿瘤疾病是一种理论可行的手段。然而,Pumilio 在哺乳动物多组织器官中表达,降低 Pumilio表达是否影响个体的重要功能仍不清楚。本研究建立了一个出生后他莫昔芬诱导敲除Pumilio的小鼠模型,为Pumilio作为肿瘤治疗靶蛋白的研究提供了研究模型和理论基础。

  • 本研究还有很多不足之处,比如敲除效率很难继续提高,他莫昔芬诱导性基因敲除系统是一种依赖雌激素受体的基因敲除系统,不同脏器中雌激素受体的表达丰度、血流量和敏感程度等存在差异,因此各脏器呈现出不同程度的基因敲除。但是本系统中大脑、小脑敲除效率如此低,甚至蛋白反常上升的现象还是出乎预料的,其他研究发现 R26⁃CreERT2 敲除系统能够顺利敲除大脑中的相关基因[18],这提示Pum1在大脑中可能具有特殊性,靠腹腔注射难以得到大脑中稳定且高效的敲除。

  • 参考文献

    • [1] SPASSOV D S,JURECIC R.The PUF family of RNA ⁃ binding proteins:does evolutionarily conserved structure equal conserved function[J].IUBMB Life,2003,55(7):359-366

    • [2] LIN K,ZHANG S,SHI Q,et al.Essential requirement of mammalian Pumilio family in embryonic development.[J].Mol Biol Cell,2018,29(24):2922-2932

    • [3] CHEN D,ZHENG W,LIN A,et al.Pumilio 1 suppresses multiple activators of p53 to safeguard spermatogenesis [J].Curr Biol,2012,22(5):420-425

    • [4] LIN K,QIANG W,ZHU M,et al.Mammalian Pum1 and Pum2 control body size via translational regulation of the cellcycle inhibitor Cdkn1b[J].Cell Rep,2019,26(9):2434-2450.e6

    • [5] GENNARINO V A,PALMER E E,MCDONELL L M,et al.A mild PUM1 mutation is associated with adult ⁃onset ataxia,whereas haploinsufficiency causes developmental delay and seizures[J].Cell,2018,172(5):924-936

    • [6] GENNARINO V A,SINGH R K,WHITE J J,et al.Pum⁃ ilio1 haploinsufficiency leads to SCA1⁃like neurodegener⁃ ation by increasing wild ⁃ type Ataxin1 levels[J].Cell,2015,160(6):1087-1098

    • [7] SILVA I L Z,KOHATA A A,SHIGUNOV P.Modulation and function of Pumilio proteins in cancer[J].Semin Can⁃ cer Biol,2022,86(3):298-309

    • [8] GUAN X,CHEN S,LIU Y,et al.PUM1 promotes ovarian cancer proliferation,migration and invasion[J].Biochem Biophys Res Commun,2018,497:313-318

    • [9] DAI H,JIANG Y,LUO Y,et al.Triptolide enhances TRAIL sensitivity of pancreatic cancer cells by activating autophagy via downregulation of PUM1[J].Phytomedi⁃ cine,2019,62:152953

    • [10] LI X,YANG J,CHEN X,et al.PUM1 represses CDKN1B translation and contributes to prostate cancer progression [J].J Biomed Res,2021,35:371-382

    • [11] SHI P,ZHANG J,LI X,et al.Long non ⁃ coding RNA NORAD inhibition upregulates microRNA ⁃ 323a ⁃ 3p to suppress tumorigenesis and development of breast cancer through the PUM1/eIF2 axis[J].Cell Cycle,2021,20:1295-1307

    • [12] LIU Q,XIN C,CHEN Y,et al.PUM1 Is Overexpressed in colon cancer cells with acquired resistance to cetuximab [J].Front Cell Dev Biol,2021,9:696558

    • [13] DING Y,YUAN X,GU W.Circular RNA RBM33 contrib⁃ utes to cervical cancer progression via modulation of the miR ⁃758⁃3p/PUM2 axis[J].J Mol Histol,2021,52:173-185

    • [14] LI Q,LI C,CHEN J,et al.High expression of long non⁃ coding RNA NORAD indicates a poor prognosis and pro⁃ motes clinical progression and metastasis in bladder can⁃ cer[J].Urol Oncol,2018,36(310):e315-e322

    • [15] JANECKI D M,SAJEK M,SMIALEK M J,et al.SPIN1 is a proto⁃oncogene and SPIN3 is a tumor suppressor in hu⁃ man seminoma[J].Oncotarget,2018,9:32466-32477

    • [16] DUAN W,NIAN L,QIAO J,et al.LncRNA TUG1 aggra⁃ vates the progression of cervical cancer by binding PUM2 [J].Eur Rev Med Pharmacol Sci,2019,23:8211-8218

    • [17] TAO W,MA J,ZHENG J,et al.Silencing SCAMP1⁃TV2 inhibited the malignant biological behaviors of breast can⁃ cer cells by interaction with PUM2 to facilitate INSM1 mRNA degradation[J].Front Oncol,2020,10(613):1-13

    • [18] BATISTA A F,SCHROEDER,M K,KHAN K,et al,Glob⁃ al complement C3 lowering in adult mice protects hippo⁃ campal synaptic function[J].Alzheimer’s Dement,2021,17(Suppl 3):e057867

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    • [9] DAI H,JIANG Y,LUO Y,et al.Triptolide enhances TRAIL sensitivity of pancreatic cancer cells by activating autophagy via downregulation of PUM1[J].Phytomedi⁃ cine,2019,62:152953

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    • [15] JANECKI D M,SAJEK M,SMIALEK M J,et al.SPIN1 is a proto⁃oncogene and SPIN3 is a tumor suppressor in hu⁃ man seminoma[J].Oncotarget,2018,9:32466-32477

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    • [17] TAO W,MA J,ZHENG J,et al.Silencing SCAMP1⁃TV2 inhibited the malignant biological behaviors of breast can⁃ cer cells by interaction with PUM2 to facilitate INSM1 mRNA degradation[J].Front Oncol,2020,10(613):1-13

    • [18] BATISTA A F,SCHROEDER,M K,KHAN K,et al,Glob⁃ al complement C3 lowering in adult mice protects hippo⁃ campal synaptic function[J].Alzheimer’s Dement,2021,17(Suppl 3):e057867

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