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Structure of the ALS Mutation Target Annexin A11 Reveals a Stabilising N-Terminal Segment. Biomolecules 2020; 10:biom10040660. [PMID: 32344647 PMCID: PMC7226064 DOI: 10.3390/biom10040660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 01/01/2023] Open
Abstract
The functions of the annexin family of proteins involve binding to Ca2+, lipid membranes, other proteins, and RNA, and the annexins share a common folded core structure at the C terminus. Annexin A11 (AnxA11) has a long N-terminal region, which is predicted to be disordered, binds RNA, and forms membraneless organelles involved in neuronal transport. Mutations in AnxA11 have been linked to amyotrophic lateral sclerosis (ALS). We studied the structure and stability of AnxA11 and identified a short stabilising segment in the N-terminal end of the folded core, which links domains I and IV. The crystal structure of the AnxA11 core highlights main-chain hydrogen bonding interactions formed through this bridging segment, which are likely conserved in most annexins. The structure was also used to study the currently known ALS mutations in AnxA11. Three of these mutations correspond to buried Arg residues highly conserved in the annexin family, indicating central roles in annexin folding. The structural data provide starting points for detailed structure-function studies of both full-length AnxA11 and the disease variants being identified in ALS.
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2
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Mirsaeidi M, Gidfar S, Vu A, Schraufnagel D. Annexins family: insights into their functions and potential role in pathogenesis of sarcoidosis. J Transl Med 2016; 14:89. [PMID: 27071553 PMCID: PMC4830063 DOI: 10.1186/s12967-016-0843-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 03/30/2016] [Indexed: 12/13/2022] Open
Abstract
Annexins are Ca2+-regulated phospholipid-binding proteins that play an important role in the cell life cycle, exocytosis, and apoptosis. Annexin A11 is one of the oldest vertebrate annexins that has a crucial role in sarcoidosis pathogenesis. The mechanism of effect in sarcoidosis granuloma cells may be due to alterations in apoptosis. Immune cells with a specific mutation at protein location 230 are resistant to apoptosis and consequently have continued effects on inflammation and progression of sarcoidosis. The mechanism of action of annexin A11 may be based upon alterations in delivering calcium to two different apoptosis pathways (caspase and P53).
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Affiliation(s)
- Mehdi Mirsaeidi
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Miami, Miller School of Medicine, 1600 NW 10th Ave # 7060A, Miami, FL, 33136, USA.
| | - Sanaz Gidfar
- Department of Ophthalmology, University of Illinois at Chicago, Chicago, IL, USA
| | - Ann Vu
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Dean Schraufnagel
- Division of Pulmonary and Critical Care, University of Illinois at Chicago, Chicago, IL, USA
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3
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Wang J, Guo C, Liu S, Qi H, Yin Y, Liang R, Sun MZ, Greenaway FT. Annexin A11 in disease. Clin Chim Acta 2014; 431:164-8. [PMID: 24508622 DOI: 10.1016/j.cca.2014.01.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/16/2014] [Accepted: 01/18/2014] [Indexed: 12/28/2022]
Abstract
Ubiquitously expressed in many cell types, annexin A11 (Anxa11) is a member of the multigene family of Ca(2+)-regulated phospholipid-dependent and membrane-binding annexin proteins. Studies have shown that Anxa11 plays an important role in cell division, Ca(2+) signaling, vesicle trafficking and apoptosis. The deregulation and mutation of Anxa11 are involved in systemic autoimmune diseases, sarcoidosis and the development, chemoresistance and recurrence of cancers. Malfunction of Anxa11 may lead to or enhance the metastasis, invasion and drug resistance of cancers through the platelet-derived growth factor receptor (PDGFR) pathway and/or the mitogen-activated protein kinase (MAPK)/p53 pathway. In a variety of diseases, Anxa11 is most commonly reported to function through interactions with apoptosis-linked gene-2 protein (ALG-2) and/or calcyclin (S100A6). Although it has been little studied, Anxa11 is a promising biomarker for the diagnosis, treatment and prognosis of certain diseases. In this review, the associations of Anxa11 with Ca(2+)-regulated exocytosis, cytokinesis, sex differentiation, autoimmune diseases, thrombolysis and cancers are summarized and interpreted.
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Affiliation(s)
- Jiasheng Wang
- Department of Biotechnology, Dalian Medical University, Dalian 116044, China
| | - Chunmei Guo
- Department of Biotechnology, Dalian Medical University, Dalian 116044, China
| | - Shuqing Liu
- Department of Biochemistry, Dalian Medical University, Dalian 116044, China
| | - Houbao Qi
- Department of Biotechnology, Dalian Medical University, Dalian 116044, China
| | - Yuling Yin
- Department of Biochemistry, Dalian Medical University, Dalian 116044, China
| | - Rui Liang
- Department of General Surgery, The Second Hospital of Dalian Medical University, Dalian 116027, China
| | - Ming-Zhong Sun
- Department of Biotechnology, Dalian Medical University, Dalian 116044, China.
| | - Frederick T Greenaway
- Carlson School of Chemistry and Biochemistry, Clark University, Worcester, MA 01610, USA
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4
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Functional variant ANXA11 R230C: true marker of protection and candidate disease modifier in sarcoidosis. Genes Immun 2011; 12:490-4. [DOI: 10.1038/gene.2011.27] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Turnay J, Lecona E, Fernández-Lizarbe S, Guzmán-Aránguez A, Fernández M, Olmo N, Lizarbe M. Structure-function relationship in annexin A13, the founder member of the vertebrate family of annexins. Biochem J 2005; 389:899-911. [PMID: 15813707 PMCID: PMC1180741 DOI: 10.1042/bj20041918] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Annexin A13 is considered the original progenitor of the 11 other members of vertebrate annexins, a superfamily of calcium/phospholipid-binding proteins. It is highly tissue-specific, being expressed only in intestinal and kidney epithelial cells. Alternative splicing generates two isoforms, both of which bind to rafts. In view of the lack of structural information supporting the physiological role of this annexin subfamily, we have cloned, expressed and purified human annexin A13b to investigate its structural and functional properties. The N-terminus of annexin A13b: (i) destabilizes the conserved protein core, as deduced from the low melting temperature in the absence (44 degrees C) or presence of calcium (55 degrees C), and (ii) impairs calcium-dependent binding to acidic phospholipids, requiring calcium concentrations >400 microM. Truncation of the N-terminus restores thermal stability and decreases the calcium requirement for phospholipid binding, confirming its essential role in the structure-function relationship of this annexin. Non-myristoylated annexin A13b only binds to acidic phospholipids at high calcium concentrations. We show for the first time that myristoylation of annexin A13b enables the direct binding to phosphatidylcholine, raft-like liposomes and acidic phospholipids in a calcium-independent manner. The conformational switch induced by calcium binding, from a 'closed' to an 'open' conformation with exposure of Trp227, can be mimicked by a decrease in pH, a process that may be relevant for membrane interactions. Our studies confirm that the common structural and functional characteristics that are dependent on the protein core of vertebrate annexins are likely to be common conserved features, whereas their variable N-termini confer distinct functional properties on annexins, as we report for myristoylation of annexin A13b.
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Affiliation(s)
- Javier Turnay
- *Departamento de Bioquímica y Biología Molecular I, Facultad de Ciencias Químicas, Universidad Complutense, 28040-Madrid, Spain
| | - Emilio Lecona
- *Departamento de Bioquímica y Biología Molecular I, Facultad de Ciencias Químicas, Universidad Complutense, 28040-Madrid, Spain
| | - Sara Fernández-Lizarbe
- *Departamento de Bioquímica y Biología Molecular I, Facultad de Ciencias Químicas, Universidad Complutense, 28040-Madrid, Spain
| | - Ana Guzmán-Aránguez
- *Departamento de Bioquímica y Biología Molecular I, Facultad de Ciencias Químicas, Universidad Complutense, 28040-Madrid, Spain
| | - María Pilar Fernández
- †Departamento de Bioquímica y Biología Molecular, Facultad de Medicina, Universidad de Oviedo, 33006-Oviedo, Spain
| | - Nieves Olmo
- *Departamento de Bioquímica y Biología Molecular I, Facultad de Ciencias Químicas, Universidad Complutense, 28040-Madrid, Spain
| | - Ma Antonia Lizarbe
- *Departamento de Bioquímica y Biología Molecular I, Facultad de Ciencias Químicas, Universidad Complutense, 28040-Madrid, Spain
- To whom correspondence should be addressed (email )
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Morgan RO, Martin-Almedina S, Iglesias JM, Gonzalez-Florez MI, Fernandez MP. Evolutionary perspective on annexin calcium-binding domains. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2004; 1742:133-40. [PMID: 15590063 DOI: 10.1016/j.bbamcr.2004.09.010] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 09/13/2004] [Indexed: 11/16/2022]
Abstract
Molecular systematic analysis of the annexin gene superfamily characterized the evolutionary origin, frequency and range of structural variation in calcium interaction domains that are considered intrinsic for membrane targeting and ion channel function. Approximately 36% of annexin repeat domains in an estimated 100 distinct subfamilies contained amino acid changes consistent with the functional loss of type two calcium-binding sites. At least 11% of annexin domains contained a novel K/H/RGD motif conserved in particular subfamilies and manifest in all phyla, apparently via convergent evolution. The first yeast annexin from Yarrowia lipolytica was classified in the ANXC1 subfamily with fungal and mycetozoan representatives. This clade had intact calcium-binding sites but disruption of the normally well-conserved, mid-repeat 4 region implicated in calcium channel regulation. Conversely, a tandem pair of novel annexins from the amphioxus Branchiostoma floridae resembled annexin A13 in gene structure and conserved the charged amino acids associated with the internal hydrophilic pore, but were devoid of external type 2 calcium-binding sites and incorporated K/RGD motifs instead, like annexin A9. The selective erosion of calcium-binding sites in annexin domains and the occurrence of alternate ligands in the same exposed, interhelical loops are pervasive features of the superfamily. This suggests greater complexity than previously appreciated in the mechanisms controlling annexin membrane interaction and calcium channel operation.
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Affiliation(s)
- R O Morgan
- Department of Biochemistry and Molecular Biology, Edificio Santiago Gascon, Faculty of Medicine, University of Oviedo, 33006 Oviedo, Spain.
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Kultima K, Nyström AM, Scholz B, Gustafson AL, Dencker L, Stigson M. Valproic acid teratogenicity: a toxicogenomics approach. ENVIRONMENTAL HEALTH PERSPECTIVES 2004; 112:1225-1235. [PMID: 15345369 PMCID: PMC1277116 DOI: 10.1289/txg.7034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Accepted: 06/03/2004] [Indexed: 05/24/2023]
Abstract
Embryonic development is a highly coordinated set of processes that depend on hierarchies of signaling and gene regulatory networks, and the disruption of such networks may underlie many cases of chemically induced birth defects. The antiepileptic drug valproic acid (VPA) is a potent inducer of neural tube defects (NTDs) in human and mouse embryos. As with many other developmental toxicants however, the mechanism of VPA teratogenicity is unknown. Using microarray analysis, we compared the global gene expression responses to VPA in mouse embryos during the critical stages of teratogen action in vivo with those in cultured P19 embryocarcinoma cells in vitro. Among the identified VPA-responsive genes, some have been associated previously with NTDs or VPA effects [vinculin, metallothioneins 1 and 2 (Mt1, Mt2), keratin 1-18 (Krt1-18)], whereas others provide novel putative VPA targets, some of which are associated with processes relevant to neural tube formation and closure [transgelin 2 (Tagln2), thyroid hormone receptor interacting protein 6, galectin-1 (Lgals1), inhibitor of DNA binding 1 (Idb1), fatty acid synthase (Fasn), annexins A5 and A11 (Anxa5, Anxa11)], or with VPA effects or known molecular actions of VPA (Lgals1, Mt1, Mt2, Id1, Fasn, Anxa5, Anxa11, Krt1-18). A subset of genes with a transcriptional response to VPA that is similar in embryos and the cell model can be evaluated as potential biomarkers for VPA-induced teratogenicity that could be exploited directly in P19 cell-based in vitro assays. As several of the identified genes may be activated or repressed through a pathway of histone deacetylase (HDAC) inhibition and specificity protein 1 activation, our data support a role of HDAC as an important molecular target of VPA action in vivo.
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Affiliation(s)
- Kim Kultima
- Department of Pharmaceutical Biosciences, Division of Toxicology, The Biomedical Center, Uppsala University, Uppsala, Sweden
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Li B, Dedman JR, Kaetzel MA. Intron disruption of the annexin IV gene reveals novel transcripts. J Biol Chem 2003; 278:43276-83. [PMID: 12912993 DOI: 10.1074/jbc.m306361200] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Annexin IV (AIV), a Ca2+-dependent membrane-binding protein, is expressed in many epithelia. Annexin IV modifies membrane bilayers by increasing rigidity, reducing water and H+ permeability, promoting vesicle aggregation, and regulating ion conductances, all in a Ca2+-dependent manner. We have characterized a mouse in which a gene trap has been inserted into the first intron of annexin IV. Processing of the primary transcript is disrupted. Northern blot and immunoblot data indicated that annexin IV expression was eliminated in many but not all tissues. Immunohistochemical analysis, however, demonstrated that annexin IV expression was eliminated in some cell types, but was unaltered in others. 5'-Rapid amplification of cDNA ends analysis of intestinal and kidney RNA revealed three transcripts, AIVa, AIVb, and AIVc. AIVa is widely distributed. AIVb is expressed only in the digestive tract. AIVc expression is very restricted. A selected number of epithelial cells of unique morphology demonstrate high concentrations. All three transcripts produce an identical annexin IV protein. The different tissue and cell-specific expression profiles of the three transcripts suggest that regulation of both the annexin IV gene expression and the cellular role of the protein are complex. The AIVa-/- mouse may become a valuable model to further study transcription and the physiological role of annexin IV.
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Affiliation(s)
- Bailing Li
- Departments of Genome Science and Molecular and Cellular Physiology, University of Cincinnati, College of Medicine, Cincinnati, Ohio 45237-0505, USA
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9
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Lecona E, Turnay J, Olmo N, Guzmán-Aránguez A, Morgan RO, Fernandez MP, Lizarbe MA. Structural and functional characterization of recombinant mouse annexin A11: influence of calcium binding. Biochem J 2003; 373:437-49. [PMID: 12689336 PMCID: PMC1223495 DOI: 10.1042/bj20021721] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2002] [Revised: 03/10/2003] [Accepted: 04/11/2003] [Indexed: 11/17/2022]
Abstract
Annexin A11 is one of the 12 vertebrate subfamilies in the annexin superfamily of calcium/phospholipid-binding proteins, distinguishable by long, non-homologous N-termini rich in proline, glycine and tyrosine residues. As there is negligible structural information concerning this annexin subfamily apart from primary sequence data, we have cloned, expressed and purified recombinant mouse annexin A11 to investigate its structural and functional properties. CD spectroscopy reveals two main secondary-structure contributions, alpha-helix and random coil (approx. 30% each), corresponding mainly to the annexin C-terminal tetrad and the N-terminus respectively. On calcium binding, an increase in alpha-helix and a decrease in random coil are detected. Fluorescence spectroscopy reveals that its only tryptophan residue, located at the N-terminus, is completely exposed to the solvent; calcium binding promotes a change in tertiary structure, which does not affect this tryptophan residue but involves the movement of approximately four tyrosine residues to a more hydrophobic environment. These calcium-induced structural changes produce a significant thermal stabilization, with an increase of approx. 14 degrees C in the melting temperature. Annexin A11 binds to acidic phospholipids and to phosphatidylethanolamine in the presence of calcium; weaker calcium-independent binding to phosphatidylserine, phosphatidic acid and phosphatidylethanolamine was also observed. The calcium-dependent binding to phosphatidylserine is accompanied by an increase in alpha-helix and a decrease in random-coil contents, with translocation of the tryptophan residue towards a more hydrophobic environment. This protein induces vesicle aggregation but requires non-physiological calcium concentrations in vitro. A three-dimensional model, consistent with these data, was generated to conceptualize annexin A11 structure-function relationships.
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Affiliation(s)
- Emilio Lecona
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense, 28040 Madrid, Spain
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Iglesias JM, Morgan RO, Jenkins NA, Copeland NG, Gilbert DJ, Fernandez MP. Comparative genetics and evolution of annexin A13 as the founder gene of vertebrate annexins. Mol Biol Evol 2002; 19:608-18. [PMID: 11961095 DOI: 10.1093/oxfordjournals.molbev.a004120] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Annexin A13 (ANXA13) is believed to be the original founder gene of the 12-member vertebrate annexin A family, and it has acquired an intestine-specific expression associated with a highly differentiated intracellular transport function. Molecular characterization of this subfamily in a range of vertebrate species was undertaken to assess coding region conservation, gene organization, chromosomal linkage, and phylogenetic relationships relevant to its progenitor role in the structure-function evolution of the annexin gene superfamily. Protein diagnostic features peculiar to this subfamily include an alternate isoform containing a KGD motif, an elevated basic amino acid content with polyhistidine expansion in the 5'-translated region, and the conservation of 15% core tetrad residues specific to annexin A13 members. The 12 coding exons comprising the 58-kb human ANXA13 gene were deduced from BAC clone sequencing, whereas internal repetitive elements and neighboring genes in chromosome 8q24.12 were identified by contig analysis of the draft sequence from the human genome project. A unique exon splicing pattern in the annexin A13 gene was corroborated by coanalysis of mouse, rat, zebrafish, and pufferfish genomic DNA and determined to be the most distinct of all vertebrate annexins. The putative promoter region was identified by phylogenetic footprinting of potential binding sites for intestine-specific transcription factors. Mouse annexin A13 cDNA was used to map the gene to an orthologous linkage group in mouse chromosome 15 (between Sdc2 and Myc by backcross analysis), and the zebrafish cDNA permitted its localization to linkage group 24. Comparative analysis of annexin A13 from nine species traced this gene's speciation history and assessed coding region variation, whereas phylogenetic analysis showed it to be the deepest-branching vertebrate annexin, and computational analysis estimated the gene age and divergence rate. The unique, conserved aspects of annexin A13 primary structure, gene organization, and genetic maps identify it as the probable common ancestor of all vertebrate annexins, beginning with the sequential duplication to annexins A7 and A11 approximately 700 MYA, before the emergence of chordates.
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Affiliation(s)
- Juan-Manuel Iglesias
- Department of Biochemistry and Molecular Biology, Edificio Santiago Gaston, University of Oviedo, E-33006 Oviedo, Spain
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Abstract
Annexins are Ca2+ and phospholipid binding proteins forming an evolutionary conserved multigene family with members of the family being expressed throughout animal and plant kingdoms. Structurally, annexins are characterized by a highly alpha-helical and tightly packed protein core domain considered to represent a Ca2+-regulated membrane binding module. Many of the annexin cores have been crystallized, and their molecular structures reveal interesting features that include the architecture of the annexin-type Ca2+ binding sites and a central hydrophilic pore proposed to function as a Ca2+ channel. In addition to the conserved core, all annexins contain a second principal domain. This domain, which NH2-terminally precedes the core, is unique for a given member of the family and most likely specifies individual annexin properties in vivo. Cellular and animal knock-out models as well as dominant-negative mutants have recently been established for a number of annexins, and the effects of such manipulations are strikingly different for different members of the family. At least for some annexins, it appears that they participate in the regulation of membrane organization and membrane traffic and the regulation of ion (Ca2+) currents across membranes or Ca2+ concentrations within cells. Although annexins lack signal sequences for secretion, some members of the family have also been identified extracellularly where they can act as receptors for serum proteases on the endothelium as well as inhibitors of neutrophil migration and blood coagulation. Finally, deregulations in annexin expression and activity have been correlated with human diseases, e.g., in acute promyelocytic leukemia and the antiphospholipid antibody syndrome, and the term annexinopathies has been coined.
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Affiliation(s)
- Volker Gerke
- Institute for Medical Biochemistry, Center for Molecular Biology of Inflammation, University of Münster, Münster, Germany
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Carcedo MT, Iglesias JM, Bances P, Morgan RO, Fernandez MP. Functional analysis of the human annexin A5 gene promoter: a downstream DNA element and an upstream long terminal repeat regulate transcription. Biochem J 2001; 356:571-9. [PMID: 11368787 PMCID: PMC1221871 DOI: 10.1042/0264-6021:3560571] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Human annexin A5 is a ubiquitous protein implicated in diverse signal transduction processes associated with cell growth and differentiation, and its gene regulation is an important component of this function. Promoter transcriptional activity was determined for a wide 5' portion of the human annexin A5 gene, from bp -1275 to +79 relative to the most 5' of several discrete transcription start points. Transfection experiments carried out in HeLa cells identified the segment from bp -202 to +79 as the minimal promoter conferring optimal transcriptional activity. Two canonical Sp1 sites in the immediate 5' flanking region of a CpG island were required for significant transcription. Strong repressive activity in the distal promoter region between bp -717 to -1153 was attributed to the presence of an endogenous retroviral long terminal repeat, homologous with long terminal repeat 47B. The downstream sequence from bp position +31 to +79 in untranslated exon 1 was also essential for transcription, as its deletion from any of the plasmid constructs abolished activity in transfection assays. Electrophoretic mobility-shift assays, Southwestern-blot analysis and affinity chromatography were used to identify a protein doublet of relative molecular mass 35 kDa that bound an octanucleotide palindromic sequence in exon 1. The DNA cis-element resembled an E-box, but did not bind higher molecular mass transcription factors, such as upstream stimulatory factor or activator protein 4. The discovery of a downstream element crucial for annexin A5 gene transcription, and its interaction with a potentially novel transcription factor or complex, may provide a clue to understanding the initiation of transcription by TATA-less, multiple start site promoters.
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Affiliation(s)
- M T Carcedo
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Oviedo, E-33006 Oviedo, Spain
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