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Labeled chemical biology tools for investigating sphingolipid metabolism, trafficking and interaction with lipids and proteins. Biochim Biophys Acta Mol Cell Biol Lipids 2013; 1841:1161-73. [PMID: 24389251 DOI: 10.1016/j.bbalip.2013.12.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/10/2013] [Accepted: 12/17/2013] [Indexed: 12/17/2022]
Abstract
The unraveling of sphingolipid metabolism and function in the last 40 years relied on the extensive study of inherited human disease and specifically-tailored mouse models. However, only few of the achievements made so far would have been possible without chemical biology tools, such as fluorescent and/or radio-labeled and other artificial substrates, (mechanism-based) enzyme inhibitors, cross-linking probes or artificial membrane models. In this review we provide an overview over chemical biology tools that have been used to gain more insight into the molecular basis of sphingolipid-related biology. Many of these tools are still of high relevance for the investigation of current sphingolipid-related questions, others may stimulate the tailoring of novel probes suitable to address recent and future issues in the field. This article is part of a Special Issue entitled Tools to study lipid functions.
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Kolter T. Ganglioside biochemistry. ISRN BIOCHEMISTRY 2012; 2012:506160. [PMID: 25969757 PMCID: PMC4393008 DOI: 10.5402/2012/506160] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 10/09/2012] [Indexed: 01/21/2023]
Abstract
Gangliosides are sialic acid-containing glycosphingolipids. They occur especially on the cellular surfaces of neuronal cells, where they form a complex pattern, but are also found in many other cell types. The paper provides a general overview on their structures, occurrence, and metabolism. Key functional, biochemical, and pathobiochemical aspects are summarized.
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Affiliation(s)
- Thomas Kolter
- Program Unit Membrane Biology & Lipid Biochemistry, LiMES, University of Bonn, Gerhard-Domagk Straße 1, 53121 Bonn, Germany
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O'Leary EM, Igdoura SA. The therapeutic potential of pharmacological chaperones and proteosomal inhibitors, Celastrol and MG132 in the treatment of sialidosis. Mol Genet Metab 2012; 107:173-85. [PMID: 22898113 DOI: 10.1016/j.ymgme.2012.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 07/12/2012] [Accepted: 07/12/2012] [Indexed: 10/28/2022]
Abstract
Sialidosis is an autosomal recessive disorder caused by a dysfunctional Sialidase enzyme. Categorised into two phenotypes, Sialidosis type I and II, Sialidosis is a highly heterogeneous disorder with varying ages of onset and pathologies. Currently, there is no viable therapy for the treatment of Sialidosis patients. At the molecular level, cells from Sialidosis patients with compound heterozygous mutations show improper enzyme folding, loss of Sialidase enzyme activity and subsequent accumulation of sialylconjugates within lysosomes. One promising treatment option is the use of small pharmacological molecules to increase the enzymatic activities of mutant proteins. In this study, we examined the efficacy of the immuno-suppressant (Celastrol) as well as a proteosomal inhibitor (MG132) to rescue mutant enzymes with altered conformation. Our results reveal that MG132 enhances enzyme activity and its localisation in cells expressing defective Sialidase. We also found that MG132 reduces accumulation of ganglioside products, GT1b, GD3, and GM3 in pre-loaded Sialidosis cells. Alternatively, Celastrol appears to reduce Sialidase expression and activity revealing a potentially novel effect of Celastrol on Sialidase. Interestingly, the combination of Celastrol and MG132 appears to amplify the beneficial impact of MG132 on both the endogenous and recombinant expression of defective Sialidase. This study explores a novel biological criteria to assess the efficacy of small molecules through accumulation analysis and points to a potential therapeutic strategy for the treatment of Sialidosis.
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Affiliation(s)
- Erin M O'Leary
- Department of Biology, McMaster University, Hamilton, Ontario, Canada
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Polyakova SM, Belov VN, Yan SF, Eggeling C, Ringemann C, Schwarzmann G, de Meijere A, Hell SW. New GM1 Ganglioside Derivatives for Selective Single and Double Labelling of the Natural Glycosphingolipid Skeleton. European J Org Chem 2009. [DOI: 10.1002/ejoc.200900645] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Sadeghlar F, Remmel N, Breiden B, Klingenstein R, Schwarzmann G, Sandhoff K. Physiological relevance of sphingolipid activator proteins in cultured human fibroblasts. Biochimie 2003; 85:439-48. [PMID: 12770782 DOI: 10.1016/s0300-9084(03)00020-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The physiological degradation of several membrane-bound glycosphingolipids (GSLs) by water-soluble lysosomal exohydrolases requires the assistance of sphingolipid activator proteins (SAPs). Four of these SAPs are synthesized from a single precursor protein (prosaposin). Inherited deficiency of this precursor results in a rare disease in humans with an accumulation of ceramide (Cer) and glycolipids such as glucosylceramide and lactosylceramide (LacCer). In a previous study, we have shown that human SAP-D stimulates the lysosomal degradation of Cer in precursor deficient cells. In order to study the role of SAPs (or saposins) A-D in cellular GSL catabolism, we recently investigated the catabolism of exogenously added [(3)H]labeled ganglioside GM1, Forssman lipid, and endogenously [(14)C]labeled GSLs in SAP-precursor deficient human fibroblasts after the addition of recombinant SAP-A, -B, -C and -D. We found that activator protein deficient cells are still able to slowly degrade gangliosides GM1 and GM3, Forssman lipid and globotriaosylceramide to a significant extent, while LacCer catabolism critically depends on the presence of SAPs. The addition of either of the SAPs, SAP-A, SAP-B or SAP-C, resulted in an efficient hydrolysis of LacCer.
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Affiliation(s)
- Farsaneh Sadeghlar
- Kekulé-Institut für Organische Chemie und Biochemie der Universität Bonn, Gerhard-Domagk-Strasse 1, 53121 Bonn, Germany
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Asfaw B, Ledvinová J, Dobrovolńy R, Bakker HD, Desnick RJ, van Diggelen OP, de Jong JGN, Kanzaki T, Chabas A, Maire I, Conzelmann E, Schindler D. Defects in degradation of blood group A and B glycosphingolipids in Schindler and Fabry diseases. J Lipid Res 2002; 43:1096-104. [PMID: 12091494 DOI: 10.1194/jlr.m100423-jlr200] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Skin fibroblast cultures from patients with inherited lysosomal enzymopathies, alpha-N-acetylgalactosaminidase (alpha-NAGA) and alpha-galactosidase A deficiencies (Schindler and Fabry disease, respectively), and from normal controls were used to study in situ degradation of blood group A and B glycosphingolipids. Glycosphingolipids A-6-2 (GalNAc (alpha 1-->3)[Fuc alpha 1-->2]Gal(beta1-->4)GlcNAc(beta 1-->3)Gal(beta 1--> 4)Glc (beta 1-->1')Cer, IV(2)-alpha-fucosyl-IV(3)-alpha-N-acetylgalactosaminylneolactotetraosylceramide), B-6-2 (Gal(alpha 1-->3)[Fuc alpha 1--> 2] Gal (beta 1-->4)GlcNAc(beta 1-->3)Gal(beta 1-->4)Glc(beta 1-->1')Cer, IV(2)- alpha-fucosyl-IV(3)-alpha-galactosylneolactotetraosylceramide), and globoside (GalNAc(beta 1-->3)Gal(alpha 1-->4)Gal(beta 1-->4)Glc(beta 1-->1') Cer, globotetraosylceramide) were tritium labeled in their ceramide moiety and used as natural substrates. The degradation rate of glycolipid A-6-2 was very low in fibroblasts of all the alpha-NAGA-deficient patients (less than 7% of controls), despite very heterogeneous clinical pictures, ruling out different residual enzyme activities as an explanation for the clinical heterogeneity. Strongly elevated urinary excretion of blood group A glycolipids was detected in one patient with blood group A, secretor status (five times higher than upper limit of controls), in support of the notion that blood group A-active glycolipids may contribute as storage compounds in blood group A patients. When glycolipid B-6-2 was fed to alpha-galactosidase A-deficient cells, the degradation rate was surprisingly high (50% of controls), while that of globotriaosylceramide was reduced to less than 15% of control average, presumably reflecting differences in the lysosomal enzymology of polar glycolipids versus less-polar ones. Relatively high-degree degradation of substrates with alpha-D-Galactosyl moieties hints at a possible contribution of other enzymes.
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Affiliation(s)
- Befekadu Asfaw
- Institute of Inherited Metabolic Disorders, First Faculty of Medicine, Charles University, 128 08 Prague, Czech Republic.
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Abstract
Exogenous glycosphingolipids, especially gangliosides, are used to study transport and metabolism of their endogenous counterparts as well as their role in cell adhesion, cell recognition and signal transduction. Unlike monodispersed solutes, in aqueous media ganglioside molecules aggregate into micelles (or bilayer structures) with a very low critical micellar concentration. Upon addition to cells in culture, exogenous gangliosides bind to the cell surface in three operationally defined modes: loosely associated micelles removable by serum; tightly attached micelles removable by proteases such as trypsin; and ganglioside molecules inserted into the outer leaflet of the plasma membrane. As shown by a biotin-labeled derivative of the ganglioside GM1 these inserted molecules are endocytosed and transported to intralysosomal membranes for catabolism. The benefit from using (partially) nondegradable as well as semi-truncated glycosphingolipids in transport studies is discussed.
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Affiliation(s)
- G Schwarzmann
- Kekulé-Institut für Organische Chemie und Biochemie der Universität Bonn, Gerhard-Domagk, Strasse 1, D-53121 Bonn, Germany.
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Affiliation(s)
- U Bierfreund
- Kekulé-Institut für Organische Chemie und Biochemie, Universität Bonn, Germany
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Raghavan S, Leshinsky E, Kolodny EH. G(M2)-ganglioside metabolism in situ in mucolipidosis IV fibroblasts. Neurochem Res 1999; 24:475-9. [PMID: 10227679 DOI: 10.1023/a:1022523527283] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Mucolipidosis IV (ML IV) is an inherited lysosomal disorder for which the primary biochemical defect has not been identified. In order to detect any defect in glycosphingolipid metabolism, we have examined the metabolism of sphingosine-labeled (3H)G(M2) in situ in fibroblasts from patients diagnosed with ML IV. Fibroblasts were exposed for 10 days in medium containing (3H)G(M2) (15 uM; Sp. Act. 35000 cpm/nmole), washed, harvested and analyzed for radioactivity in extracted lipids. Control cells metabolized about half of the internalized ganglioside, mostly to ceramide. In ML IV fibroblasts, 70-80% of the cellular radioactivity was present as G(M2) indicating reduced degradation. This is not as severe as in G(M2) gangliosidosis as a small amount of G(M2) was metabolized in ML IV cells to ceramide. Since there is no defect in the lysosomal enzyme profile in these cells, it is possible that an abnormality in the translocation of membrane constituents to the lysosomes may explain the slower ganglioside metabolism.
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Affiliation(s)
- S Raghavan
- NYU Medical Center, Dept. of Neurology, New York, NY 10016, USA
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Asfaw B, Schindler D, Ledvinová J, Černý B, Šmíd F, Conzelmann E. Degradation of blood group A glycolipid A-6-2 by normal and mutant human skin fibroblasts. J Lipid Res 1998. [DOI: 10.1016/s0022-2275(20)32164-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Hiesberger T, Hüttler S, Rohlmann A, Schneider W, Sandhoff K, Herz J. Cellular uptake of saposin (SAP) precursor and lysosomal delivery by the low density lipoprotein receptor-related protein (LRP). EMBO J 1998; 17:4617-25. [PMID: 9707421 PMCID: PMC1170791 DOI: 10.1093/emboj/17.16.4617] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Sphingolipid activator proteins SAP-A, -B, -C and -D (also called saposins) are generated by proteolytic processing from a 73 kDa precursor and function as obligatory activators of lysosomal enzymes involved in glycosphingolipid metabolism. Although the SAP precursor can be recognized by the mannose-6-phosphate (M-6-P) receptor and shuttled directly from the secretory pathway to the lysosome, a substantial fraction of newly synthesized precursor is secreted from the cell where it may participate in sphingolipid transport and signaling events. Re-uptake of the secreted precursor is mediated by high-affinity cell surface receptors that are apparently distinct from the M-6-P receptor. We found that the low density lipoprotein receptor-related protein (LRP), a multifunctional endocytic receptor that is expressed on most cells, can mediate cellular uptake and lysosomal delivery of SAP precursor. Additional in vivo experiments in mice revealed that the mannose receptor system on macrophages also participates in precursor internalization. We conclude that SAP precursor gains entry into cells by at least three independent receptor mechanisms including the M-6-P receptor, the mannose receptor and LRP.
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Affiliation(s)
- T Hiesberger
- Department of Molecular Genetics, UT Southwestern Medical Center, Dallas, TX, USA
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Schauer R, Kamerling JP. Chemistry, biochemistry and biology of sialic acids ☆. NEW COMPREHENSIVE BIOCHEMISTRY 1997; 29. [PMCID: PMC7147860 DOI: 10.1016/s0167-7306(08)60624-9] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Roland Schauer
- Biochemisches Institut, Christian-Albrechls-Universität zu Kiel, Germany
| | - Johannis P. Kamerling
- Bijuoet Center, Department of Bio-Organic Chemistry, Utrecht University, The Netherlands
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Levade T, Leruth M, Graber D, Moisand A, Vermeersch S, Salvayre R, Courtoy PJ. In situ assay of acid sphingomyelinase and ceramidase based on LDL-mediated lysosomal targeting of ceramide-labeled sphingomyelin. J Lipid Res 1996. [DOI: 10.1016/s0022-2275(20)37457-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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14
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Agmon V, Khosravi R, Marchesini S, Dinur T, Dagan A, Gatt S, Navon R. Intracellular degradation of sulforhodamine-GM1: use for a fluorescence-based characterization of GM2-gangliosidosis variants in fibroblasts and white blood cells. Clin Chim Acta 1996; 247:105-20. [PMID: 8920231 DOI: 10.1016/0009-8981(96)85130-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A novel fluorescent ganglioside, sulforhodamine-GM1 was administered into cells derived from carriers and patients with different subtypes of GM2 gangliosidosis, resulting from various mutations in the gene encoding the lysosomal enzyme hexosaminidase (Hex) A. The cells used were skin fibroblasts and white blood cells, i.e. lymphocytes, monocytes and macrophages. In the severe infantile form of the GM2 gangliosidosis, Tay-Sachs disease, the sulforhodamine-GM1 was hydrolyzed within the lysosomes to the corresponding sulforhodamine-GM2 which, because of lack of Hex A activity, was not further degraded. In comparison, in the cells derived from GM2 gangliosidoses carriers, as well as pseudodeficient and adult forms of GM2 gangliosidosis, the sulforhodamine-GM2 was further processed and sequentially degraded by the lysosomal glycosidases to sulforhodamine-ceramide. The latter was converted to sulforhodamine-sphingomyelin, which was secreted into the culture medium. The fluorescence of the sulforhodamine ceramide in cell extracts and/or sulforhodamine-sphingomyelin in the culture medium was quantified and related to parallel data obtained using cells of normal individuals. This permitted distinguishing between the various GM2 gangliosidoses subtypes and relating the intracellular hydrolysis of sulforhodamine-GM1 to the genotypes of the respective GM2 gangliosidoses variants.
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Affiliation(s)
- V Agmon
- Department of Biochemistry, Hebrew University-Hadassah School of Medicine, Jerusalem, Israel
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Fujiwaki T, Hamanaka S, Tate S, Inagaki F, Suzuki M, Suzuki A, Mori C. Tissue accumulation of sulfatide and GM3 ganglioside in a patient with variant Farber disease. Clin Chim Acta 1995; 234:23-36. [PMID: 7758220 DOI: 10.1016/0009-8981(94)05970-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We analyzed the lipids in the tissues of a patient with an atypical form of Farber disease who developed several clinical symptoms not seen in patients with typical Farber disease (acid ceramidase deficiency). Lipids were extracted from formalin-fixed brain, liver and kidney and purified by ion exchange and silica gel column chromatographies and further by high-performance liquid chromatography on a silica gel column. We performed structural and quantitative analyses of three lipids named lipids X, Y and Z. Lipid X accumulated in the liver but not in the brain. Accumulation of lipids Y and Z was observed in liver and kidney. The content of lipid Y in the patients liver was more than ten times that in a control. The structures of lipids X, Y and Z were confirmed by means of 1H-nuclear magnetic resonance spectroscopy, fast atom bombardment mass spectrometry, infrared absorption spectroscopy, and component analysis involving gas liquid chromatography and gas chromatography-mass spectrometry. The structures of lipids X, Y and Z were identified as those of ceramide, sulfatide and GM3 ganglioside, respectively. These results suggest two possibilities. One is that the accumulation of glycolipids such as sulfatide and GM3 ganglioside is a secondary event produced by the accumulation of ceramide due to ceramidase deficiency. The other is that the accumulation of glycolipids other than ceramide is due to a deficiency of sphingolipid activator proteins which may affect the degradation of sulfatide and GM3 ganglioside as well as ceramide.
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Affiliation(s)
- T Fujiwaki
- Department of Pediatrics, Tsuwano Kyozon Hospital, Japan
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Marchesini S, Demasi L, Cestone P, Preti A, Agmon V, Dagan A, Navon R, Gatt S. Sulforhodamine GM1-ganglioside: synthesis and physicochemical properties. Chem Phys Lipids 1994; 72:143-52. [PMID: 7954976 DOI: 10.1016/0009-3084(94)90098-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A fluorescent derivative of GM1-ganglioside was synthesized by linking sulforhodamine 101 to the sphingosine moiety through amino dodecanoyl residue. The product (SR-12GM1) was quantitatively converted to SR-12GM2 by treatment with bovine testes beta-galactosidase and in intact cultured human skin fibroblasts was catabolized to sulforhodamine GM2, GM3 and ceramide; the latter product was further converted to sphingomyelin. In aqueous medium SR-12GM1 formed micelles. When transfer from micelles to vesicles and between vesicles was compared with that of pyrene-GM1, the transfer of SR-12GM1 occurred at higher rates, following in both cases a biexponential curve.
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Affiliation(s)
- S Marchesini
- Department of Biomedical Sciences and Biotechnology, University of Brescia, Italy
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Sandhoff K, van Echten G. Ganglioside metabolism: enzymology, topology and regulation. PROGRESS IN BRAIN RESEARCH 1994; 101:17-29. [PMID: 8029449 DOI: 10.1016/s0079-6123(08)61937-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- K Sandhoff
- Institut für Organische Chemie und Biochemie, Universität Bonn, Germany
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Bradová V, Smíd F, Ulrich-Bott B, Roggendorf W, Paton BC, Harzer K. Prosaposin deficiency: further characterization of the sphingolipid activator protein-deficient sibs. Multiple glycolipid elevations (including lactosylceramidosis), partial enzyme deficiencies and ultrastructure of the skin in this generalized sphingolipid storage disease. Hum Genet 1993; 92:143-52. [PMID: 8370580 DOI: 10.1007/bf00219682] [Citation(s) in RCA: 88] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Sphingolipid activator protein (SAP) deficiency, previously described in two sibs and shown to be caused by the absence of the common saposin precursor (prosaposin), was further characterized by biochemical lipid and enzyme studies and by ultrastructural analysis. The 20-week-old fetal sib had increased concentrations of neutral glycolipids, including mono-, di-, tri- and tetrahexosylceramide, in liver, kidney and cultured skin fibroblasts compared with the controls. Glucosylceramide and lactosylceramide were particularly elevated. The kidney of the affected fetus showed additional increases in the concentration of sulphatide, galactosylceramide and digalactosylceramide. Free ceramide was stored in the liver and kidney, and GM3 and GM2 gangliosides were elevated in the liver, but not the brain, of the fetus. Phospholipids, however, were normal in the affected fetus. In the liver biopsy of the propositus, who later died at 16 weeks of age, only a few lipids could be studied. Glucosylceramide, dihexosylceramide and ceramide were elevated in agreement with our previous study. Enzyme studies were undertaken using detergent-free liposomal substrate preparations and fibroblast extracts. The sibs' beta-glucocerebrosidase and beta-galactocerebrosidase activities were clearly reduced, but their sphingomyelinase activities were normal. The normal activity of the latter enzyme and the almost normal tissue concentration of sphingomyelin in prosaposin deficiency suggest that the prosaposin-derived SAPs are not required for sphingomyelinase activity in vivo. In keeping with the biochemical findings, skin biopsies from the sibs showed massive lysosomal storage with a vesicular and membranous ultrastructure. The function of SAPs in sphingolipid degradation and the role of SAPs for enzyme activity in vitro are discussed. In addition, the similarity in neutral glycolipid accumulations in Niemann-Pick disease type C and in prosaposin deficiency are noted. The phenotype of the prosaposin deficient sibs resembled acute neuronopathic (type 2) Gaucher disease more than Farber disease in several aspects, but their genotype was unique.
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Affiliation(s)
- V Bradová
- Hlava Institute of Pathology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
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