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Wang X, Tazearslan C, Kim S, Guo Q, Contreras D, Yang J, Hudgins AD, Suh Y. In vitro heterochronic parabiosis identifies pigment epithelium-derived factor as a systemic mediator of rejuvenation by young blood. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.02.592258. [PMID: 38746475 PMCID: PMC11092633 DOI: 10.1101/2024.05.02.592258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Several decades of heterochronic parabiosis (HCPB) studies have demonstrated the restorative impact of young blood, and deleterious influence of aged blood, on physiological function and homeostasis across tissues, although few of the factors responsible for these observations have been identified. Here we develop an in vitro HCPB system to identify these circulating factors, using replicative lifespan (RLS) of primary human fibroblasts as an endpoint of cellular health. We find that RLS is inversely correlated with serum donor age and sensitive to the presence or absence of specific serum components. Through in vitro HCPB, we identify the secreted protein pigment epithelium-derived factor (PEDF) as a circulating factor that extends RLS of primary human fibroblasts and declines with age in mammals. Systemic administration of PEDF to aged mice reverses age-related functional decline and pathology across several tissues, improving cognitive function and reducing hepatic fibrosis and renal lipid accumulation. Together, our data supports PEDF as a systemic mediator of the effect of young blood on organismal health and homeostasis and establishes our in vitro HCPB system as a valuable screening platform for the identification of candidate circulating factors involved in aging and rejuvenation.
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Affiliation(s)
- Xizhe Wang
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
- These authors contributed equally
| | - Cagdas Tazearslan
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY
- These authors contributed equally
| | - Seungsoo Kim
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Qinghua Guo
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Daniela Contreras
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Jiping Yang
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Adam D. Hudgins
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | - Yousin Suh
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
- Department of Genetics and Development, Columbia University Medical Center, New York, NY
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Alhajlah S. Suppression of Fibroblast Growth Factor Receptor-5 (FGFR5) has no Impact on Axon Regeneration after SCI. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2023; 15:S1111-S1115. [PMID: 37693980 PMCID: PMC10485452 DOI: 10.4103/jpbs.jpbs_199_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 09/12/2023] Open
Abstract
One of the most common forms of the mammalian central nervous system (CNS) injuries is spinal cord injury (SCI), and any lesion to the CNS can result in a lifelong functional impairment since CNS axons cannot regenerate. The relative axon regenerating genes following spinal SCI were examined using the regenerative SN, pSN + DC, and non-regenerating DC lesion models. By using qRT-PCR, we discovered that fibroblast growth factor receptor-5 (FGFR5) was 4.2-fold more highly expressed in non-regeneration lesions compared to intact control and regenerating animals. Furthermore, in cultured dorsal root ganglion neurons (DRGN), short interfering RNA (siRNA)-mediated knockdown of FGFR5 had no effect on DRGN neurite outgrowth, indicating that the gene's suppression has no effect on axon regeneration and may play other roles in the CNS besides axon regeneration.
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Affiliation(s)
- Sharif Alhajlah
- Department of Medical Laboratories, College of Applied Medical Sciences, Shaqra University, Shaqra, Saudi Arabia
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Science, University of Birmingham, Edgbaston, Birmingham, B15 2TT , United Kingdom
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3
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Matthews J, Surey S, Grover LM, Logan A, Ahmed Z. Thermosensitive collagen/fibrinogen gels loaded with decorin suppress lesion site cavitation and promote functional recovery after spinal cord injury. Sci Rep 2021; 11:18124. [PMID: 34518601 PMCID: PMC8438067 DOI: 10.1038/s41598-021-97604-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
The treatment of spinal cord injury (SCI) is a complex challenge in regenerative medicine, complicated by the low intrinsic capacity of CNS neurons to regenerate their axons and the heterogeneity in size, shape and extent of human injuries. For example, some contusion injuries do not compromise the dura mater and in such cases implantation of preformed scaffolds or drug delivery systems may cause further damage. Injectable in situ thermosensitive scaffolds are therefore a less invasive alternative. In this study, we report the development of a novel, flowable, thermosensitive, injectable drug delivery system comprising bovine collagen (BC) and fibrinogen (FB) that forms a solid BC/FB gel (Gel) immediately upon exposure to physiological conditions and can be used to deliver reparative drugs, such as the naturally occurring anti-inflammatory, anti-scarring agent Decorin, into adult rat spinal cord lesion sites. In dorsal column lesions of adult rats treated with the Gel + Decorin, cavitation was completely suppressed and instead lesion sites became filled with injury-responsive cells and extracellular matrix materials, including collagen and laminin. Decorin increased the intrinsic potential of dorsal root ganglion neurons (DRGN) by increasing their expression of regeneration associated genes (RAGs), enhanced local axon regeneration/sprouting, as evidenced both histologically and by improved electrophysiological, locomotor and sensory function recovery. These results suggest that this drug formulated, injectable hydrogel has the potential to be further studied and translated into the clinic.
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Affiliation(s)
- Jacob Matthews
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Sarina Surey
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Liam M Grover
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Ann Logan
- Warwick Medical School, Biomedical Sciences, University of Warwick, Coventry, CV4 7AL, UK
| | - Zubair Ahmed
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. .,Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Inhibition of calpain reduces cell apoptosis by suppressing mitochondrial fission in acute viral myocarditis. Cell Biol Toxicol 2021; 38:487-504. [PMID: 34365571 PMCID: PMC9200683 DOI: 10.1007/s10565-021-09634-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 07/13/2021] [Indexed: 11/16/2022]
Abstract
Cardiomyocyte apoptosis is critical for the development of viral myocarditis (VMC), which is one of the leading causes of cardiac sudden death in young adults. Our previous studies have demonstrated that elevated calpain activity is involved in the pathogenesis of VMC. This study aimed to further explore the underlying mechanisms. Neonatal rat cardiomyocytes (NRCMs) and transgenic mice overexpressing calpastatin were infected with coxsackievirus B3 (CVB3) to establish a VMC model. Apoptosis was detected with flow cytometry, TUNEL staining, and western blotting. Cardiac function was measured using echocardiography. Mitochondrial function was measured using ATP assays, JC-1, and MitoSOX. Mitochondrial morphology was observed using MitoTracker staining and transmission electron microscopy. Colocalization of dynamin-related protein 1 (Drp-1) in mitochondria was examined using immunofluorescence. Phosphorylation levels of Drp-1 at Ser637 site were determined using western blotting analysis. We found that CVB3 infection impaired mitochondrial function as evidenced by increased mitochondrial ROS production, decreased ATP production and mitochondrial membrane potential, induced myocardial apoptosis and damage, and decreased myocardial function. These effects of CVB3 infection were attenuated by inhibition of calpain both by PD150606 treatment and calpastatin overexpression. Furthermore, CVB3-induced mitochondrial dysfunction was associated with the accumulation of Drp-1 in the outer membrane of mitochondria and subsequent increase in mitochondrial fission. Mechanistically, calpain cleaved and activated calcineurin A, which dephosphorylated Drp-1 at Ser637 site and promoted its accumulation in the mitochondria, leading to mitochondrial fission and dysfunction. In summary, calpain inhibition attenuated CVB3-induced myocarditis by reducing mitochondrial fission, thereby inhibiting cardiomyocyte apoptosis. Graphical abstract Calpain is activated by CVB3 infection. Activated calpain cleaves calcineurin A and converts it to active form which could dephosphorylate Drp-1 at Ser637 site. Then, the active Drp-1 translocates from the cytoplasm to mitochondria and triggers excessive mitochondrial fission. Eventually, the balance of mitochondrial dynamics is broken, and apoptosis occurs. ![]()
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Alhajlah S, Thompson AM, Ahmed Z. Overexpression of Reticulon 3 Enhances CNS Axon Regeneration and Functional Recovery after Traumatic Injury. Cells 2021; 10:2015. [PMID: 34440784 PMCID: PMC8395006 DOI: 10.3390/cells10082015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 11/29/2022] Open
Abstract
CNS neurons are generally incapable of regenerating their axons after injury due to several intrinsic and extrinsic factors, including the presence of axon growth inhibitory molecules. One such potent inhibitor of CNS axon regeneration is Reticulon (RTN) 4 or Nogo-A. Here, we focused on RTN3 as its contribution to CNS axon regeneration is currently unknown. We found that RTN3 expression correlated with an axon regenerative phenotype in dorsal root ganglion neurons (DRGN) after injury to the dorsal columns, a well-characterised model of spinal cord injury. Overexpression of RTN3 promoted disinhibited DRGN neurite outgrowth in vitro and dorsal column axon regeneration/sprouting and electrophysiological, sensory and locomotor functional recovery after injury in vivo. Knockdown of protrudin, however, ablated RTN3-enhanced neurite outgrowth/axon regeneration in vitro and in vivo. Moreover, overexpression of RTN3 in a second model of CNS injury, the optic nerve crush injury model, enhanced retinal ganglion cell (RGC) survival, disinhibited neurite outgrowth in vitro and survival and axon regeneration in vivo, an effect that was also dependent on protrudin. These results demonstrate that RTN3 enhances neurite outgrowth/axon regeneration in a protrudin-dependent manner after both spinal cord and optic nerve injury.
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Affiliation(s)
- Sharif Alhajlah
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK; (S.A.); (A.M.T.)
- Applied Medical Science College, Shaqra University, P.O. Box 1678, Ad-Dawadmi 11911, Saudi Arabia
| | - Adam M Thompson
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK; (S.A.); (A.M.T.)
| | - Zubair Ahmed
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK; (S.A.); (A.M.T.)
- Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Blazejewski SM, Bennison SA, Ha NT, Liu X, Smith TH, Dougherty KJ, Toyo-Oka K. Rpsa Signaling Regulates Cortical Neuronal Morphogenesis via Its Ligand, PEDF, and Plasma Membrane Interaction Partner, Itga6. Cereb Cortex 2021; 32:770-795. [PMID: 34347028 DOI: 10.1093/cercor/bhab242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/25/2022] Open
Abstract
Neuromorphological defects underlie neurodevelopmental disorders and functional defects. We identified a function for Rpsa in regulating neuromorphogenesis using in utero electroporation to knockdown Rpsa, resulting in apical dendrite misorientation, fewer/shorter extensions, and decreased spine density with altered spine morphology in upper neuronal layers and decreased arborization in upper/lower cortical layers. Rpsa knockdown disrupts multiple aspects of cortical development, including radial glial cell fiber morphology and neuronal layering. We investigated Rpsa's ligand, PEDF, and interacting partner on the plasma membrane, Itga6. Rpsa, PEDF, and Itga6 knockdown cause similar phenotypes, with Rpsa and Itga6 overexpression rescuing morphological defects in PEDF-deficient neurons in vivo. Additionally, Itga6 overexpression increases and stabilizes Rpsa expression on the plasma membrane. GCaMP6s was used to functionally analyze Rpsa knockdown via ex vivo calcium imaging. Rpsa-deficient neurons showed less fluctuation in fluorescence intensity, suggesting defective subthreshold calcium signaling. The Serpinf1 gene coding for PEDF is localized at chromosome 17p13.3, which is deleted in patients with the neurodevelopmental disorder Miller-Dieker syndrome. Our study identifies a role for Rpsa in early cortical development and for PEDF-Rpsa-Itga6 signaling in neuromorphogenesis, thus implicating these molecules in the etiology of neurodevelopmental disorders like Miller-Dieker syndrome and identifying them as potential therapeutics.
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Affiliation(s)
- Sara M Blazejewski
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Sarah A Bennison
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Ngoc T Ha
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Xiaonan Liu
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Trevor H Smith
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Kimberly J Dougherty
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Kazuhito Toyo-Oka
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, USA
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Shang Z, Li C, Liu X, Xu M, Zhang X, Li X, Barnstable CJ, Zhao S, Tombran-Tink J. PEDF Gene Deletion Disrupts Corneal Innervation and Ocular Surface Function. Invest Ophthalmol Vis Sci 2021; 62:18. [PMID: 34132748 PMCID: PMC8212434 DOI: 10.1167/iovs.62.7.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The cornea is richly innervated by the trigeminal ganglion (TG) and its function supported by secretions from the adjacent lacrimal (LG) and meibomian glands (MG). In this study we examined how pigment epithelium–derived factor (PEDF) gene deletion affects the cornea structure and function. Methods We used PEDF hemizygous and homozygous knockout mice to study effects of PEDF deficiency on corneal innervation assessed by beta tubulin staining, mRNA expression of trophic factors, and PEDF receptors by adjacent supporting glands, corneal sensitivity measured using a Cochet-Bonnet esthesiometer, and tear production using phenol red cotton thread wetting. Results Loss of PEDF was accompanied by reduced corneal innervation and sensitivity, increased corneal surface injury and tear production, thinning of the corneal stroma and loss of stromal cells. PEDF mRNA was expressed in the cornea and its supporting tissues, the TG, LG, and MG. Deletion of one or both PEDF alleles resulted in decreased expression of essential trophic support in the TG, LG, and MG including nerve growth factor, brain-derived neurotrophic growth factor, and GDNF with significantly increased levels of NT-3 in the LG and decreased EGF expression in the cornea. Decreased transcription of the putative PEDF receptors, adipose triglyceride lipase, lipoprotein receptor–related protein 6, laminin receptor, PLXDC1, and PLXDC2 was also evident in the TG, LG and MG with the first three showing increased levels in corneas of the Pedf+/− and Pedf−/− mice compared to wildtype controls. Constitutive inactivation of ERK1/2 and Akt was pronounced in the TG and cornea, although their protein levels were dramatically increased in Pedf−/− mice. Conclusions This study highlights an essential role for PEDF in corneal structure and function and confirms the reported rescue of exogenous PEDF treatment in corneal pathologies. The pleiotropic effects of PEDF deletion on multiple trophic factors, receptors and signaling molecules are strong indications that PEDF is a key coordinator of molecular mechanisms that maintain corneal function and could be exploited in therapeutic options for several ocular surface diseases.
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Affiliation(s)
- Zhenying Shang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Chenxi Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Xuemei Liu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Manhong Xu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Xiaomin Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Xiaorong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Colin J Barnstable
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China.,Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States.,Department of Ophthalmology, Penn State College of Medicine, Hershey, Pennsylvania, United States
| | - Shaozhen Zhao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Joyce Tombran-Tink
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China.,Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States.,Department of Ophthalmology, Penn State College of Medicine, Hershey, Pennsylvania, United States
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de Diego-Otero Y, Giráldez-Pérez RM, Lima-Cabello E, Heredia-Farfan R, Calvo Medina R, Sanchez-Salido L, Pérez Costillas L. Pigment epithelium-derived factor (PEDF) and PEDF-receptor in the adult mouse brain: Differential spatial/temporal localization pattern. J Comp Neurol 2020; 529:141-158. [PMID: 32427349 DOI: 10.1002/cne.24940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 12/11/2022]
Abstract
Pigment epithelium-derived factor (PEDF) is a multifunctional protein which was initially described in the retina, although it is also present in other tissues. It functions as an antioxidant agent promoting neuronal survival. Recently, a PEDF receptor has shown an elevated binding affinity for PEDF. There are no relevant data regarding the distribution of both proteins in the brain, therefore the main goal of this work was to investigate the spatiotemporal presence of PEDF and PEDFR in the adult mouse brain, and to determine the PEDF blood level in mouse and human. The localization of both proteins was analyzed by different experimental methods such as immunohistochemistry, western-blotting, and also by enzyme-linked immunosorbent assay. Differential expression was found in some telencephalic structures and positive signals for both proteins were detected in the cerebellum. The magnitude of the PEDFR labeling pattern was higher than PEDF and included some cortical and subventricular areas. Age-dependent changes in intensity of both protein immunoreactions were found in the cortical and hippocampal areas with greater reactivity between 4 and 8 months of age, whilst others, like the subventricular zones, these differences were more evident for PEDFR. Although ubiquitous presence was not found in the brain for these two proteins, their relevant functions must not be underestimated. It has been described that PEDF plays an important role in neuroprotection and data provided in the present work represents the first extensive study to understand the relevance of these two proteins in specific brain areas.
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Affiliation(s)
- Yolanda de Diego-Otero
- Research Laboratory, Hospital Civil, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain.,Mental Health Clinic Unit, .Regional University Hospital, Hospital Civil, Málaga, Spain.,Research Unit, International Institute of Innovation and Attention to Neurodevelopment and Language, Málaga, Spain
| | - Rosa María Giráldez-Pérez
- Cellular Biology, Physiology and Immunology Department, University of Cordoba, Edificio Charles Darwin, Córdoba, Spain
| | - Elena Lima-Cabello
- Research Laboratory, Hospital Civil, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
| | - Raúl Heredia-Farfan
- Research Laboratory, Hospital Civil, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
| | - Rocío Calvo Medina
- Pediatric Clinic Unit. Regional University Hospital, Hospital Materno-Infantil Avd, Arroyo de los Angeles, Málaga, Spain
| | - Lourdes Sanchez-Salido
- Research Laboratory, Hospital Civil, Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
| | - Lucía Pérez Costillas
- Mental Health Clinic Unit, .Regional University Hospital, Hospital Civil, Málaga, Spain.,Psychiatry and Physiotherapy Department, University of Malaga. Medical School, Málaga, Spain
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