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Karpicheva OE, Avrova SV, Bogdanov AL, Sirenko VV, Redwood CS, Borovikov YS. Molecular Mechanisms of Deregulation of Muscle Contractility Caused by the R168H Mutation in TPM3 and Its Attenuation by Therapeutic Agents. Int J Mol Sci 2023; 24:ijms24065829. [PMID: 36982903 PMCID: PMC10051413 DOI: 10.3390/ijms24065829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
The substitution for Arg168His (R168H) in γ-tropomyosin (TPM3 gene, Tpm3.12 isoform) is associated with congenital muscle fiber type disproportion (CFTD) and muscle weakness. It is still unclear what molecular mechanisms underlie the muscle dysfunction seen in CFTD. The aim of this work was to study the effect of the R168H mutation in Tpm3.12 on the critical conformational changes that myosin, actin, troponin, and tropomyosin undergo during the ATPase cycle. We used polarized fluorescence microscopy and ghost muscle fibers containing regulated thin filaments and myosin heads (myosin subfragment-1) modified with the 1,5-IAEDANS fluorescent probe. Analysis of the data obtained revealed that a sequential interdependent conformational-functional rearrangement of tropomyosin, actin and myosin heads takes place when modeling the ATPase cycle in the presence of wild-type tropomyosin. A multistep shift of the tropomyosin strands from the outer to the inner domain of actin occurs during the transition from weak to strong binding of myosin to actin. Each tropomyosin position determines the corresponding balance between switched-on and switched-off actin monomers and between the strongly and weakly bound myosin heads. At low Ca2+, the R168H mutation was shown to switch some extra actin monomers on and increase the persistence length of tropomyosin, demonstrating the freezing of the R168HTpm strands close to the open position and disruption of the regulatory function of troponin. Instead of reducing the formation of strong bonds between myosin heads and F-actin, troponin activated it. However, at high Ca2+, troponin decreased the amount of strongly bound myosin heads instead of promoting their formation. Abnormally high sensitivity of thin filaments to Ca2+, inhibition of muscle fiber relaxation due to the appearance of the myosin heads strongly associated with F-actin, and distinct activation of the contractile system at submaximal concentrations of Ca2+ can lead to muscle inefficiency and weakness. Modulators of troponin (tirasemtiv and epigallocatechin-3-gallate) and myosin (omecamtiv mecarbil and 2,3-butanedione monoxime) have been shown to more or less attenuate the negative effects of the tropomyosin R168H mutant. Tirasemtiv and epigallocatechin-3-gallate may be used to prevent muscle dysfunction.
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Affiliation(s)
- Olga E Karpicheva
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., St. Petersburg 194064, Russia
| | - Stanislava V Avrova
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., St. Petersburg 194064, Russia
| | - Andrey L Bogdanov
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., St. Petersburg 194064, Russia
| | - Vladimir V Sirenko
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., St. Petersburg 194064, Russia
| | - Charles S Redwood
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Yurii S Borovikov
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., St. Petersburg 194064, Russia
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Molecular Mechanisms of the Deregulation of Muscle Contraction Induced by the R90P Mutation in Tpm3.12 and the Weakening of This Effect by BDM and W7. Int J Mol Sci 2021; 22:ijms22126318. [PMID: 34204776 PMCID: PMC8231546 DOI: 10.3390/ijms22126318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 11/17/2022] Open
Abstract
Point mutations in the genes encoding the skeletal muscle isoforms of tropomyosin can cause a range of muscle diseases. The amino acid substitution of Arg for Pro residue in the 90th position (R90P) in γ-tropomyosin (Tpm3.12) is associated with congenital fiber type disproportion and muscle weakness. The molecular mechanisms underlying muscle dysfunction in this disease remain unclear. Here, we observed that this mutation causes an abnormally high Ca2+-sensitivity of myofilaments in vitro and in muscle fibers. To determine the critical conformational changes that myosin, actin, and tropomyosin undergo during the ATPase cycle and the alterations in these changes caused by R90P replacement in Tpm3.12, we used polarized fluorimetry. It was shown that the R90P mutation inhibits the ability of tropomyosin to shift towards the outer domains of actin, which is accompanied by the almost complete depression of troponin’s ability to switch actin monomers off and to reduce the amount of the myosin heads weakly bound to F-actin at a low Ca2+. These changes in the behavior of tropomyosin and the troponin–tropomyosin complex, as well as in the balance of strongly and weakly bound myosin heads in the ATPase cycle may underlie the occurrence of both abnormally high Ca2+-sensitivity and muscle weakness. BDM, an inhibitor of myosin ATPase activity, and W7, a troponin C antagonist, restore the ability of tropomyosin for Ca2+-dependent movement and the ability of the troponin–tropomyosin complex to switch actin monomers off, demonstrating a weakening of the damaging effect of the R90P mutation on muscle contractility.
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The Primary Causes of Muscle Dysfunction Associated with the Point Mutations in Tpm3.12; Conformational Analysis of Mutant Proteins as a Tool for Classification of Myopathies. Int J Mol Sci 2018; 19:ijms19123975. [PMID: 30544720 PMCID: PMC6321504 DOI: 10.3390/ijms19123975] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/29/2018] [Accepted: 12/07/2018] [Indexed: 12/28/2022] Open
Abstract
Point mutations in genes encoding isoforms of skeletal muscle tropomyosin may cause nemaline myopathy, cap myopathy (Cap), congenital fiber-type disproportion (CFTD), and distal arthrogryposis. The molecular mechanisms of muscle dysfunction in these diseases remain unclear. We studied the effect of the E173A, R90P, E150A, and A155T myopathy-causing substitutions in γ-tropomyosin (Tpm3.12) on the position of tropomyosin in thin filaments, and the conformational state of actin monomers and myosin heads at different stages of the ATPase cycle using polarized fluorescence microscopy. The E173A, R90P, and E150A mutations produced abnormally large displacement of tropomyosin to the inner domains of actin and an increase in the number of myosin heads in strong-binding state at low and high Ca2+, which is characteristic of CFTD. On the contrary, the A155T mutation caused a decrease in the amount of such heads at high Ca2+ which is typical for mutations associated with Cap. An increase in the number of the myosin heads in strong-binding state at low Ca2+ was observed for all mutations associated with high Ca2+-sensitivity. Comparison between the typical conformational changes in mutant proteins associated with different myopathies observed with α-, β-, and γ-tropomyosins demonstrated the possibility of using such changes as tests for identifying the diseases.
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Simonyan AO, Sirenko VV, Karpicheva OE, Robaszkiewicz K, Śliwinska M, Moraczewska J, Krutetskaya ZI, Borovikov YS. The primary cause of muscle disfunction associated with substitutions E240K and R244G in tropomyosin is aberrant behavior of tropomyosin and response of actin and myosin during ATPase cycle. Arch Biochem Biophys 2018; 644:17-28. [PMID: 29510086 DOI: 10.1016/j.abb.2018.03.002] [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: 06/26/2017] [Revised: 02/16/2018] [Accepted: 03/02/2018] [Indexed: 10/17/2022]
Abstract
Using the polarized photometry technique we have studied the effects of two amino acid replacements, E240K and R244G, in tropomyosin (Tpm1.1) on the position of Tpm1.1 on troponin-free actin filaments and the spatial arrangement of actin monomers and myosin heads at various mimicked stages of the ATPase cycle in the ghost muscle fibres. E240 and R244 are located in the C-terminal, seventh actin-binding period, in f and b positions of the coiled-coil heptapeptide repeat. Actin, Tpm1.1, and myosin subfragment-1 (S1) were fluorescently labeled: 1.5-IAEDANS was attached to actin and S1, 5-IAF was bound to Tpm1.1. The labeled proteins were incorporated in the ghost muscle fibres and changes in polarized fluorescence during the ATPase cycle have been measured. It was found that during the ATPase cycle both mutant tropomyosins occupied a position close to the inner domain of actin. The relative amount of the myosin heads in the strongly-bound conformations and of the switched on actin monomers increased at mimicking different stages of the ATPase cycle. This might be one of the reasons for muscle dysfunction in congenital fibre type disproportion caused by the substitutions E240K and R244G in tropomyosin.
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Affiliation(s)
- Armen O Simonyan
- Institute of Cytology of the Russian Academy of Sciences, Laboratory of Molecular Basis of Cell Motility, 4 Tikhoretsky Ave., 194064, Saint Petersburg, Russia; Saint Petersburg State University, Faculty of Biology, Department of Biophysics, 7/9 Universitetskaya Emb., 199034, Saint Petersburg, Russia
| | - Vladimir V Sirenko
- Institute of Cytology of the Russian Academy of Sciences, Laboratory of Molecular Basis of Cell Motility, 4 Tikhoretsky Ave., 194064, Saint Petersburg, Russia
| | - Olga E Karpicheva
- Institute of Cytology of the Russian Academy of Sciences, Laboratory of Molecular Basis of Cell Motility, 4 Tikhoretsky Ave., 194064, Saint Petersburg, Russia
| | - Katarzyna Robaszkiewicz
- Kazimierz Wielki University in Bydgoszcz, Institute of Experimental Biology, Department of Biochemistry and Cell Biology, Ks. J. Poniatowski 12 Str., 85-671, Bydgoszcz, Poland
| | - Małgorzata Śliwinska
- Kazimierz Wielki University in Bydgoszcz, Institute of Experimental Biology, Department of Biochemistry and Cell Biology, Ks. J. Poniatowski 12 Str., 85-671, Bydgoszcz, Poland
| | - Joanna Moraczewska
- Kazimierz Wielki University in Bydgoszcz, Institute of Experimental Biology, Department of Biochemistry and Cell Biology, Ks. J. Poniatowski 12 Str., 85-671, Bydgoszcz, Poland
| | - Zoya I Krutetskaya
- Saint Petersburg State University, Faculty of Biology, Department of Biophysics, 7/9 Universitetskaya Emb., 199034, Saint Petersburg, Russia
| | - Yurii S Borovikov
- Institute of Cytology of the Russian Academy of Sciences, Laboratory of Molecular Basis of Cell Motility, 4 Tikhoretsky Ave., 194064, Saint Petersburg, Russia.
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Borovikov YS, Rysev NA, Karpicheva OE, Sirenko VV, Avrova SV, Piers A, Redwood CS. Molecular mechanisms of dysfunction of muscle fibres associated with Glu139 deletion in TPM2 gene. Sci Rep 2017; 7:16797. [PMID: 29196649 PMCID: PMC5711931 DOI: 10.1038/s41598-017-17076-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 11/22/2017] [Indexed: 01/01/2023] Open
Abstract
Deletion of Glu139 in β-tropomyosin caused by a point mutation in TPM2 gene is associated with cap myopathy characterized by high myofilament Ca2+-sensitivity and muscle weakness. To reveal the mechanism of these disorders at molecular level, mobility and spatial rearrangements of actin, tropomyosin and the myosin heads at different stages of actomyosin cycle in reconstituted single ghost fibres were investigated by polarized fluorescence microscopy. The mutation did not alter tropomyosin's affinity for actin but increased strongly the flexibility of tropomyosin and kept its strands near the inner domain of actin. The ability of troponin to switch actin monomers "on" and "off" at high and low Ca2+, respectively, was increased, and the movement of tropomyosin towards the blocked position at low Ca2+ was inhibited, presumably causing higher Ca2+-sensitivity. The mutation decreased also the amount of the myosin heads which bound strongly to actin at high Ca2+ and increased the number of these heads at relaxation; this may contribute to contractures and muscle weakness.
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Affiliation(s)
- Yurii S Borovikov
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg, 194064, Russia.
| | - Nikita A Rysev
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg, 194064, Russia
| | - Olga E Karpicheva
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg, 194064, Russia
| | - Vladimir V Sirenko
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg, 194064, Russia
| | - Stanislava V Avrova
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg, 194064, Russia
| | - Adam Piers
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
| | - Charles S Redwood
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom
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Borovikov YS, Rysev NA, Avrova SV, Karpicheva OE, Borys D, Moraczewska J. Molecular mechanisms of deregulation of the thin filament associated with the R167H and K168E substitutions in tropomyosin Tpm1.1. Arch Biochem Biophys 2016; 614:28-40. [PMID: 27956029 DOI: 10.1016/j.abb.2016.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/06/2016] [Accepted: 12/08/2016] [Indexed: 12/01/2022]
Abstract
Point mutations R167H and K168E in tropomyosin Tpm1.1 (TM) disturb Ca2+-dependent regulation of the actomyosin ATPase. To understand mechanisms of this defect we studied multistep changes in mobility and spatial arrangement of tropomyosin, actin and myosin heads during the ATPase cycle in reconstituted ghost fibres using the polarized fluorescence microscopy. It was found that both mutations disturbed the mode of troponin operation in the fibres. At high Ca2+, troponin increased the fraction of actin monomers that were in the "switched on" state, but both mutant tropomyosins were shifted toward the outer actin domains, which decreased the fraction of strongly bound myosin heads throughout the ATPase cycle. At low Ca2+, the R167H-TM was located close to the outer actin domains, which reduced the number of strongly-bound myosin heads. However, under these conditions troponin increased the number of actin monomers that were switched on. The K168E-TM was displaced far to the outer actin domains and troponin binding decreased the fraction of switched on actin monomers, but the proportion of the strongly bound myosin heads was abnormally high. Thus, the mutations differently disturbed transmission of conformational changes between troponin, tropomyosin and actin, which is essential for the Са2+-dependent regulation of the thin filament.
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Affiliation(s)
- Yurii S Borovikov
- Institute of Cytology, Tikhoretsky Pr., 4, Saint Petersburg, 194064, Russia.
| | - Nikita A Rysev
- Institute of Cytology, Tikhoretsky Pr., 4, Saint Petersburg, 194064, Russia
| | | | - Olga E Karpicheva
- Institute of Cytology, Tikhoretsky Pr., 4, Saint Petersburg, 194064, Russia
| | - Danuta Borys
- Kazimierz Wielki University in Bydgoszcz, Ks. J. Poniatowski 12, Str., 85-671 Bydgoszcz, Poland
| | - Joanna Moraczewska
- Kazimierz Wielki University in Bydgoszcz, Ks. J. Poniatowski 12, Str., 85-671 Bydgoszcz, Poland
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Abnormal movement of tropomyosin and response of myosin heads and actin during the ATPase cycle caused by the Arg167His, Arg167Gly and Lys168Glu mutations in TPM1 gene. Arch Biochem Biophys 2016; 606:157-66. [PMID: 27480605 DOI: 10.1016/j.abb.2016.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/27/2016] [Accepted: 07/28/2016] [Indexed: 01/10/2023]
Abstract
Amino acid substitutions: Arg167His, Arg167Gly and Lys168Glu, located in a consensus actin-binding site of the striated muscle tropomyosin Tpm1.1 (TM), were used to investigate mechanisms of the thin filament regulation. The azimuthal movement of TM strands on the actin filament and the responses of the myosin heads and actin subunits during the ATPase cycle were studied using fluorescence polarization of muscle fibres. The recombinant wild-type and mutant TMs labelled with 5-IAF, 1,5-IAEDANS-labelled S1and FITC-phalloidin F-actin were incorporated into the ghost muscle fibres to acquire information on the orientation of the probes relative to the fibre axis. The substitutions Arg167Gly and Lys168Glu shifted TM strands into the actin filament centre, whereas Arg167His moved TM towards the periphery of the filament. In the presence of Arg167Gly-TM and Lys168Glu-TM the fraction of actin monomers that were switched on and the number of the myosin heads strongly bound to F-actin were abnormally high even under conditions close to relaxation. In contrast, Arg167His-TM decreased the fraction of switched on actin and reduced the formation of strongly bound myosin heads throughout the ATPase cycle. We concluded that the altered TM-actin contacts destabilized the thin filament and affected the actin-myosin interactions.
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Karpicheva OE, Simonyan AO, Kuleva NV, Redwood CS, Borovikov YS. Myopathy-causing Q147P TPM2 mutation shifts tropomyosin strands further towards the open position and increases the proportion of strong-binding cross-bridges during the ATPase cycle. BIOCHIMICA ET BIOPHYSICA ACTA-PROTEINS AND PROTEOMICS 2015; 1864:260-267. [PMID: 26708479 DOI: 10.1016/j.bbapap.2015.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/16/2015] [Accepted: 12/01/2015] [Indexed: 11/20/2022]
Abstract
The molecular mechanisms of skeletal muscle dysfunction in congenital myopathies remain unclear. The present study examines the effect of a myopathy-causing mutation Q147P in β-tropomyosin on the position of tropomyosin on troponin-free filaments and on the actin–myosin interaction at different stages of the ATP hydrolysis cycle using the technique of polarized fluorimetry. Wild-type and Q147P recombinant tropomyosins, actin, and myosin subfragment-1 were modified by 5-IAF, 1,5-IAEDANS or FITC-phalloidin, and 1,5-IAEDANS, respectively, and incorporated into single ghost muscle fibers, containing predominantly actin filaments which were free of troponin and tropomyosin. Despite its reduced affinity for actin in co-sedimentation assay, the Q147P mutant incorporates into the muscle fiber. However, compared to wild-type tropomyosin, it locates closer to the center of the actin filament. The mutant tropomyosin increases the proportion of the strong-binding myosin heads and disrupts the co-operation of actin and myosin heads during the ATPase cycle. These changes are likely to underlie the contractile abnormalities caused by this mutation.
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Affiliation(s)
- Olga E Karpicheva
- Laboratory of Mechanisms of Cell Motility, Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., 194064 St Petersburg, Russia
| | - Armen O Simonyan
- Laboratory of Mechanisms of Cell Motility, Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., 194064 St Petersburg, Russia; Saint Petersburg State University, 7/9 Universitetskaya nab., 199034 St Petersburg, Russia
| | - Nadezhda V Kuleva
- Saint Petersburg State University, 7/9 Universitetskaya nab., 199034 St Petersburg, Russia
| | - Charles S Redwood
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, OX3 9DU Oxford, UK
| | - Yurii S Borovikov
- Laboratory of Mechanisms of Cell Motility, Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Av., 194064 St Petersburg, Russia.
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Borovikov YS, Avrova SV, Rysev NA, Sirenko VV, Simonyan AO, Chernev AA, Karpicheva OE, Piers A, Redwood CS. Aberrant movement of β-tropomyosin associated with congenital myopathy causes defective response of myosin heads and actin during the ATPase cycle. Arch Biochem Biophys 2015; 577-578:11-23. [PMID: 25978979 DOI: 10.1016/j.abb.2015.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 04/22/2015] [Accepted: 05/07/2015] [Indexed: 01/07/2023]
Abstract
We have investigated the effect of the E41K, R91G, and E139del β-tropomyosin (TM) mutations that cause congenital myopathy on the position of TM and orientation of actin monomers and myosin heads at different mimicked stages of the ATPase cycle in troponin-free ghost muscle fibers by polarized fluorimetry. A multi-step shifting of wild-type TM to the filament center accompanied by an increase in the amount of switched on actin monomers and the strongly bound myosin heads was observed during the ATPase cycle. The R91G mutation shifts TM further towards the inner and outer domains of actin at the strong- and weak-binding stages, respectively. The E139del mutation retains TM near the inner domains, while the E41K mutation captures it near the outer domains. The E41K and R91G mutations can induce the strong binding of myosin heads to actin, when TM is located near the outer domains. The E139del mutation inhibits the amount of strongly bound myosin heads throughout the ATPase cycle.
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Affiliation(s)
- Yurii S Borovikov
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg 194064, Russia.
| | - Stanislava V Avrova
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg 194064, Russia
| | - Nikita A Rysev
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg 194064, Russia
| | - Vladimir V Sirenko
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg 194064, Russia
| | - Armen O Simonyan
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg 194064, Russia; Saint Petersburg State University, Universitetskaya nab., 7-9, Saint Petersburg 199034, Russia
| | - Aleksey A Chernev
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg 194064, Russia; Saint Petersburg State University, Universitetskaya nab., 7-9, Saint Petersburg 199034, Russia
| | - Olga E Karpicheva
- Institute of Cytology, Russian Academy of Sciences, 4 Tikhoretsky Avenue, St. Petersburg 194064, Russia
| | - Adam Piers
- University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - Charles S Redwood
- University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
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