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Mavropalias G, Boppart M, Usher KM, Grounds MD, Nosaka K, Blazevich AJ. Exercise builds the scaffold of life: muscle extracellular matrix biomarker responses to physical activity, inactivity, and aging. Biol Rev Camb Philos Soc 2023; 98:481-519. [PMID: 36412213 DOI: 10.1111/brv.12916] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/23/2022]
Abstract
Skeletal muscle extracellular matrix (ECM) is critical for muscle force production and the regulation of important physiological processes during growth, regeneration, and remodelling. ECM remodelling is a tightly orchestrated process, sensitive to multi-directional tensile and compressive stresses and damaging stimuli, and its assessment can convey important information on rehabilitation effectiveness, injury, and disease. Despite its profound importance, ECM biomarkers are underused in studies examining the effects of exercise, disuse, or aging on muscle function, growth, and structure. This review examines patterns of short- and long-term changes in the synthesis and concentrations of ECM markers in biofluids and tissues, which may be useful for describing the time course of ECM remodelling following physical activity and disuse. Forces imposed on the ECM during physical activity critically affect cell signalling while disuse causes non-optimal adaptations, including connective tissue proliferation. The goal of this review is to inform researchers, and rehabilitation, medical, and exercise practitioners better about the role of ECM biomarkers in research and clinical environments to accelerate the development of targeted physical activity treatments, improve ECM status assessment, and enhance function in aging, injury, and disease.
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Affiliation(s)
- Georgios Mavropalias
- Centre for Human Performance, School of Medical and Health Sciences, Edith Cowan University, 270 Joondalup Drive, Joondalup, WA, 6027, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, and Centre for Healthy Aging, Health Futures Institute, Murdoch University, Murdoch, WA, 6150, Australia
- Discipline of Exercise Science, Murdoch University, Murdoch, WA, 6150, Australia
| | - Marni Boppart
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, 1206 South Fourth St, Urbana, IL, 61801, USA
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana- Champaign, 405 N. Mathews Avenue, Urbana, IL, 61801, USA
| | - Kayley M Usher
- School of Biomedical Sciences, University of Western Australia (M504), 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - Miranda D Grounds
- School of Human Sciences, University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - Kazunori Nosaka
- Centre for Human Performance, School of Medical and Health Sciences, Edith Cowan University, 270 Joondalup Drive, Joondalup, WA, 6027, Australia
| | - Anthony J Blazevich
- Centre for Human Performance, School of Medical and Health Sciences, Edith Cowan University, 270 Joondalup Drive, Joondalup, WA, 6027, Australia
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2
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Rivera CN, Watne RM, Brown ZA, Mitchell SA, Wommack AJ, Vaughan RA. Effect of AMPK activation and glucose availability on myotube LAT1 expression and BCAA utilization. Amino Acids 2023; 55:275-286. [PMID: 36547760 DOI: 10.1007/s00726-022-03224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
Those with insulin resistance often display increased circulating branched-chain amino acids (BCAA), which has been largely attributable to reduced BCAA catabolic capacity. Metabolic stimuli such as exercise activates AMP-activated kinase (AMPK), which promotes the metabolism of BCAA and induction/activation of BCAA catabolic enzymes. Though much attention has been paid to BCAA catabolic machinery, few studies have assessed the effect of AMPK activation on the predominant BCAA transporter, L-type amino acid transporter 1 (LAT1). This study assessed the effect of AMPK activation on LAT1 expression via common chemical AMPK activators in a cell model of skeletal muscle. C2C12 myotubes were treated with either 1 mM AICAR, 1 mM Metformin, or filter-sterilized water (control) for 24 h with either low- (5 mM) or high-glucose (25 mM) media. LAT1 and pAMPK protein content were measured via western blot. BCAA media content was measured using liquid chromatography-mass spectrometry. AICAR treatment significantly increased pAMPK and reduced LAT1 expression. Collectively, pAMPK and LAT1 displayed a significant inverse relationship independent of glucose levels. During low-glucose experiments, AICAR-treated cells had higher BCAA media content compared to other groups, and an inverse relationship between LAT1 and BCAA media content was observed, however, these effects were not consistently observed during high-glucose conditions. Further investigation with AICAR with and without concurrent LAT1 inhibition (via JPH203) also revealed reduced BCAA utilization in AICAR-treated cells regardless of LAT1 inhibition (which also independently reduced BCAA utilization). pAMPK activation via AICAR (but not Metformin) may reduce LAT1 expression and BCAA uptake in a glucose-dependent manner.
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Affiliation(s)
- Caroline N Rivera
- Department of Exercise Science, High Point University, One University Parkway, High Point, NC, 27268, USA
| | - Rachel M Watne
- Department of Chemistry, High Point University, One University Parkway, High Point, NC, 27268, USA
| | - Zoe A Brown
- Department of Chemistry, High Point University, One University Parkway, High Point, NC, 27268, USA
| | - Samantha A Mitchell
- Department of Chemistry, High Point University, One University Parkway, High Point, NC, 27268, USA
| | - Andrew J Wommack
- Department of Chemistry, High Point University, One University Parkway, High Point, NC, 27268, USA
| | - Roger A Vaughan
- Department of Exercise Science, High Point University, One University Parkway, High Point, NC, 27268, USA.
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3
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Rivera CN, Kamer MM, Rivera ME, Watne RM, Macgowan TC, Wommack AJ, Vaughan RA. Insulin resistance promotes extracellular BCAA accumulation without altering LAT1 content, independent of prior BCAA treatment in a myotube model of skeletal muscle. Mol Cell Endocrinol 2023; 559:111800. [PMID: 36270542 DOI: 10.1016/j.mce.2022.111800] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Type 2 diabetes is characterized by reduced insulin sensitivity which correlates with increased circulating BCAA. These experiments investigated the effects of insulin resistance with and without excess BCAA on myotube insulin sensitivity and L-type amino acid transporter-1 (LAT1). METHODS C2C12 myotubes were treated with or without excess BCAA for 1 or 6 days, both with and without insulin resistance. Western blot was used to assess insulin sensitivity and LAT1 content. Liquid chromatography-mass spectrometry was used to evaluate BCAA media content. RESULTS Insulin resistance was associated with significantly increased extracellular BCAA accumulation independent of LAT1 content. Conversely, prior BCAA treatment was not associated with extracellular BCAA accumulation regardless of level of insulin sensitivity. CONCLUSION These data suggest insulin resistance, but not BCAA treatment, promotes extracellular BCAA accumulation independent of changes in LAT1 content, implicating insulin resistance as a causal agent of extracellular BCAA accumulation.
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Affiliation(s)
- Caroline N Rivera
- Department of Exercise Science, High Point University, High Point, NC, USA.
| | - Madison M Kamer
- Department of Exercise Science, High Point University, High Point, NC, USA.
| | - Madison E Rivera
- Department of Exercise Science, High Point University, High Point, NC, USA.
| | - Rachel M Watne
- Department of Chemistry, High Point University, High Point, NC, USA.
| | - Trent C Macgowan
- Department of Chemistry, High Point University, High Point, NC, USA.
| | - Andrew J Wommack
- Department of Chemistry, High Point University, High Point, NC, USA.
| | - Roger A Vaughan
- Department of Exercise Science, High Point University, High Point, NC, USA.
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Kilroy EA, Ignacz AC, Brann KL, Schaffer CE, Varney D, Alrowaished SS, Silknitter KJ, Miner JN, Almaghasilah A, Spellen TL, Lewis AD, Tilbury K, King BL, Kelley JB, Henry CA. Beneficial impacts of neuromuscular electrical stimulation on muscle structure and function in the zebrafish model of Duchenne muscular dystrophy. eLife 2022; 11:62760. [PMID: 35324428 PMCID: PMC8947762 DOI: 10.7554/elife.62760] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/10/2022] [Indexed: 12/20/2022] Open
Abstract
Neuromuscular electrical stimulation (NMES) allows activation of muscle fibers in the absence of voluntary force generation. NMES could have the potential to promote muscle homeostasis in the context of muscle disease, but the impacts of NMES on diseased muscle are not well understood. We used the zebrafish Duchenne muscular dystrophy (dmd) mutant and a longitudinal design to elucidate the consequences of NMES on muscle health. We designed four neuromuscular stimulation paradigms loosely based on weightlifting regimens. Each paradigm differentially affected neuromuscular structure, function, and survival. Only endurance neuromuscular stimulation (eNMES) improved all outcome measures. We found that eNMES improves muscle and neuromuscular junction morphology, swimming, and survival. Heme oxygenase and integrin alpha7 are required for eNMES-mediated improvement. Our data indicate that neuromuscular stimulation can be beneficial, suggesting that the right type of activity may benefit patients with muscle disease.
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Affiliation(s)
- Elisabeth A Kilroy
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States
| | - Amanda C Ignacz
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States
| | - Kaylee L Brann
- School of Biology and Ecology, University of Maine, Orono, United States
| | - Claire E Schaffer
- School of Biology and Ecology, University of Maine, Orono, United States
| | - Devon Varney
- School of Biology and Ecology, University of Maine, Orono, United States
| | | | - Kodey J Silknitter
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States
| | - Jordan N Miner
- Department of Chemical and Biomedical Engineering, University of Maine, Orono, United States
| | - Ahmed Almaghasilah
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States
| | - Tashawna L Spellen
- School of Biology and Ecology, University of Maine, Orono, United States
| | - Alexandra D Lewis
- School of Biology and Ecology, University of Maine, Orono, United States
| | - Karissa Tilbury
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States.,Department of Chemical and Biomedical Engineering, University of Maine, Orono, United States
| | - Benjamin L King
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States.,Department of Molecular and Biomedical Sciences, University of Maine, Orono, United States
| | - Joshua B Kelley
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States.,Department of Molecular and Biomedical Sciences, University of Maine, Orono, United States
| | - Clarissa A Henry
- Graduate School of Biomedical Science and Engineering, University of Maine, Orono, United States.,School of Biology and Ecology, University of Maine, Orono, United States
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Tao L, Zhu Y, Wang R, Han J, Ma Y, Guo H, Tang W, Zhuo L, Fan Z, Yin A, Hou W, Li Y. N-myc downstream-regulated gene 2 deficiency aggravates memory impairment in Alzheimer's disease. Behav Brain Res 2019; 379:112384. [PMID: 31778735 DOI: 10.1016/j.bbr.2019.112384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 11/20/2019] [Accepted: 11/24/2019] [Indexed: 12/28/2022]
Abstract
Alzheimer's disease (AD) is a chronic degenerative disease of the central nervous system and the most common dementia type in elderly people. N-myc downstream-regulated gene 2 (NDRG2), a cell stress response gene, is primarily expressed in astrocytes in mammalian brains. The hippocampal protein levels of NDRG2 in AD patients were significantly higher than those in healthy peers. However, whether the increase in NDRG2 is involved in the development of AD or is an endogenous protective response initiated by stress remains unknown. Here, we investigated the roles of NDRG2 in the development of memory impairment in AD using mouse models established by amyloid β injection or crossing of APP/PS1 mice. We found that NDRG2 deficiency worsened the memory impairment in AD mice. In addition, NDRG2 deletion induced downregulation of the proteasome functional subunit PSMB6 in AD mice. These findings suggest that NDRG2 is an endogenous neuroprotectant that participates in the pathological course of waste-clearing impairment and memory damage in AD. NDRG2 may be a therapeutic target for the intervention of AD memory degradation.
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Affiliation(s)
- Liang Tao
- Center for Brain Science & Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China; Department of Anesthesiology and Perioperative Medicine, Xijing Hospital of The Fourth Military Medical University, Xi'an, China
| | - Yuanyuan Zhu
- Department of Neurobiology, The Fourth Military Medical University, Xi'an, China
| | - Rui Wang
- Department of Neurobiology, The Fourth Military Medical University, Xi'an, China
| | - Jiao Han
- Center for Brain Science & Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yulong Ma
- Anesthesia and Operation Center, The First Medical Center to Chinese PLA General Hospital, Beijing, China
| | - Hang Guo
- Department of Anesthesiology, The Seventh Medical Center to Chinese PLA General Hospital, Beijing, China
| | - Wenhong Tang
- Department of Anesthesiology, the 960th Hospital of PLA, Jinan, China
| | - Lixia Zhuo
- Center for Brain Science & Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ze Fan
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital of The Fourth Military Medical University, Xi'an, China
| | - Anqi Yin
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital of The Fourth Military Medical University, Xi'an, China
| | - Wugang Hou
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital of The Fourth Military Medical University, Xi'an, China
| | - Yan Li
- Center for Brain Science & Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.
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Boppart MD, Mahmassani ZS. Integrin signaling: linking mechanical stimulation to skeletal muscle hypertrophy. Am J Physiol Cell Physiol 2019; 317:C629-C641. [PMID: 31314586 DOI: 10.1152/ajpcell.00009.2019] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The α7β1-integrin is a transmembrane adhesion protein that connects laminin in the extracellular matrix (ECM) with actin in skeletal muscle fibers. The α7β1-integrin is highly expressed in skeletal muscle and is concentrated at costameres and myotendious junctions, providing the opportunity to transmit longitudinal and lateral forces across the membrane. Studies have demonstrated that α7-integrin subunit mRNA and protein are upregulated following eccentric contractions as a mechanism to reinforce load-bearing structures and resist injury with repeated bouts of exercise. It has been hypothesized for many years that the integrin can also promote protein turnover in a manner that can promote beneficial adaptations with resistance exercise training, including hypertrophy. This review provides basic information about integrin structure and activation and then explores its potential to serve as a critical mechanosensor and activator of muscle protein synthesis and growth. Overall, the hypothesis is proposed that the α7β1-integrin can contribute to mechanical-load induced skeletal muscle growth via an mammalian target of rapamycin complex 1-independent mechanism.
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Affiliation(s)
- Marni D Boppart
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois.,Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Ziad S Mahmassani
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah
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Munroe M, Dvoretskiy S, Lopez A, Leong J, Dyle MC, Kong H, Adams CM, Boppart MD. Pericyte transplantation improves skeletal muscle recovery following hindlimb immobilization. FASEB J 2019; 33:7694-7706. [PMID: 31021652 PMCID: PMC6529341 DOI: 10.1096/fj.201802580r] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/04/2019] [Indexed: 02/06/2023]
Abstract
Conditions of extended bed rest and limb immobilization can initiate rapid and significant loss of skeletal muscle mass and function. Physical rehabilitation is standard practice following a period of disuse, yet mobility may be severely compromised, and recovery is commonly delayed or incomplete in special populations. Thus, a novel approach toward recovery of muscle mass is highly desired. Pericytes [neuron-glial antigen 2 (NG2)+CD31-CD45- (Lineage- [Lin-]) and CD146+Lin-] demonstrate capacity to facilitate muscle repair, yet the ability to enhance myofiber growth following disuse is unknown. In the current study, 3-4-mo-old mice were unilaterally immobilized for 14 d (IM) or immobilized for 14 d followed by 14 d of remobilization (RE). Flow cytometry and targeted gene expression analyses were completed to assess pericyte quantity and function following IM and RE. In addition, a transplantation study was conducted to assess the impact of pericytes on recovery. Results from targeted analyses suggest minimal impact of disuse on pericyte gene expression, yet NG2+Lin- pericyte quantity is reduced following IM (P < 0.05). Remarkably, pericyte transplantation recovered losses in myofiber cross-sectional area and the capillary-to-fiber ratio following RE, whereas deficits remained with vehicle alone (P = 0.01). These findings provide the first evidence that pericytes effectively rehabilitate skeletal muscle mass following disuse atrophy.-Munroe, M., Dvoretskiy, S., Lopez, A., Leong, J., Dyle, M. C., Kong, H., Adams, C. M., Boppart, M. D. Pericyte transplantation improves skeletal muscle recovery following hindlimb immobilization.
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Affiliation(s)
- Michael Munroe
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Svyatoslav Dvoretskiy
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Amber Lopez
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Jiayu Leong
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Michael C. Dyle
- Departments of Internal Medicine and University of Iowa, Iowa City, Iowa, USA
- Department of Molecular Physiology and Biophysics, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Hyunjoon Kong
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Carl R. Woese Institute for Genomic Biology, University of Illinois–Urbana-Champaign, Urbana, Illinois, USA
| | - Christopher M. Adams
- Departments of Internal Medicine and University of Iowa, Iowa City, Iowa, USA
- Department of Molecular Physiology and Biophysics, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Marni D. Boppart
- Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Carl R. Woese Institute for Genomic Biology, University of Illinois–Urbana-Champaign, Urbana, Illinois, USA
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Hentilä J, Ahtiainen JP, Paulsen G, Raastad T, Häkkinen K, Mero AA, Hulmi JJ. Autophagy is induced by resistance exercise in young men, but unfolded protein response is induced regardless of age. Acta Physiol (Oxf) 2018; 224:e13069. [PMID: 29608242 DOI: 10.1111/apha.13069] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/12/2018] [Accepted: 03/24/2018] [Indexed: 12/13/2022]
Abstract
AIM Autophagy and unfolded protein response (UPR) appear to be important for skeletal muscle homoeostasis and may be altered by exercise. Our aim was to investigate the effects of resistance exercise and training on indicators of UPR and autophagy in healthy untrained young men (n = 12, 27 ± 4 years) and older men (n = 8, 61 ± 6 years) as well as in resistance-trained individuals (n = 15, 25 ± 5 years). METHODS Indicators of autophagy and UPR were investigated from the muscle biopsies after a single resistance exercise bout and after 21 weeks of resistance training. RESULTS Lipidated LC3II as an indicator of autophagosome content increased at 48 hours post-resistance exercise (P < .05) and after a resistance training period (P < .01) in untrained young men but not in older men. Several UPRER markers, typically induced by protein misfolding in endoplasmic reticulum, were increased at 48 hours post-resistance exercise in untrained young and older men (P < .05) but were unaltered after the 21-week resistance training period regardless of age. UPR was unchanged within the first few hours after the resistance exercise bout regardless of the training status. Changes in autophagy and UPRER indicators did not correlate with a resistance training-induced increase in muscle strength and size. CONCLUSION Autophagosome content is increased by resistance training in young previously untrained men, but this response may be blunted by ageing. However, unfolded protein response is induced by an unaccustomed resistance exercise bout in a delayed manner regardless of age.
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Affiliation(s)
- J. Hentilä
- Biology of Physical Activity; Neuromuscular Research Center; Faculty of Sport and Health Sciences; University of Jyväskylä; Jyväskylä Finland
| | - J. P. Ahtiainen
- Biology of Physical Activity; Neuromuscular Research Center; Faculty of Sport and Health Sciences; University of Jyväskylä; Jyväskylä Finland
| | - G. Paulsen
- The Norwegian Olympic and Paralympic Committee and Confederation of Sports; Oslo Norway
| | - T. Raastad
- Department of Physical Performance; Norwegian School of Sport Sciences; Oslo Norway
| | - K. Häkkinen
- Biology of Physical Activity; Neuromuscular Research Center; Faculty of Sport and Health Sciences; University of Jyväskylä; Jyväskylä Finland
| | - A. A. Mero
- Biology of Physical Activity; Neuromuscular Research Center; Faculty of Sport and Health Sciences; University of Jyväskylä; Jyväskylä Finland
| | - J. J. Hulmi
- Biology of Physical Activity; Neuromuscular Research Center; Faculty of Sport and Health Sciences; University of Jyväskylä; Jyväskylä Finland
- Department of Physiology; Faculty of Medicine; University of Helsinki; Helsinki Finland
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