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1.
bioRxiv ; 2024 May 09.
Artículo en Inglés | MEDLINE | ID: mdl-38766176

RESUMEN

Recombinant adeno-associated viral vectors (rAAV) hold an intrinsic ability to stimulate homologous recombination (AAV-HR) and are the most used in clinical settings for in vivo gene therapy. However, rAAVs also integrate throughout the genome. Here, we describe DNA-RNA immunoprecipitation sequencing (DRIP-seq) in murine HEPA1-6 hepatoma cells and whole murine liver to establish the similarities and differences in genomic R-loop formation in a transformed cell line and intact tissue. We show enhanced AAV-HR in mice upon genetic and pharmacological upregulation of R-loops. Selecting the highly expressed Albumin gene as a model locus for genome editing in both in vitro and in vivo experiments showed that the R-loop prone, 3' end of Albumin was efficiently edited by AAV-HR, whereas the upstream R-loop-deficient region did not result in detectable vector integration. In addition, we found a positive correlation between previously reported off-target rAAV integration sites and R-loop enriched genomic regions. Thus, we conclude that high levels of R-loops, present in highly transcribed genes, promote rAAV vector genome integration. These findings may shed light on potential mechanisms for improving the safety and efficacy of genome editing by modulating R-loops and may enhance our ability to predict regions most susceptible to off-target insertional mutagenesis by rAAV vectors.

3.
bioRxiv ; 2023 Oct 27.
Artículo en Inglés | MEDLINE | ID: mdl-37961428

RESUMEN

G-quadruplexes (G4s) form throughout the genome and influence important cellular processes, but their deregulation can challenge DNA replication fork progression and threaten genome stability. Here, we demonstrate an unexpected, dual role for the dsDNA translocase HLTF in G4 metabolism. First, we find that HLTF is enriched at G4s in the human genome and suppresses G4 accumulation throughout the cell cycle using its ATPase activity. This function of HLTF affects telomere maintenance by restricting alternative lengthening of telomeres, a process stimulated by G4s. We also show that HLTF and MSH2, a mismatch repair factor that binds G4s, act in independent pathways to suppress G4s and to promote resistance to G4 stabilization. In a second, distinct role, HLTF restrains DNA synthesis upon G4 stabilization by suppressing PrimPol-dependent repriming. Together, the dual functions of HLTF in the G4 response prevent DNA damage and potentially mutagenic replication to safeguard genome stability.

4.
Mol Cell ; 83(20): 3582-3587, 2023 10 19.
Artículo en Inglés | MEDLINE | ID: mdl-37863025

RESUMEN

In recent years, increasing evidence has highlighted the profound connection between DNA damage repair and the activation of immune responses. We spoke with researchers about their mechanistic interplays and the implications for cancer and other diseases.


Asunto(s)
Daño del ADN , Reparación del ADN , Transducción de Señal , Inmunidad
5.
Nat Struct Mol Biol ; 30(3): 348-359, 2023 03.
Artículo en Inglés | MEDLINE | ID: mdl-36864174

RESUMEN

Transcription-replication collisions (TRCs) are crucial determinants of genome instability. R-loops were linked to head-on TRCs and proposed to obstruct replication fork progression. The underlying mechanisms, however, remained elusive due to the lack of direct visualization and of non-ambiguous research tools. Here, we ascertained the stability of estrogen-induced R-loops on the human genome, visualized them directly by electron microscopy (EM), and measured R-loop frequency and size at the single-molecule level. Combining EM and immuno-labeling on locus-specific head-on TRCs in bacteria, we observed the frequent accumulation of DNA:RNA hybrids behind replication forks. These post-replicative structures are linked to fork slowing and reversal across conflict regions and are distinct from physiological DNA:RNA hybrids at Okazaki fragments. Comet assays on nascent DNA revealed a marked delay in nascent DNA maturation in multiple conditions previously linked to R-loop accumulation. Altogether, our findings suggest that TRC-associated replication interference entails transactions that follow initial R-loop bypass by the replication fork.


Asunto(s)
Replicación del ADN , ARN , Humanos , ADN/química , Proteínas de Unión al ADN/metabolismo , Cromosomas/metabolismo , Inestabilidad Genómica
6.
Nature ; 613(7942): 187-194, 2023 01.
Artículo en Inglés | MEDLINE | ID: mdl-36544021

RESUMEN

R-loops are RNA-DNA-hybrid-containing nucleic acids with important cellular roles. Deregulation of R-loop dynamics can lead to DNA damage and genome instability1, which has been linked to the action of endonucleases such as XPG2-4. However, the mechanisms and cellular consequences of such processing have remained unclear. Here we identify a new population of RNA-DNA hybrids in the cytoplasm that are R-loop-processing products. When nuclear R-loops were perturbed by depleting the RNA-DNA helicase senataxin (SETX) or the breast cancer gene BRCA1 (refs. 5-7), we observed XPG- and XPF-dependent cytoplasmic hybrid formation. We identify their source as a subset of stable, overlapping nuclear hybrids with a specific nucleotide signature. Cytoplasmic hybrids bind to the pattern recognition receptors cGAS and TLR3 (ref. 8), activating IRF3 and inducing apoptosis. Excised hybrids and an R-loop-induced innate immune response were also observed in SETX-mutated cells from patients with ataxia oculomotor apraxia type 2 (ref. 9) and in BRCA1-mutated cancer cells10. These findings establish RNA-DNA hybrids as immunogenic species that aberrantly accumulate in the cytoplasm after R-loop processing, linking R-loop accumulation to cell death through the innate immune response. Aberrant R-loop processing and subsequent innate immune activation may contribute to many diseases, such as neurodegeneration and cancer.


Asunto(s)
Citoplasma , ADN , Reconocimiento de Inmunidad Innata , Ácidos Nucleicos Heterodúplex , Estructuras R-Loop , ARN , Humanos , Apoptosis , Citoplasma/inmunología , Citoplasma/metabolismo , ADN/química , ADN/inmunología , ADN Helicasas/genética , ADN Helicasas/metabolismo , Genes BRCA1 , Enzimas Multifuncionales/genética , Enzimas Multifuncionales/metabolismo , Mutación , Neoplasias , Ácidos Nucleicos Heterodúplex/química , Ácidos Nucleicos Heterodúplex/inmunología , Estructuras R-Loop/inmunología , ARN/química , ARN/inmunología , ARN Helicasas/genética , ARN Helicasas/metabolismo , Ataxias Espinocerebelosas/genética
7.
Methods Mol Biol ; 2528: 381-410, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35704206

RESUMEN

R-loops are three-stranded nucleic acid structures, comprising an RNA-DNA hybrid and a displaced strand of ssDNA. R-loops have important physiological roles in cells, but deregulation of R-loop dynamics can also have harmful cellular outcomes. The genome-wide mapping of R-loops offers an unbiased approach to study R-loop biology in a wide range of contexts. Here we present a protocol to sequence RNA-DNA hybrids genome-wide with strand-specificity and high resolution. We also include information on how to prepare and incorporate into the workflow appropriate internal spike-in standards which facilitate accurate normalization of the sequencing signal, thereby providing quantitative insights into R-loop formation between different experimental samples.


Asunto(s)
Estructuras R-Loop , ARN , Mapeo Cromosómico , ADN/química , ADN/genética , Inmunoprecipitación , ARN/química , ARN/genética
8.
Mol Cell ; 82(12): 2267-2297, 2022 06 16.
Artículo en Inglés | MEDLINE | ID: mdl-35508167

RESUMEN

Although transcription is an essential cellular process, it is paradoxically also a well-recognized cause of genomic instability. R-loops, non-B DNA structures formed when nascent RNA hybridizes to DNA to displace the non-template strand as single-stranded DNA (ssDNA), are partially responsible for this instability. Yet, recent work has begun to elucidate regulatory roles for R-loops in maintaining the genome. In this review, we discuss the cellular contexts in which R-loops contribute to genomic instability, particularly during DNA replication and double-strand break (DSB) repair. We also summarize the evidence that R-loops participate as an intermediate during repair and may influence pathway choice to preserve genomic integrity. Finally, we discuss the immunogenic potential of R-loops and highlight their links to disease should they become pathogenic.


Asunto(s)
Estructuras R-Loop , Transcripción Genética , ADN/metabolismo , Reparación del ADN , Replicación del ADN , ADN de Cadena Simple/genética , Inestabilidad Genómica , Humanos , Estructuras R-Loop/genética
9.
Proc Natl Acad Sci U S A ; 119(18): e2115638119, 2022 05 03.
Artículo en Inglés | MEDLINE | ID: mdl-35476521

RESUMEN

A key property of adult stem cells is their ability to persist in a quiescent state for prolonged periods of time. The quiescent state is thought to contribute to stem cell resilience by limiting accumulation of DNA replication­associated mutations. Moreover, cellular stress response factors are thought to play a role in maintaining quiescence and stem cell integrity. We utilized muscle stem cells (MuSCs) as a model of quiescent stem cells and find that the replication stress response protein, ATR (Ataxia Telangiectasia and Rad3-Related), is abundant and active in quiescent but not activated MuSCs. Concurrently, MuSCs display punctate RPA (replication protein A) and R-loop foci, both key triggers for ATR activation. To discern the role of ATR in MuSCs, we generated MuSC-specific ATR conditional knockout (ATRcKO) mice. Surprisingly, ATR ablation results in increased MuSC quiescence exit. Phosphoproteomic analysis of ATRcKO MuSCs reveals enrichment of phosphorylated cyclin F, a key component of the Skp1­Cul1­F-box protein (SCF) ubiquitin ligase complex and regulator of key cell-cycle transition factors, such as the E2F family of transcription factors. Knocking down cyclin F or inhibiting the SCF complex results in E2F1 accumulation and in MuSCs exiting quiescence, similar to ATR-deficient MuSCs. The loss of ATR could be counteracted by inhibiting casein kinase 2 (CK2), the kinase responsible for phosphorylating cyclin F. We propose a model in which MuSCs express cell-cycle progression factors but ATR, in coordination with the cyclin F­SCF complex, represses premature stem cell quiescence exit via ubiquitin­proteasome degradation of these factors.


Asunto(s)
Proteínas de Ciclo Celular , Ciclinas , Ciclo Celular , Proteínas de Ciclo Celular/metabolismo , División Celular , Ciclinas/genética , Ciclinas/metabolismo , Células Madre/metabolismo
10.
J Cell Biol ; 220(9)2021 09 06.
Artículo en Inglés | MEDLINE | ID: mdl-34232287

RESUMEN

R-loops are three-stranded nucleic acid structures with both physiological and pathological roles in cells. R-loop imaging generally relies on detection of the RNA-DNA hybrid component of these structures using the S9.6 antibody. We show that the use of this antibody for imaging can be problematic because it readily binds to double-stranded RNA (dsRNA) in vitro and in vivo, giving rise to nonspecific signal. In contrast, purified, catalytically inactive human RNase H1 tagged with GFP (GFP-dRNH1) is a more specific reagent for imaging RNA-DNA hybrids. GFP-dRNH1 binds strongly to RNA-DNA hybrids but not to dsRNA oligonucleotides in fixed human cells and is not susceptible to binding endogenous RNA. Furthermore, we demonstrate that purified GFP-dRNH1 can be applied to fixed cells to detect hybrids after their induction, thereby bypassing the need for cell line engineering. GFP-dRNH1 therefore promises to be a versatile tool for imaging and quantifying RNA-DNA hybrids under a wide range of conditions.


Asunto(s)
ADN/metabolismo , Secuencias Invertidas Repetidas , ARN Bicatenario/metabolismo , Proteínas Recombinantes de Fusión/metabolismo , Ribonucleasa H/metabolismo , Coloración y Etiquetado/métodos , Anticuerpos/química , Anticuerpos/metabolismo , Proteína BRCA1/antagonistas & inhibidores , Proteína BRCA1/genética , Proteína BRCA1/metabolismo , Clonación Molecular , ADN/química , ADN/ultraestructura , ADN Helicasas/antagonistas & inhibidores , ADN Helicasas/genética , ADN Helicasas/metabolismo , Escherichia coli/genética , Escherichia coli/metabolismo , Colorantes Fluorescentes/química , Colorantes Fluorescentes/metabolismo , Expresión Génica , Genes Reporteros , Vectores Genéticos/química , Vectores Genéticos/metabolismo , Proteínas Fluorescentes Verdes/genética , Proteínas Fluorescentes Verdes/metabolismo , Células HeLa , Compuestos Heterocíclicos de 4 o más Anillos/química , Compuestos Heterocíclicos de 4 o más Anillos/metabolismo , Humanos , Enzimas Multifuncionales/antagonistas & inhibidores , Enzimas Multifuncionales/genética , Enzimas Multifuncionales/metabolismo , Hibridación de Ácido Nucleico , Imagen Óptica/métodos , Unión Proteica , ARN Helicasas/antagonistas & inhibidores , ARN Helicasas/genética , ARN Helicasas/metabolismo , ARN Bicatenario/química , ARN Bicatenario/ultraestructura , ARN Interferente Pequeño/genética , ARN Interferente Pequeño/metabolismo , Proteínas Recombinantes de Fusión/genética , Ribonucleasa H/genética
11.
J Clin Invest ; 131(11)2021 06 01.
Artículo en Inglés | MEDLINE | ID: mdl-34060485

RESUMEN

Hypoxia, a hallmark feature of the tumor microenvironment, causes resistance to conventional chemotherapy, but was recently reported to synergize with poly(ADP-ribose) polymerase inhibitors (PARPis) in homologous recombination-proficient (HR-proficient) cells through suppression of HR. While this synergistic killing occurs under severe hypoxia (<0.5% oxygen), our study shows that moderate hypoxia (2% oxygen) instead promotes PARPi resistance in both HR-proficient and -deficient cancer cells. Mechanistically, we identify reduced ROS-induced DNA damage as the cause for the observed resistance. To determine the contribution of hypoxia to PARPi resistance in tumors, we used the hypoxic cytotoxin tirapazamine to selectively kill hypoxic tumor cells. We found that the selective elimination of hypoxic tumor cells led to a substantial antitumor response when used with PARPi compared with that in tumors treated with PARPi alone, without enhancing normal tissue toxicity. Since human breast cancers with BRAC1/2 mutations have an increased hypoxia signature and hypoxia reduces the efficacy of PARPi, then eliminating hypoxic tumor cells should enhance the efficacy of PARPi therapy.


Asunto(s)
Daño del ADN , Recombinación Homóloga , Neoplasias Experimentales , Inhibidores de Poli(ADP-Ribosa) Polimerasas/farmacología , Especies Reactivas de Oxígeno/metabolismo , Animales , Hipoxia de la Célula/efectos de los fármacos , Hipoxia de la Célula/genética , Línea Celular Tumoral , Femenino , Humanos , Ratones , Ratones Desnudos , Neoplasias Experimentales/tratamiento farmacológico , Neoplasias Experimentales/genética , Neoplasias Experimentales/metabolismo , Ensayos Antitumor por Modelo de Xenoinjerto
12.
Nucleic Acids Res ; 48(14): e84, 2020 08 20.
Artículo en Inglés | MEDLINE | ID: mdl-32544226

RESUMEN

R-loops are dynamic, co-transcriptional nucleic acid structures that facilitate physiological processes but can also cause DNA damage in certain contexts. Perturbations of transcription or R-loop resolution are expected to change their genomic distribution. Next-generation sequencing approaches to map RNA-DNA hybrids, a component of R-loops, have so far not allowed quantitative comparisons between such conditions. Here, we describe quantitative differential DNA-RNA immunoprecipitation (qDRIP), a method combining synthetic RNA-DNA-hybrid internal standards with high-resolution, strand-specific sequencing. We show that qDRIP avoids biases inherent to read-count normalization by accurately profiling signal in regions unaffected by transcription inhibition in human cells, and by facilitating accurate differential peak calling between conditions. We also use these quantitative comparisons to make the first estimates of the absolute count of RNA-DNA hybrids per cell and their half-lives genome-wide. Finally, we identify a subset of RNA-DNA hybrids with high GC skew which are partially resistant to RNase H. Overall, qDRIP allows for accurate normalization in conditions where R-loops are perturbed and for quantitative measurements that provide previously unattainable biological insights.


Asunto(s)
ADN/metabolismo , Inmunoprecipitación/métodos , Hibridación de Ácido Nucleico , Estructuras R-Loop , ARN/metabolismo , Animales , Línea Celular , Drosophila/citología , Biblioteca de Genes , Genoma , Semivida , Células HeLa , Humanos , Reacción en Cadena de la Polimerasa , Ribonucleasa H , Sonicación , Transcripción Genética
13.
Mol Cell ; 78(6): 1237-1251.e7, 2020 06 18.
Artículo en Inglés | MEDLINE | ID: mdl-32442397

RESUMEN

DNA replication stress can stall replication forks, leading to genome instability. DNA damage tolerance pathways assist fork progression, promoting replication fork reversal, translesion DNA synthesis (TLS), and repriming. In the absence of the fork remodeler HLTF, forks fail to slow following replication stress, but underlying mechanisms and cellular consequences remain elusive. Here, we demonstrate that HLTF-deficient cells fail to undergo fork reversal in vivo and rely on the primase-polymerase PRIMPOL for repriming, unrestrained replication, and S phase progression upon limiting nucleotide levels. By contrast, in an HLTF-HIRAN mutant, unrestrained replication relies on the TLS protein REV1. Importantly, HLTF-deficient cells also exhibit reduced double-strand break (DSB) formation and increased survival upon replication stress. Our findings suggest that HLTF promotes fork remodeling, preventing other mechanisms of replication stress tolerance in cancer cells. This remarkable plasticity of the replication fork may determine the outcome of replication stress in terms of genome integrity, tumorigenesis, and response to chemotherapy.


Asunto(s)
Replicación del ADN/fisiología , Proteínas de Unión al ADN/metabolismo , ADN/biosíntesis , Factores de Transcripción/metabolismo , Línea Celular Tumoral , ADN/genética , Daño del ADN/genética , ADN Primasa/metabolismo , ADN Primasa/fisiología , Reparación del ADN/genética , Replicación del ADN/genética , Proteínas de Unión al ADN/genética , ADN Polimerasa Dirigida por ADN/metabolismo , ADN Polimerasa Dirigida por ADN/fisiología , Células HEK293 , Humanos , Células K562 , Enzimas Multifuncionales/metabolismo , Enzimas Multifuncionales/fisiología , Nucleotidiltransferasas/metabolismo , Nucleotidiltransferasas/fisiología , Factores de Transcripción/genética
14.
Mol Cell ; 73(3): 398-411, 2019 02 07.
Artículo en Inglés | MEDLINE | ID: mdl-30735654

RESUMEN

During transcription, the nascent RNA strand can base pair with its template DNA, displacing the non-template strand as ssDNA and forming a structure called an R-loop. R-loops are common across many domains of life and cause DNA damage in certain contexts. In this review, we summarize recent results implicating R-loops as important regulators of cellular processes such as transcription termination, gene regulation, and DNA repair. We also highlight recent work suggesting that R-loops can be problematic to cells as blocks to efficient transcription and replication that trigger the DNA damage response. Finally, we discuss how R-loops may contribute to cancer, neurodegeneration, and inflammatory diseases and compare the available next-generation sequencing-based approaches to map R-loops genome wide.


Asunto(s)
Núcleo Celular/fisiología , ADN/genética , Genoma , Inestabilidad Genómica , Ácidos Nucleicos Heterodúplex/genética , ARN/genética , Animales , ADN/química , ADN/metabolismo , Daño del ADN , Reparación del ADN , Regulación de la Expresión Génica , Humanos , Conformación de Ácido Nucleico , Ácidos Nucleicos Heterodúplex/química , Ácidos Nucleicos Heterodúplex/metabolismo , ARN/química , ARN/metabolismo , Relación Estructura-Actividad , Transcripción Genética
15.
Cell Rep ; 26(5): 1333-1343.e7, 2019 01 29.
Artículo en Inglés | MEDLINE | ID: mdl-30699358

RESUMEN

Using proteomic approaches, we uncovered a DNA damage response (DDR) function for peroxisome proliferator activated receptor γ (PPARγ) through its interaction with the DNA damage sensor MRE11-RAD50-NBS1 (MRN) and the E3 ubiquitin ligase UBR5. We show that PPARγ promotes ATM signaling and is essential for UBR5 activity targeting ATM interactor (ATMIN). PPARγ depletion increases ATMIN protein independent of transcription and suppresses DDR-induced ATM signaling. Blocking ATMIN in this context restores ATM activation and DNA repair. We illustrate the physiological relevance of PPARγ DDR functions by using pulmonary arterial hypertension (PAH) as a model that has impaired PPARγ signaling related to endothelial cell (EC) dysfunction and unresolved DNA damage. In pulmonary arterial ECs (PAECs) from PAH patients, we observed disrupted PPARγ-UBR5 interaction, heightened ATMIN expression, and DNA lesions. Blocking ATMIN in PAH PAEC restores ATM activation. Thus, impaired PPARγ DDR functions may explain the genomic instability and loss of endothelial homeostasis in PAH.


Asunto(s)
Reparación del ADN , Células Endoteliales/metabolismo , Homeostasis , PPAR gamma/metabolismo , Factores de Transcripción/metabolismo , Ubiquitina-Proteína Ligasas/metabolismo , Proteínas de la Ataxia Telangiectasia Mutada/metabolismo , Daño del ADN , Inestabilidad Genómica , Células HEK293 , Humanos , Modelos Biológicos , Unión Proteica , Arteria Pulmonar/patología , Transducción de Señal , Ubiquitinación
16.
Science ; 361(6404): 806-810, 2018 08 24.
Artículo en Inglés | MEDLINE | ID: mdl-30139873

RESUMEN

The cell cycle is strictly ordered to ensure faithful genome duplication and chromosome segregation. Control mechanisms establish this order by dictating when a cell transitions from one phase to the next. Much is known about the control of the G1/S, G2/M, and metaphase/anaphase transitions, but thus far, no control mechanism has been identified for the S/G2 transition. Here we show that cells transactivate the mitotic gene network as they exit the S phase through a CDK1 (cyclin-dependent kinase 1)-directed FOXM1 phosphorylation switch. During normal DNA replication, the checkpoint kinase ATR (ataxia-telangiectasia and Rad3-related) is activated by ETAA1 to block this switch until the S phase ends. ATR inhibition prematurely activates FOXM1, deregulating the S/G2 transition and leading to early mitosis, underreplicated DNA, and DNA damage. Thus, ATR couples DNA replication with mitosis and preserves genome integrity by enforcing an S/G2 checkpoint.


Asunto(s)
Fase G2/genética , Mitosis/genética , Fase S/genética , Antígenos de Superficie/metabolismo , Proteínas de la Ataxia Telangiectasia Mutada/genética , Proteínas de la Ataxia Telangiectasia Mutada/fisiología , Ciclina B1/antagonistas & inhibidores , Ciclina B1/metabolismo , Daño del ADN/genética , Replicación del ADN/genética , Proteína Forkhead Box M1/metabolismo , Redes Reguladoras de Genes , Células HCT116 , Humanos , Fosforilación , Telomerasa
17.
Cell Syst ; 7(1): 17-27.e3, 2018 07 25.
Artículo en Inglés | MEDLINE | ID: mdl-29909278

RESUMEN

Faithful DNA replication is challenged by stalling of replication forks during S phase. Replication stress is further increased in cancer cells or in response to genotoxic insults. Using live single-cell image analysis, we found that CDK2 activity fluctuates throughout an unperturbed S phase. We show that CDK2 fluctuations result from transient ATR signals triggered by stochastic replication stress events. In turn, fluctuating endogenous CDK2 activity causes corresponding decreases and increases in DNA synthesis rates, linking changes in stochastic replication stress to fluctuating global DNA replication rates throughout S phase. Moreover, cells that re-enter the cell cycle after mitogen stimulation have increased CDK2 fluctuations and prolonged S phase resulting from increased replication stress-induced CDK2 suppression. Thus, our study reveals a dynamic control principle for DNA replication whereby CDK2 activity is suppressed and fluctuates throughout S phase to continually adjust global DNA synthesis rates in response to recurring stochastic replication stress events.


Asunto(s)
Proteínas de la Ataxia Telangiectasia Mutada/metabolismo , Quinasa 2 Dependiente de la Ciclina/metabolismo , ADN/biosíntesis , Proteínas de la Ataxia Telangiectasia Mutada/genética , Ciclo Celular/fisiología , Proteínas de Ciclo Celular/genética , División Celular , Línea Celular , Quinasa 2 Dependiente de la Ciclina/fisiología , Quinasas Ciclina-Dependientes/genética , Daño del ADN , Replicación del ADN , Proteínas de Unión al ADN/genética , Humanos , Células MCF-7 , Fase S/fisiología , Análisis de la Célula Individual/métodos
19.
Science ; 359(6371): 30-31, 2018 01 05.
Artículo en Inglés | MEDLINE | ID: mdl-29302000
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