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In order to unravel the nature of FAN interaction with actin cytoskeleton machinery, FAN/actin direct interaction was analyzed in an in vitro F-actin binding assay using recombinant FAN-GST and F-actin. As shown in Figure 7C, FAN-GST but not GST alone was co-sedimented with F-actin, demonstrating a direct F-actin binding capability of FAN. The observed interactions provide a functional link between FAN and the actin cytoskeleton machinery, which may result in co-precipitation of proteins involved in filopodia formation like VASP, as shown in Figure 7A and B.
Further investigations on the impact of the PH domain of FAN on the actin binding capacity in HEK 293 cells revealed that deletion of the PH domain, which abrogates plasma membrane association of FAN (Figure 5C) also abolished the interaction of FAN with actin, whereas binding to TNF-RI remained unaffected (Figure 7D). Finally, no actin binding was detected with FAN-PH alone, suggesting that PH modulates FAN actin binding by promoting correct subcellular localization at the plasma membrane.
Discussion In contrast to other TNF receptor adaptor proteins such as TRADD, FADD, RIP or TRAF2, FAN does not bind to, or interact with death domains, and its precise function in specific cellular responses to TNF remained largely unclear. Here, we show that FAN is crucial for the formation of filopodia and actin cytoskeleton reorganization induced by TNF. A major finding of our study demonstrates specific binding of the FAN PH domain to PtdIns(4,5)P, which directs FAN to the plasma membrane. Additionally, FAN binds to the actin cytoskeleton machinery upon TNF treatment, which is modulated by PH action. FAN-PH mutants with a non-functional PtdIns(4,5)P binding site were unable to mediate TNF-induced filopodia formation. Furthermore, disruption of the intramolecular interaction between the PH and BEACH domains abrogated the actin modulatory function of FAN without affecting membrane localization. Thus, the molecular mode of PH domain action in FAN signaling is defined by two independent functional features, that is, targeting of FAN to the plasma membrane and correct interdomain interaction between BEACH and PH regulating FAN function.
Several proteins involved in modulating the actin cytoskeleton via regulation of Rho GTPases contain PH or PH-like domains with lipid binding properties (Bellanger et al, 2000; Ohta et al, 2006), which enable these proteins to localize correctly to the plasma membrane (Cozier et al, 2004; Lemmon, 2004). PtdIns(4,5)P has been shown to directly interact with a large number of regulators of the actin cytoskeleton and control their activity at the plasma membrane (Hilpela et al, 2004). Accumulating evidence also suggests PtdIns(4,5)P as a spatial marker for directing actin polymerization close to the plasma membrane (Insall and Weiner, 2001). Like other cytoskeletal modulators FAN contains a PH domain that can bind to PtdIns(4,5)P (Figure 5). FAN utilizes its PtdIns(4,5)P binding ability to associate with the plasma membrane, where interaction with plasma membrane TNF-RI and possibly additional proteins can occur (Tcherkasowa et al, 2002).
In this study FAN was identified as a TNF-RI binding adaptor protein, which promotes Cdc42 activation upon TNF stimulation (Figure 3). Since FAN does not contain any known Rho GTPase regulatory capacities like GAP (GTPase-activating protein) or GEF (guanine nucleotide-exchange factor) activity, further modulators of actin cytoskeleton might be the downstream target of FAN. As shown in Figure 7, FAN appeared as a functionally dormant, plasma membrane-associated protein without actin cytoskeleton binding property in untreated cells. Upon TNF stimulation FAN interacted with the actin cytoskeleton machinery demonstrated by co-precipitation with actin and VASP and by F-actin co-sedimentation (Figure 7A–C). A fundamental property of many actin cytoskeleton modulators including ERM and WASP/WAVE proteins is their association with the plasma membrane and the underlying cytoskeleton connecting the plasma membrane and plasma membrane proteins to the cortical cytoskeleton (Bretscher et al, 2002; Takenawa and Suetsugu, 2007). These proteins are mainly activated by extracellular signals, undergo conformational change and bind to the actin cytoskeleton. Similarly, FAN binds TNF-RI, associates with the plasma membrane (Figure 5) and interacts with actin cytoskeleton machinery upon TNF treatment (Figure 7). By interaction with the actin cytoskeleton machinery and TNF-RI, FAN could form a signaling platform, which locally modulates TNF-induced actin reorganization in a phosphoinositide-dependent manner, a mechanism similar to what has been recently shown for Toll-like receptor signaling (Kagan and Medzhitov, 2006). In this context, the PH domain may modulate the actin binding capacity of FAN in a dual way: first by correct subcellular localization of FAN and second by promoting a conformational change of FAN (Jogl et al, 2002) upon specific PtdIns(4,5)P binding (Figure 6B), as described for N-WASP (neural WASP) (Prehoda et al, 2000). In contrast to ERM proteins, which are mainly linked to the plasma membrane by additional membrane proteins, FAN can directly associate with the plasma membrane via its specific PtdIns(4,5)P binding capacity. The direct association with plasma membrane lipids enables FAN for immediate early reaction to plasma membrane lipid modification, probably resulting in modulation of its downstream binding partners.
It has been proposed that PtdIns(4,5)P accumulates at plasma membrane lipid-microdomains, where it modulates the activity of proteins that regulate the actin cytoskeleton (Chong et al, 1994; Honda et al, 1999; Laux et al, 2000). Sphingolipids are known to form liquid-ordered microdomains that segregate from the more fluid regions of membranes. In particular, sphingomyelin (SM) has been shown to form tight hydrophobic interactions with cholesterol and to play a key role in the formation of lipid rafts (Barenholz, 2004). FAN has been initially identified as the factor associated with nSMase activity, an enzyme belonging to the family of sphingomyelinases that hydrolyze SM to ceramide (Cer), and thereby alter membrane lipid composition (Cremesti et al, 2002). A recently identified novel nSMase3 was shown to be TNF responsive in a FAN-dependent manner (Krut et al, 2006), and to localize to the plasma membrane (K Wiegmann and M Krönke, unpublished data). By modulating nSMase3 activity, FAN could influence membrane lipid composition and PtdIns(4,5)P distribution, and thus modulate downstream signaling of TNF-RI.
FAN appears to be important for TNF-induced Cdc42 activation. It is worth noting that, next to neutral sphingomyelinases including nSMase3, Cdc42 is the first signaling component identified to be regulated by FAN (Figure 3). Strikingly, Hanna et al (2001) have previously reported that exogenous sphingomyelinase and synthetic C2-ceramide induce membrane association of Rho GTPases like Cdc42 and phosphorylation of paxillin and focal adhesion kinase. Thus, it will be interesting to test a possible functional link between FAN and nSMase3 in TNF-induced activation of Cdc42 and subsequent formation of filopodia. This idea is supported by the observation that mutations of PH or BEACH that disrupt the interaction between the PH and BEACH domains not only block TNF-induced filopodia formation but also destroy FAN-mediated activation of nSMase (Jogl et al, 2002).
Reorganization of the actin cytoskeleton in response to cytokines like TNF plays a central role in modulating the shape and behavior of cells. Cellular motility modulated by TNF has been shown to be especially important in epidermal repair and wound healing (Cumberbatch et al, 1997; Banno et al, 2004; Lokuta and Huttenlocher, 2005). The identification of FAN as a mediator of Cdc42 activation and cell polarization closes an important gap in our understanding of TNF-induced molecular pathways regulating cytoskeletal reorganization.
Materials and methods Cell culture and transfection
Mouse embryonic fibroblasts (MEFs), Swiss 3T3 fibroblasts and COS-7 cells were cultured at 37°C in DMEM (Biochrom, Berlin, Germany) and 10% fetal bovine serum. HEK 293FT cells were cultured as described above supplemented with 2 mM L-glutamine, non-essential amino acids and 10 mM sodium pyruvate (Biochrom). For F-actin staining, cells were plated on coverslips and transfected using ExGENE (Fermentas, St Leon-Rot, Germany) (MEFs) or the calcium phosphate method (COS-7 and HEK 293FT cells).
Antibodies and reagents
Goat polyclonal anti-GST antibody was obtained from Amersham Corp. (Freiburg, Germany). Rabbit polyclonal antibody JNK and phospho-JNK was obtained from Cell Signaling Technology (Danvers, USA). Phycoerythrin-conjugated (PE) mouse anti-human TNF-RI monoclonal antibody was obtained from R&D Systems (Wiesbaden, Germany). Mouse anti-His antibody was obtained form Quiagen (Hilden, Germany). Rabbit polyclonal anti-Cdc42 and mouse monoclonal anti-RhoA antibodies were obtained from Santa Cruz Biotechnologies (Heidelberg, Germany). Mouse monoclonal anti-Rac1 antibody was obtained from Upstate (Dundee, UK). Rabbit polyclonal anti-VASP antibody was obtained from Axxora (Lörrach, Germany). Mouse monoclonal anti- -actin and horseradish peroxidase (HRP) conjugates of anti-rabbit and anti-mouse IgG were obtained from Sigma (München, Germany). AlexaFluor-568 and AlexaFluor-488 conjugated phalloidin were purchased from Molecular Probes (Karlsruhe, Germany). Rabbit anti-Bax antibody was obtained from BD Biosciences (Heidelberg, Germany). All chemicals were purchased from Sigma (München, Germany), unless indicated otherwise.
DNA constructs
Open reading frames of genes encoding human FAN and different variants of FAN were cloned into pEGFP-C3 vector (Invitrogen, Karlsruhe, Germany) for immunofluorescence, into pRK-GST vector for GST pull-down experiments, or pET-20b vector (Novagen/Merck Biosciences, Darmstadt, Germany) or pGEX-4T3 vector (Amersham Corp., Freiburg, Germany) for prokaryotic protein expression. All constructs were verified by sequence analysis.
Immunofluorescence
Cells grown on coverslips were stimulated with TNF (100 ng/ml) for 10 min and washed twice with cold PBS. Cells were then fixed with 3% paraformaldehyde/PBS for 20 min and blocked with 3% bovine serum albumin in PBS for 30 min. For staining of surface TNF-RI, cells were incubated with PE-conjugated TNF-RI specific antibody for 1 h without permeabilization, and washed twice with PBS. For staining of the actin cytoskeleton, cells were permeabilized with 0.1% saponin during blocking, and incubated with AlexaFluor568- or AlexaFluor488-conjugated phalloidin in PBS/0.1% saponin. Cells were mounted on glass slides and examined using an Olympus IX81 fluorescence microscope or a Leica DMIRE2 confocal microscope. If appropriate, images were processed using CellP deconvolution software (Olympus SIS). For quantification of filopodia, >100 cells were evaluated under the microscope, and the percentage of cells that showed more than five filopodia was calculated (Gadea et al, 2004).
GTPase activation assay
The Cdc42/Rac1 activation assay was performed as described (Sander et al, 1998; Malliri et al, 2002). Briefly, cells were treated with TNF (100 ng/ml), PDGF (20 ng/ml), bradykinin (400 ng/ml) or left untreated, and were lysed before incubation with GST-CRIB fusion protein, which contains the GTPase binding domain from human PAK1B coupled to glutathione–Sepharose beads (Amersham Corp., Freiburg, Germany). After precipitation, beads were washed four times, eluted in SDS sample buffer and immunoblotted with antibodies against Cdc42 or Rac1. For RhoA activation, the same principle was applied using the Rho binding domain of Rhotekin (Ren et al, 1999) and RhoA-specific antibody for immunoblot analysis.
Protein expression and purification
The part of FAN containing the PH domain (residues 1–275) cloned into pET20b vector was expressed in E. coli at 37°C for 3 h. Soluble protein was bound to nickel–agarose affinity resin (Novagen/Merck Biosciences, Darmstadt, Germany) and eluted as described by the manufacturer in a buffer containing 20 mM Tris–HCl (pH 7.5), 500 mM NaCl, 1 mM PMSF and 100 mM imidazole. For production of FAN-GST, FAN cloned into pGEX-4T3 vector was expressed in E. coli at 25°C for 5 h and purified using glutathione–Sepharose 4B beads (Amersham Corp., Freiburg, Germany).
Protein–lipid overlay assay
The protein–lipid overlay assay was performed as described previously (Dowler et al, 2000). Briefly, a nitrocellulose membrane spotted with 1 l of lipid solution containing 0.5 nmol of phospholipids was blocked for 1 h in 3% BSA in TBST (50 mM Tris–HCl, pH 7.5, 150 mM NaCl, 0.1% Tween 20) and incubated overnight with approximately 0.1 g/ml of the indicated His-fusion proteins. After washing in TBST, membranes were incubated with monoclonal anti-His antibody and secondary HRP-conjugated antibody. Bound protein was detected by enhanced chemiluminescence.
F-actin sedimentation assay
The F-actin sedimentation assay was performed using the Actin Binding Protein Biochem Kit (Cytoskeleton, Inc., Denver, USA) according to the manufacturer's instructions. Briefly, polymerized actin was incubated with approximately 0.5 g recombinant FAN-GST or control GST protein for 30 min at room temperature and centrifuged at 150 000 g for 90 min. FAN-GST and GST protein was detected in supernatants and pellets using anti-GST antibody after immunoblotting.
GST pull-down assay
A total of 3 106 HEK 293 cells were transiently transfected with the DNA constructs coding for the indicated proteins. After 24 h, cells were stimulated with TNF (100 ng/ml) for 10 min or left untreated, lysed in 50 mM Tris–HCl, 15 mM EGTA, 100 mM NaCl, 0.1% Triton X-100, 1 mM DTT and 1 mM PMSF at pH 7.5, and centrifuged for 30 min at 20 000 g. Supernatants were incubated with 25 l glutathione–Sepharose beads for 1 h at 4°C. Beads were washed extensively, resuspended in SDS sample buffer and analyzed by SDS–PAGE and immunoblotting.
Real-time light-cycler RT–PCR
Swiss 3T3 fibroblasts were transiently transfected with two different predesigned siRNAs against murine FAN (NSMAF, Ambion Europe, Huntingdon, UK) (FAN-siRNA1 and 2) or control scrambled siRNA (scr-siRNA) using Hyperfect (Quiagen, Hilden, Germany). Total RNA was isolated 48 h after transfection and reverse transcribed into cDNA using Superscript IIITM First-Strand Synthesis Supermix for qRT-PCR (Invitrogen, Karlsruhe, Germany). A 2 l (10%) volume of the appropriate cDNA samples was subjected to the Light Cycler real-time PCR using the LC FastStart DNA MasterPLUS SYBR Green 1 Kit (Roche) and sequence-specific oligonucleotide for FAN. For relative quantification, the FAN cDNA levels were determined relative to a calibrator cDNA and normalized for hypoxanthine-phosphoribosyl-transferase (HPRT) or for hydroxymethylbilane synthase (HMBS) gene expression (reference genes) employing the LightCycler Relative Quantification Software (Roche Diagnostics, Mannheim, Germany). Expression levels determined in untreated cells were set to 100%.
Electrophoretic mobility shift assay (NF-B activity)
Electrophoretic mobility shift assays (EMSAs) were performed as described previously (Kashkar et al, 2007) using the NF- B-specific oligonucleotides (Applied Biosystems, Darmstadt, Germany) end labeled with -32P-ATP (Amersham Corp., Freiburg, Germany).
Cell polarity determination
Cell polarity was determined by analyzing reorientation of the Golgi apparatus in a wound-scratch test, essentially as described (Kupfer et al, 1982; Nobes, 2000). Briefly, after wounding, monolayers of MEFs were immediately incubated with TNF (100 ng/ml) and fixed at the indicated times. The Golgi apparatus was stained using anti-Rab6 antibody, and nuclei were counterstained using Hoechst 33258. The percentage of cells with their Golgi orientated toward the wound was evaluated under the microscope.
Supplementary data
Supplementary data are available at The EMBO Journal Online (http://www.embojournal.org).
References
Abramoff M, Magelhaes P, Ram S (2004) Image processing with ImageJ. Biophotonics International 11: 36–42 Adam D, Wiegmann K, Adam-Klages S, Ruff A, Krönke M (1996) A novel cytoplasmic domain of the p55 tumor necrosis factor receptor initiates the neutral sphingomyelinase pathway. J Biol Chem 271: 14617–14622 | Article | PubMed | ISI | ChemPort | Adam-Klages S, Adam D, Wiegmann K, Struve S, Kolanus W, Schneider-Mergener J, Krönke M (1996) FAN, a novel WD-repeat protein, couples the p55 TNF-receptor to neutral sphingomyelinase. Cell 86: 937–947 | PubMed | ChemPort | Adam-Klages S, Schwandner R, Adam D, Kreder D, Bernardo K, Krönke M (1998) Distinct adapter proteins mediate acid versus neutral sphingomyelinase activation through the p55 receptor for tumor necrosis factor. J Leukoc Biol 63: 678–682 | PubMed | ISI | ChemPort | Banno T, Gazel A, Blumenberg M (2004) Effects of tumor necrosis factor-alpha (TNF alpha) in epidermal keratinocytes revealed using global transcriptional profiling. J Biol Chem 279: 32633–32642 | Article | PubMed | ISI | ChemPort | Barenholz Y (2004) Sphingomyelin and cholesterol: from membrane biophysics and rafts to potential medical applications. Subcell Biochem 37: 167–215 | PubMed | ChemPort | Bellanger JM, Astier C, Sardet C, Ohta Y, Stossel TP, Debant A (2000) The Rac1- and RhoG-specific GEF domain of Trio targets filamin to remodel cytoskeletal actin. Nat Cell Biol 2: 888–892 | Article | PubMed | ISI | ChemPort | Bishop AL, Hall A (2000) Rho GTPases and their effector proteins. Biochem J 348 (Pt 2): 241–255 | Article | Boldin MP, Mett IL, Wallach D (1995) A protein related to a proteasomal subunit binds to the intracellular domain of the p55 TNF receptor upstream to its 'death domain'. FEBS Lett 367: 39–44 | Article | PubMed | ISI | ChemPort | Bretscher A, Edwards K, Fehon RG (2002) ERM proteins and merlin: integrators at the cell cortex. Nat Rev Mol Cell Biol 3: 586–599 | Article | PubMed | ISI | ChemPort | Canton DA, Olsten ME, Kim K, Doherty-Kirby A, Lajoie G, Cooper JA, Litchfield DW (2005) The pleckstrin homology domain-containing protein CKIP-1 is involved in regulation of cell morphology and the actin cytoskeleton and interaction with actin capping protein. Mol Cell Biol 25: 3519–3534 | Article | PubMed | ISI | ChemPort | Chen G, Goeddel DV (2002) TNF-R1 signaling: a beautiful pathway. Science 296: 1634–1635 | Article | PubMed | ISI | ChemPort | Chong LD, Traynor-Kaplan A, Bokoch GM, Schwartz MA (1994) The small GTP-binding protein Rho regulates a phosphatidylinositol 4-phosphate 5-kinase in mammalian cells. Cell 79: 507–513 | Article | PubMed | ISI | ChemPort | Cozier GE, Bouyoucef D, Cullen PJ (2003) Engineering the phosphoinositide-binding profile of a class I pleckstrin homology domain. J Biol Chem 278: 39489–39496 | Article | PubMed | ISI | ChemPort | Cozier GE, Carlton J, Bouyoucef D, Cullen PJ (2004) Membrane targeting by pleckstrin homology domains. Curr Top Microbiol Immunol 282: 49–88 | PubMed | ISI | ChemPort | Cremesti AE, Goni FM, Kolesnick R (2002) Role of sphingomyelinase and ceramide in modulating rafts: do biophysical properties determine biologic outcome? FEBS Lett 531: 47–53 | Article | PubMed | ISI | ChemPort | Cumberbatch M, Dearman RJ, Kimber I (1997) Langerhans cells require signals from both tumour necrosis factor-alpha and interleukin-1 beta for migration. Immunology 92: 388–395 | Article | PubMed | ISI | ChemPort | Dowler S, Currie RA, Campbell DG, Deak M, Kular G, Downes CP, Alessi DR (2000) Identification of pleckstrin-homology-domain-containing proteins with novel phosphoinositide-binding specificities. Biochem J 351: 19–31 | Article | PubMed | ISI | ChemPort | Edlich C, Stier G, Simon B, Sattler M, Muhle-Goll C (2005) Structure and phosphatidylinositol-(3,4)-bisphosphate binding of the C-terminal PH domain of human pleckstrin. Structure 13: 277–286 | Article | PubMed | ISI | ChemPort | Etienne-Manneville S, Hall A (2001) Integrin-mediated activation of Cdc42 controls cell polarity in migrating astrocytes through PKCzeta. Cell 106: 489–498 | Article | PubMed | ISI | ChemPort | Gadea G, Roger L, Anguille C, de Toledo M, Gire V, Roux P (2004) TNFalpha induces sequential activation of Cdc42- and p38/p53-dependent pathways that antagonistically regulate filopodia formation. J Cell Sci 117: 6355–6364 | Article | PubMed | ISI | ChemPort | Hall A (1998) Rho GTPases and the actin cytoskeleton. Science 279: 509–514 | Article | PubMed | ISI | ChemPort | Hanna AN, Berthiaume LG, Kikuchi Y, Begg D, Bourgoin S, Brindley DN (2001) Tumor necrosis factor-alpha induces stress fiber formation through ceramide production: role of sphingosine kinase. Mol Biol Cell 12: 3618–3630 | PubMed | ISI | ChemPort | Hilpela P, Vartiainen MK, Lappalainen P (2004) Regulation of the actin cytoskeleton by PI(4, 5)P2 and PI(3, 4, 5)P3. Curr Top Microbiol Immunol 282: 117–163 | PubMed | ISI | ChemPort | Hogan A, Yakubchyk Y, Chabot J, Obagi C, Daher E, Maekawa K, Gee SH (2004) The phosphoinositol 3, 4-bisphosphate-binding protein TAPP1 interacts with syntrophins and regulates actin cytoskeletal organization. J Biol Chem 279: 53717–53724 | Article | PubMed | ISI | ChemPort | Honda M, Takiguchi K, Ishikawa S, Hotani H (1999) Morphogenesis of liposomes encapsulating actin depends on the type of actin-crosslinking. J Mol Biol 287: 293–300 | Article | PubMed | ISI | ChemPort | Insall RH, Weiner OD (2001) PIP3, PIP2, and cell movement—similar messages, different meanings? Dev Cell 1: 743–747 | Article | PubMed | ISI | ChemPort | Jogl G, Shen Y, Gebauer D, Li J, Wiegmann K, Kashkar H, Krönke M, Tong L (2002) Crystal structure of the BEACH domain reveals an unusual fold and extensive association with a novel PH domain. EMBO J 21: 4785–4795 | Article | PubMed | ISI | ChemPort | Kagan JC, Medzhitov R (2006) Phosphoinositide-mediated adaptor recruitment controls Toll-like receptor signaling. Cell 125: 943–955 | Article | PubMed | ISI | ChemPort | Kashkar H, Deggerich A, Seeger JM, Yazdanpanah B, Wiegmann K, Haubert D, Pongratz C, Kronke M (2007) NF-kB independent down-regulation of XIAP by bortezomib sensitizes HL B-cells against cytotoxic drugs. Blood 109: 3982–3988 | Article | PubMed | ISI | ChemPort | Kaverina I, Krylyshkina O, Small JV (2002) Regulation of substrate adhesion dynamics during cell motility. Int J Biochem Cell Biol 34: 746–761 | Article | PubMed | ISI | ChemPort | Kozma R, Ahmed S, Best A, Lim L (1995) The Ras-related protein Cdc42Hs and bradykinin promote formation of peripheral actin microspikes and filopodia in Swiss 3T3 fibroblasts. Mol Cell Biol 15: 1942–1952 | PubMed | ISI | ChemPort | Kreder D, Krut O, Adam-Klages S, Wiegmann K, Scherer G, Plitz T, Jensen JM, Proksch E, Steinmann J, Pfeffer K, Krönke M (1999) Impaired neutral sphingomyelinase activation and cutaneous barrier repair in FAN-deficient mice. EMBO J 18: 2472–2479 | Article | PubMed | ISI | ChemPort | Krut O, Wiegmann K, Kashkar H, Yazdanpanah B, Kronke M (2006) Novel tumor necrosis factor-responsive mammalian neutral sphingomyelinase-3 is a C-tail-anchored protein. J Biol Chem 281: 13784–13793 | Article | PubMed | ISI | ChemPort | Kupfer A, Louvard D, Singer SJ (1982) Polarization of the Golgi apparatus and the microtubule-organizing center in cultured fibroblasts at the edge of an experimental wound. Proc Natl Acad Sci USA 79: 2603–2607 | Article | PubMed | ChemPort | Kutsuna H, Suzuki K, Kamata N, Kato T, Hato F, Mizuno K, Kobayashi H, Ishii M, Kitagawa S (2004) Actin reorganization and morphological changes in human neutrophils stimulated by TNF, GM-CSF, and G-CSF: the role of MAP kinases. Am J Physiol Cell Physiol 286: C55–C64 | PubMed | |