1
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Bettini M, Scavuzzo MA, Liu B, Kolawole E, Guo L, Evavold BD, Borowiak M, Bettini ML. A Critical Insulin TCR Contact Residue Selects High-Affinity and Pathogenic Insulin-Specific T Cells. Diabetes 2020; 69:392-400. [PMID: 31836691 PMCID: PMC7034183 DOI: 10.2337/db19-0821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/08/2019] [Indexed: 02/05/2023]
Abstract
Type 1 diabetes is an autoimmune-mediated disease that culminates in the targeted destruction of insulin-producing β-cells. CD4 responses in NOD mice are dominated by insulin epitope B:9-23 (InsB9-23) specificity, and mutation of the key T-cell receptor (TCR) contact residue within the epitope prevents diabetes development. However, it is not clear how insulin self-antigen controls the selection of autoimmune and regulatory T cells (Tregs). Here we demonstrate that mutation of insulin epitope results in escape of highly pathogenic T cells. We observe an increase in antigen reactivity, clonality, and pathogenicity of insulin-specific T cells that develop in the absence of cognate antigen. Using a single TCR system, we demonstrate that Treg development is greatly diminished in mice with the Y16A mutant epitope. Collectively, these results suggest that the tyrosine residue at position 16 is necessary to constrain TCR reactivity for InsB9-23 by both limiting the development of pathogenic T cells and supporting the selection of Tregs.
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MESH Headings
- Adoptive Transfer
- Animals
- Diabetes Mellitus, Experimental/genetics
- Diabetes Mellitus, Experimental/immunology
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/immunology
- Epitopes, T-Lymphocyte/genetics
- Epitopes, T-Lymphocyte/immunology
- Forkhead Transcription Factors/metabolism
- Insulin/genetics
- Insulin/immunology
- Mice
- Mice, Inbred NOD
- Mutation
- Peptide Fragments/genetics
- Peptide Fragments/immunology
- Receptors, Antigen, T-Cell/genetics
- Receptors, Antigen, T-Cell/immunology
- T-Lymphocytes/immunology
- T-Lymphocytes, Regulatory/immunology
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Affiliation(s)
- Maria Bettini
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- McNair Medical Institute, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marissa A Scavuzzo
- Program in Developmental Biology, Baylor College of Medicine, Houston, TX
| | - Baoyu Liu
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, UT
| | - Elizabeth Kolawole
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, UT
| | - Lin Guo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Brian D Evavold
- Division of Microbiology and Immunology, Department of Pathology, University of Utah, Salt Lake City, UT
| | - Malgorzata Borowiak
- McNair Medical Institute, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
- Program in Developmental Biology, Baylor College of Medicine, Houston, TX
- Department of Molecular and Cellular Biology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX
| | - Matthew L Bettini
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- McNair Medical Institute, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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2
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Gu BH, Sprouse ML, Madison MC, Hong MJ, Yuan X, Tung HY, Landers CT, Song LZ, Corry DB, Bettini M, Kheradmand F. A Novel Animal Model of Emphysema Induced by Anti-Elastin Autoimmunity. THE JOURNAL OF IMMUNOLOGY 2019; 203:349-359. [PMID: 31182478 DOI: 10.4049/jimmunol.1900113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022]
Abstract
Loss of immune tolerance to self-antigens can promote chronic inflammation and disrupt the normal function of multiple organs, including the lungs. Degradation of elastin, a highly insoluble protein and a significant component of the lung structural matrix, generates proinflammatory molecules. Elastin fragments (EFs) have been detected in the serum of smokers with emphysema, and elastin-specific T cells have also been detected in the peripheral blood of smokers with emphysema. However, an animal model that could recapitulate T cell-specific autoimmune responses by initiating and sustaining inflammation in the lungs is lacking. In this study, we report an animal model of autoimmune emphysema mediated by the loss of tolerance to elastin. Mice immunized with a combination of human EFs plus rat EFs but not mouse EFs showed increased infiltration of innate and adaptive immune cells to the lungs and developed emphysema. We cloned and expanded mouse elastin-specific CD4+ T cells from the lung and spleen of immunized mice. Finally, we identified TCR sequences from the autoreactive T cell clones, suggesting possible pathogenic TCRs that can cause loss of immune tolerance against elastin. This new autoimmune model of emphysema provides a useful tool to examine the immunological factors that promote loss of immune tolerance to self.
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Affiliation(s)
- Bon-Hee Gu
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030
| | - Maran L Sprouse
- Section of Diabetes and Endocrinology, Department of Pediatrics, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030
| | - Matthew C Madison
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030
| | - Monica J Hong
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030
| | - Xiaoyi Yuan
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030
| | - Hui-Ying Tung
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030
| | - Cameron T Landers
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030
| | - Li-Zhen Song
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030
| | - David B Corry
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030.,Center for Translational Research in Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, TX 77030.,Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030; and.,Biology of Inflammation Center, Baylor College of Medicine, Houston, TX 77030
| | - Maria Bettini
- Section of Diabetes and Endocrinology, Department of Pediatrics, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030; .,Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030; and.,Biology of Inflammation Center, Baylor College of Medicine, Houston, TX 77030
| | - Farrah Kheradmand
- Department of Medicine, Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX 77030; .,Center for Translational Research in Inflammatory Diseases, Michael E. DeBakey VA Medical Center, Houston, TX 77030.,Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030; and.,Biology of Inflammation Center, Baylor College of Medicine, Houston, TX 77030
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3
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Abstract
The ability to express and study a single T cell receptor (TCR) in vivo is an important aspect of both basic and translational immunological research. Traditionally, this was achieved by using TCR transgenic mice. In the past decade, a more efficient approach for single TCR expression was developed. This relatively rapid and accessible method utilizes retrovirus-mediated stem cell-based gene transfer and is commonly referred to as the TCR retrogenic approach. In this approach, hematopoietic bone marrow precursors are transduced with retroviral vector carrying both alpha and beta chains of a T cell receptor. After successful transduction, bone marrow is injected into recipient mice, in which T cell development is driven by expression of the vector-encoded TCR. This article details the materials and methods required to generate TCR retrogenic mice. It is divided into three sections and provides detailed methods for generation of stable retroviral producer cell lines, isolation and optimal transduction of hematopoietic bone marrow cells, and subsequent analysis of TCR retrogenic T cells. A detailed example of such analysis is provided. The current protocol is a culmination of many years of optimization and is the most efficient approach to date. Bone marrow transduction and transfer into recipient mice can now be achieved in a short period of four days. The protocol can be followed in most laboratories with standard biomedical equipment, and is supported by a troubleshooting guide that covers potential pitfalls and unexpected results. © 2019 by John Wiley & Sons, Inc.
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Affiliation(s)
- Yuelin Kong
- Department of Pediatrics, Section of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Yi Jing
- Department of Pediatrics, Section of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Maria Bettini
- Department of Pediatrics, Section of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.,McNair Medical Institute, Houston, Texas
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4
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Toribio-Fernandez R, Zorita V, Herrero-Fernandez B, Gonzalez-Granado JM. An In Vivo Mouse Model to Measure Naïve CD4 T Cell Activation, Proliferation and Th1 Differentiation Induced by Bone Marrow-derived Dendritic Cells. J Vis Exp 2018. [PMID: 30199029 DOI: 10.3791/58118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Quantification of naïve CD4 T cell activation, proliferation, and differentiation to T helper 1 (Th1) cells is a useful way to assess the role played by T cells in an immune response. This protocol describes the in vitro differentiation of bone marrow (BM) progenitors to obtain granulocyte macrophage colony-stimulating factor (GM-CSF) derived-dendritic cells (DCs). The protocol also describes the adoptive transfer of ovalbumin peptide (OVAp)-loaded GM-CSF-derived DCs and naïve CD4 T cells from OTII transgenic mice in order to analyze the in vivo activation, proliferation, and Th1 differentiation of the transferred CD4 T cells. This protocol circumvents the limitation of purely in vivo methods imposed by the inability to specifically manipulate or select the studied cell population. Moreover, this protocol allows studies in an in vivo environment, thus avoiding alterations to functional factors that may occur in vitro and including the influence of cell types and other factors only found in intact organs. The protocol is a useful tool for generating changes in DCs and T cells that modify adaptive immune responses, potentially providing important results to understand the origin or development of numerous immune associated diseases.
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Affiliation(s)
| | - Virginia Zorita
- LamImSys Lab, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC)
| | | | - Jose M Gonzalez-Granado
- LamImSys Lab, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC); LamImSys Lab, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12); CIBER de Enfermedades Cardiovasculares;
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5
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Sprouse ML, Shevchenko I, Scavuzzo MA, Joseph F, Lee T, Blum S, Borowiak M, Bettini ML, Bettini M. Cutting Edge: Low-Affinity TCRs Support Regulatory T Cell Function in Autoimmunity. THE JOURNAL OF IMMUNOLOGY 2017; 200:909-914. [PMID: 29282307 DOI: 10.4049/jimmunol.1700156] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 11/27/2017] [Indexed: 12/31/2022]
Abstract
Regulatory T cells (Tregs) use a distinct TCR repertoire and are more self-reactive compared with conventional T cells. However, the extent to which TCR affinity regulates the function of self-reactive Tregs is largely unknown. In this study, we used a two-TCR model to assess the role of TCR affinity in Treg function during autoimmunity. We observed that high- and low-affinity Tregs were recruited to the pancreas and contributed to protection from autoimmune diabetes. Interestingly, high-affinity cells preferentially upregulated the TCR-dependent Treg functional mediators IL-10, TIGIT, GITR, and CTLA4, whereas low-affinity cells displayed increased transcripts for Areg and Ebi3, suggesting distinct functional profiles. The results of this study suggest mechanistically distinct and potentially nonredundant roles for high- and low-affinity Tregs in controlling autoimmunity.
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Affiliation(s)
- Maran L Sprouse
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030
| | - Ivan Shevchenko
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030
| | - Marissa A Scavuzzo
- Program in Developmental Biology, Baylor College of Medicine, Houston, TX 77030
| | - Faith Joseph
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030
| | - Thomas Lee
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030
| | - Samuel Blum
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030
| | - Malgorzata Borowiak
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030.,Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030; and.,McNair Medical Institute, Houston, TX 77030
| | - Matthew L Bettini
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030.,McNair Medical Institute, Houston, TX 77030
| | - Maria Bettini
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030; .,McNair Medical Institute, Houston, TX 77030
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6
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Sprouse ML, Blahnik G, Lee T, Tully N, Benarjee P, James EA, Redondo MJ, Bettini ML, Bettini M. Streamlined Single Cell TCR Isolation and Generation of Retroviral Vectors for In Vitro and In Vivo Expression of Human TCRs. J Vis Exp 2017. [PMID: 28930975 DOI: 10.3791/55379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Although, several methods for sequencing of paired T cell receptor (TCR) alpha and beta chains from single T cells have been developed, none so far have been conducive to downstream in vivo functional analysis of TCR heterodimers. We have developed an improved protocol based on a two-step multiplex-nested PCR, which results in a PCR product that spans entire variable regions of a human TCR alpha and beta chains. By identifying unique restriction sites and incorporating them into the PCR primers, we have made the PCR product compatible with direct sub-cloning into the template retroviral vector. The resulting retroviral construct encodes a chimeric human/mouse TCR with a mouse intracellular domain, which is functional in mouse cells or in in vivo mouse models. Overall, the protocol described here combines human single cell paired TCR alpha and beta chain identification with streamlined generation of retroviral vectors readily adaptable for in vitro and in vivo TCR expression. The video and the accompanying material are designed to give a highly detailed description of the single cell PCR, so that the critical steps can be followed and potential pitfalls avoided. Additionally, we provide a detailed description of the cloning steps necessary to generate the expression vector. Once mastered, the whole procedure from single cell sorting to TCR expression could be performed in a short two-week period.
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Affiliation(s)
- Maran L Sprouse
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital
| | | | - Thomas Lee
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital
| | - Natalie Tully
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital
| | - Pinaki Benarjee
- Center for Human Immunobiology, Baylor College of Medicine, Texas Children's Hospital
| | | | - Maria J Redondo
- Department of Pediatrics, Section of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children's Hospital
| | - Matthew L Bettini
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital
| | - Maria Bettini
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital;
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7
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Lee T, Sprouse ML, Banerjee P, Bettini M, Bettini ML. Ectopic Expression of Self-Antigen Drives Regulatory T Cell Development and Not Deletion of Autoimmune T Cells. THE JOURNAL OF IMMUNOLOGY 2017; 199:2270-2278. [PMID: 28835461 DOI: 10.4049/jimmunol.1700207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 07/27/2017] [Indexed: 01/18/2023]
Abstract
Type 1 diabetes is a T cell-mediated autoimmune disease that is characterized by Ag-specific targeting and destruction of insulin-producing β cells. Although multiple studies have characterized the pathogenic potential of β cell-specific T cells, we have limited mechanistic insight into self-reactive autoimmune T cell development and their escape from negative selection in the thymus. In this study, we demonstrate that ectopic expression of insulin epitope B:9-23 (InsB9-23) by thymic APCs is insufficient to induce deletion of high- or low-affinity InsB9-23-reactive CD4+ T cells; however, we observe an increase in the proportion and number of thymic and peripheral Foxp3+ regulatory T cells. In contrast, the MHC stable insulin mimetope (InsB9-23 R22E) efficiently deletes insulin-specific T cells and prevents escape of high-affinity thymocytes. Collectively, these results suggest that Ag dose and peptide-MHC complex stability can lead to multiple fates of insulin-reactive CD4+ T cell development and autoimmune disease outcome.
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Affiliation(s)
- Thomas Lee
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030; and
| | - Maran L Sprouse
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030; and
| | - Pinaki Banerjee
- Center for Human Immunobiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030
| | - Maria Bettini
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030; and
| | - Matthew L Bettini
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030; and
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8
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Bettini ML, Bettini M. Understanding Autoimmune Diabetes through the Prism of the Tri-Molecular Complex. Front Endocrinol (Lausanne) 2017; 8:351. [PMID: 29312143 PMCID: PMC5735072 DOI: 10.3389/fendo.2017.00351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/30/2017] [Indexed: 12/15/2022] Open
Abstract
The strongest susceptibility allele for Type 1 Diabetes (T1D) is human leukocyte antigen (HLA), which supports a central role for T cells as the drivers of autoimmunity. However, the precise mechanisms that allow thymic escape and peripheral activation of beta cell antigen-specific T cells are still largely unknown. Studies performed with the non-obese diabetic (NOD) mouse have challenged several immunological dogmas, and have made the NOD mouse a key experimental system to study the steps of immunodysregulation that lead to autoimmune diabetes. The structural similarities between the NOD I-Ag7 and HLA-DQ8 have revealed the stability of the T cell receptor (TCR)/HLA/peptide tri-molecular complex as an important parameter in the development of autoimmune T cells, as well as afforded insights into the key antigens targeted in T1D. In this review, we will provide a summary of the current understanding with regard to autoimmune T cell development, the significance of the antigens targeted in T1D, and the relationship between TCR affinity and immune regulation.
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Affiliation(s)
- Matthew L. Bettini
- Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, McNair Medical Institute, Houston, TX, United States
- *Correspondence: Matthew L. Bettini, ; Maria Bettini,
| | - Maria Bettini
- Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, McNair Medical Institute, Houston, TX, United States
- *Correspondence: Matthew L. Bettini, ; Maria Bettini,
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9
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Sprouse ML, Blahnik G, Lee T, Tully N, Banerjee P, James EA, Redondo MJ, Bettini ML, Bettini M. Rapid identification and expression of human TCRs in retrogenic mice. J Immunol Methods 2016; 439:29-36. [PMID: 27589924 DOI: 10.1016/j.jim.2016.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 08/25/2016] [Accepted: 08/29/2016] [Indexed: 10/21/2022]
Abstract
Single-cell paired TCR identification is a powerful tool, but has been limited in its previous incompatibility with further functional analysis. The current protocol describes a method to clone and functionally evaluate in vivo TCRs derived from single antigen-responsive human T cells and monoclonal T cell lines. We have improved upon current PCR-based TCR sequencing protocols by developing primers that allow amplification of human TCRα and TCRβ variable regions, while incorporating specific restriction cut sites for direct subcloning into the template retroviral vector. This streamlined approach for generating human:mouse chimeric TCR vectors allows for rapid TCR expression in humanized-retrogenic (hu-Rg) mice through retroviral mediated stem cell gene transfer. Using widely available techniques and equipment, this method is easily adaptable by most laboratories. This is the first TCR identification protocol that is efficiently combined with subsequent in vivo TCR expression.
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Affiliation(s)
- Maran L Sprouse
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | | | - Thomas Lee
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Natalie Tully
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Pinaki Banerjee
- Center for Human Immunobiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Eddie A James
- Benaroya Research Institute at Virginia Mason, Seattle, WA, USA
| | - Maria J Redondo
- Department of Pediatrics, Section of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Matthew L Bettini
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Maria Bettini
- Department of Pediatrics, Section of Diabetes and Endocrinology, McNair Medical Institute, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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