The activity of the enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), which converts inactive cortisone (11-dehydrocorticosterone (11-DHC)) (in mice) into the active glucocorticoid (GC) cortisol (corticosterone in mice), can amplify tissue GC exposure. Elevated TNFα is a common feature in a range of inflammatory disorders and is detrimental to muscle function in diseases such as rheumatoid arthritis and chronic obstructive pulmonary disease. We have previously demonstrated that 11β-HSD1 activity is increased in the mesenchymal stromal cells (MSCs) by TNFα treatment and suggested that this is an autoregulatory anti-inflammatory mechanism. This upregulation was mediated by the P2 promoter of the Hsd11b1 gene and was dependent on the NF-κB signalling pathway. In this study, we show that in contrast to MSCs, in differentiated C2C12 and primary murine myotubes, TNFα suppresses Hsd11b1 mRNA expression and activity through the utilization of the alternative P1 promoter. As with MSCs, in response to TNFα treatment, NF-κB p65 was translocated to the nucleus. However, ChIP analysis demonstrated that the direct binding was seen at position -218 to -245 bp of the Hsd11b1 gene's P1 promoter but not at the P2 promoter. These studies demonstrate the existence of differential regulation of 11β-HSD1 expression in muscle cells through TNFα/p65 signalling and the P1 promoter, further enhancing our understanding of the role of 11β-HSD1 in the context of inflammatory disease.
The activity of the enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), which converts inactive cortisone (11-dehydrocorticosterone (11-DHC)) (in mice) into the active glucocorticoid (GC) cortisol (corticosterone in mice), can amplify tissue GC exposure. Elevated TNFα is a common feature in a range of inflammatory disorders and is detrimental to muscle function in diseases such as rheumatoid arthritis and chronic obstructive pulmonary disease. We have previously demonstrated that 11β-HSD1 activity is increased in the mesenchymal stromal cells (MSCs) by TNFα treatment and suggested that this is an autoregulatory anti-inflammatory mechanism. This upregulation was mediated by the P2 promoter of the Hsd11b1 gene and was dependent on the NF-κB signalling pathway. In this study, we show that in contrast to MSCs, in differentiated C2C12 and primary murine myotubes, TNFα suppresses Hsd11b1 mRNA expression and activity through the utilization of the alternative P1 promoter. As with MSCs, in response to TNFα treatment, NF-κB p65 was translocated to the nucleus. However, ChIP analysis demonstrated that the direct binding was seen at position -218 to -245 bp of the Hsd11b1 gene's P1 promoter but not at the P2 promoter. These studies demonstrate the existence of differential regulation of 11β-HSD1 expression in muscle cells through TNFα/p65 signalling and the P1 promoter, further enhancing our understanding of the role of 11β-HSD1 in the context of inflammatory disease.
The endogenous glucocorticoid (GC) concentrations are determined by the activity of
the hypothalamic–pituitary–adrenal axis, with tissue and intracellular
exposure further augmented through the activity of the enzyme
11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), which converts
inactive cortisone (11-dehydrocorticosterone (11-DHC) in mice) to the active GC
cortisol (corticosterone in mice) (Stewart
2003, 2005, Zhang ). The
ability of 11β-HSD1 to elevate cellular GC levels has led it to be implicated
in the modulation of a number of metabolic and inflammatory disease processes (Hardy , Morgan , Kaur ).
Therefore, the identification of factors and mechanisms regulating 11β-HSD1
expression and activity could further highlight its physiological and
pathophysiological roles.Elevation of the pro-inflammatory cytokine TNFα is a cardinal feature of a
range of inflammatory disorders (Bamias , Golikova
, Khosravi , Moelants ). We have previously reported that
TNFα increases 11β-HSD1 expression and activity in the cells of the
mesenchymal lineage, including osteoblasts and fibroblasts. In these cells, it was
demonstrated that this was mediated through the classical Hsd11b1
P2 promoter and that the induction of 11β-HSD1 activity by TNFα was
dependent upon NF-κB signalling. However, no direct binding site of the
NF-κB p65 subunit to the P2 promoter could be identified. Basal NF-κB
signalling plays a fundamental role in skeletal muscle myogenesis; however, during
prolonged inflammatory stress, TNFα-mediated NF-κB activity can abrogate
myogenesis, inhibiting differentiation and increasing catabolic processes
contributing to muscle wasting (Yamaki ). Previous research has demonstrated
down-regulation of 11β-HSD1 activity when mature C2C12 muscle cell myotubes are
stimulated with TNFα and it was proposed that NF-κB binding to sites in
the Hsd11b1 promoter may be directly responsible for this
regulation (Aubry & Odermatt 2009).In this study, we demonstrate that in contrast to TNFα upregulation of
11β-HSD1 in mesenchymal stromal cells (MSCs) acting through indirect
NF-κB regulation at the P2 promoter, in C2C12 and primary murine myotubes
TNFα stimulates the NF-κB p65 subunit to bind the alternate
Hsd11b1 P1 promoter and mediate inhibition of 11β-HSD1
activity.
Materials and methods
C2C12 cell culture
Mouse skeletal muscle cell line C2C12 (European Collection of Cell Cultures
(ECACC), Salisbury, Wiltshire, UK ) myoblasts were maintained in DMEM (PAA
Laboratories, Yeovil, Somerset, UK), high-glucose, supplemented with FBS (10%)
penicillin/streptomycin (ten units) and incubated at 37 °C in the
presence of 5% CO2. The media were replaced for every 48 h and
the cells were split three times weekly. To differentiate myoblasts into
myotubes, they were cultivated to 70% confluence before addition of DMEM,
high-glucose, supplemented with 5% horse serum and penicillin/streptomycin (ten
units), and the media were replaced every 48 h.
Primary mouse muscle cell culture
Primary muscle dissection and culture of myotubes derived from muscle satellite
cells were conducted as reported by Rosenblatt
. Briefly, extensor digitorum
longus (EDL) was dissected from mice at 5 weeks of age. These were digested in
type 1 collagenase for 2 h. Individual fibres of the muscle were then
disrupted gently using a glass pipette. Individual muscle fibre was then placed
into 24-well plates coated with Matrigel and left for 72 h. After
72 h the satellite cells had migrated from the fibre and the fibres were
removed from the plate, satellite cell proliferation media were added. Satellite
cells-derived myoblasts were then cultured to confluence and differentiated to
myotubes stable in culture for ∼14 days. Treatments were for 24 h
unless otherwise indicated and occurred in serum-free media using murine
TNFα (10 ng/ml); the vehicle control used was 0.1% BSA and
dexamethasone (1 μM).
RNA extraction, RT-PCR and quantitative real-time PCR
Total RNA was isolated and extracted from cell lysates using TRI-Reagent
(Sigma–Aldrich). The quality and quantity of RNA recovered were assessed
by running on 1.5% agarose gel and Nanodrop spectrophotometer. RT-PCR used
1 μg RNA per sample and was carried out using the reverse
transcription kit (CODE) Applied Biosciences (kit code is 4368814). Specific
mRNA levels were determined using an ABI 7900 sequence detection system (Applied
Biosystems). Reactions were carried out in 12.5 μl volumes on 384 well
plates (Applied Biosystems) in a reaction buffer containing 2× Taqman
Universal PCR Master Mix (Applied Biosystems). Primers and probes for specific
genes were purchased in ‘Assay on Demand’ format from Applied
Biosystems (IGF1:Mm00439560_m1, MYOD:Mm00521984_m1,TP53:Mm00480750_m1,
H6PD:Mm00557617). These were normalised against 18S rRNA (Applied Biosystems) as
an internal control. Raw data were recovered as CT values and
analysed as per the 2−ΔΔ
method.RT-PCR of alternative transcripts from the Hsd11b1 gene was
carried out as described in Staab .
Western immunoblotting
Protein lysates were collected in RIPA buffer (50 mmol/l Tris pH 7.4, 1%
NP-40, 0.25% sodium deoxycholate, 150 mmol/l NaCl, 1 mmol/l EDTA),
1 mmol/l phenylmethylsulfonyl fluoride and protease inhibitor cocktail
(Roche), stored at −80 °C (30 min), defrosted on ice and
centrifuged at 4 °C (10 min,
11 269 ). The supernatant
was recovered and total protein concentration was assessed by Bio-Rad assay.
Total proteins (25 μg) were resolved on a 12% SDS–PAGE gel and
transferred onto a nitrocellulose membrane. Primary antibodies used were mouse
anti-p65 (Santa Cruz Sc-8008), mouse anti-β-actin (Sigma–Aldrich
A-5441), mouse anti-α-tubulin (Santa Cruz Sc-5286) and rabbit
anti-11β-HSD1 (Ricketts ).Secondary antibodies (Dako, Ely, Cambridgeshire, UK) anti-mouse and anti-rabbit
conjugated with HRP were added at a dilution of 1/5000. Equal loading of protein
content was verified using β-actin and the bands were visualised using ECL
detection system (GE Healthcare, Little Chalfont, Buckinghamshire, UK).
Chromatin immunoprecipitation
Chromatin immunoprecipitation was conducted using the EZ-ChIP kit from Millipore
(Watford, Hertfordshire, UK). The C2C12 myotubes were differentiated in T175
volumes flasks. The cells were cross-linked with formaldehyde (1%) for
10 min at room temperature. Glycine at a final concentration of
125 mM was added to quench and left at room temperature for 5 min.
The flasks were washed twice in ice-cold PBS and sonicated using a Bioruptor
(Diagenode, Seraing, Belgium) to produce chromatin smears with an average size
of 500–1000 bp. Chromatin immunoprecipitations were carried out
using the anti-p65 (Santa Cruz Sc-8008) alongside IgG control. DNA recovery was
conducted and SYBR green PCR was carried out using the primer sequences
described in Table 1.
Table 1
Primers used for ChIP detection of p65 binding
Putative response element 1 LEFT
ACCTGGGATGAACTGGATTG
Putative response element 1 RIGHT
ACTTTCTGTAGGCCTGTGTGC
Putative response element 2 LEFT
TCTGAGGCAAAGCCAAGACT
Putative response element 2 RIGHT
TAGCCAATCCAGCCATAACC
Putative response element 3 LEFT
GGTGAGCTCCCTTGCACTT
Putative response element 3 RIGHT
AGTTGCAACCCAGCCAGAC
NF-κB IκBα promoter LEFT
TAGCCAGCGTTTCCACTCTT
NF-κB IκBα promoter RIGHT
GGTCATGCACAGGGAACTTT
−10 kb 11β-HSD flanking LEFT
ACTAGCAATGTTCCCGCTGT
−10 kb 11β-HSD flanking RIGHT
AATGAGGGAATCTGGGGTTC
11β-HSD1 activity assay
Briefly, the cells were incubated with 100 nmol/l 11-DHC and tritiated
tracer (3HA) made in-house was added to each well at
0.22 μCi/reaction. Steroids were then extracted using dichloromethane,
separated using a mobile phase consisting of ethanol and chloroform (8:92) by
thin layer chromatography and scanned using a Bioscan 3000 image analyser
(Lablogic, Sheffield, South Yorkshire, UK). The calculations of 11-DHC (A) to
corticosterone (B) were conducted as follows B/(A+B)×100=%
Conversion.
Statistical analysis
Data shown are mean±s.e.m. of at least three independent
experiments with statistical significance defined as P<0.05
(*P<0.05; **P<0.01;
***P<0.001) using unpaired Student's
t-test and were conducted with Prism (GraphPad, La Jolla, CA,
USA). Statistical analysis on real-time PCR data was carried out on mean
ΔCt values.
Results
TNFα induces p65 nuclear translocation in C2C12 cells
Treatment of cells with TNFα (10 ng/ml) for 1 or 2 h produced
no overall change in p65 cell content. However, isolation of the nuclear
fraction showed enrichment of p65 in the nucleus upon TNFα stimulation,
validating a functional NF-κB signalling pathway in 5-day-differentiated
C2C12 myotubes (Fig. 1A). To assess
archetypal responses to TNFα, mRNA levels were examined for the cell-cycle
arrest gene Tp53 (Trp53) and pro-growth
pro-differentiation genes Igf1 and Myod1
(Fig. 1B). TNFα treatment
induced a significant increase in TP53 and significant decrease in
Igf1 and Myod1 levels, validating the
functionality of the model as has been described previously (Frost , Langen ,
Schwarzkopf ).
Figure 1
Archetypal response of C2C12 myotubes to TNFα. (A) Western blot
analysis of p65 expression in C2C12 myotubes for 1, 2 and 24 h post
treatment with either 0.1% BSA as control or TNFα (10 ng/ml).
(B) Real-time PCR analysis of C2C12 myotube response to TNFα treatment
(*P<0.05, **P<0.01).
TNFα suppresses 11β-HSD1 mRNA and protein expression
TNFα treatment of C2C12 myotubes decreases 11β-HSD1 mRNA in comparison
with controls. Furthermore, analysis of H6pdh
(H6pd) mRNA which is the enzyme that provides NADPH to
support 11β-HSD1 activity showed no change (Fig. 2A; Lavery ). To establish if this response was detectable
at a protein level, myotubes were challenged with TNFα for 24 h and
were examined for levels of 11β-HSD1 protein. TNFα treatment produced
a significant decrease in the expression of 11β-HSD1 protein within
myotubes, compared with vehicle control (Fig.
2B).
Figure 2
TNFα suppresses 11β-HSD1 mRNA and protein expression. (A)
Real-time PCR analysis of 11β-HSD1 and H6PDH mRNA in C2C12 myotubes
treated for 24 h with TNFα. (B) Western immunoblot analysis of
p65 and β-actin from C2C12 myotubes treated for 24 h with
TNFα compared to control. Densitometry of the western immunoblots were
carried out using ImageJ (*P<0.05).
TNFα suppresses 11β-HSD1 enzyme activity
It is well established that 11β-HSD1 activity increases during the process
of C2C12 differentiation into myotubes (Aubry
& Odermatt 2009). In order to establish the relative functional
impact of TNFα on 11β-HSD1 enzyme activity, C2C12 cells were
differentiated for 4 days and activity assessed or vehicle/TNFα-treated
for a further day (5 day total). The conversion of 11-DHC to corticosterone by
11β-HSD1 increased from day 4 to day 5 (Fig. 3A). However, TNFα treatment at day 4 of differentiation
for an additional day significantly reduced 11β-HSD1 activity, suppressing
it to the level of 4-day differentiated cells (Fig. 3A). We also tested cells with a greater degree of
differentiation, examining C2C12 cells at day 11 and day 12 (Fig. 3B). The conversion rate increased
significantly from day 11 to day 12 and TNFα treatment on day 12
suppressed 11β-HSD1 activity back towards that of day 11, confirming a
robust effect equivalent to the effect seen at the earlier day 4 and 5 time
points. To endorse these findings, we prepared 7-day differentiated myotubes
from primary EDL muscle. Again, we saw a significant suppression of
11β-HSD1 activity following 1-day treatment with TNFα, consistent
with the data from the fully differentiated C2C12 cells (Fig. 3C).
Figure 3
TNFα suppresses 11β-HSD1 activity in C2C12 and primary mouse
myotubes. (A) C2C12 control cells were differentiated for 5 days, TNFα
treatments were added 24 h before being assayed for 11β-HSD1
activity. (B) C2C12 control cells were differentiated for 12 days,
TNFα treatments were added 24 h before being assayed for
11β-HSD1 activity. Protein lysates from C2C12 cells differentiated for
5 and 12 days (+/− TNFα for 24 h) were subject to
western immunoblots demonstrating p65 expression levels. (C) Primary
myotubes differentiated from mouse EDL muscle satellite cells were treated
with TNFα or control for 24 h before conducting being assayed
for 11β-HSD1 activity (*P<0.05,
**P<0.01, ***P<0.001).
These data suggest that the suppression of 11β-HSD1 activity in response to
TNFα is unlikely to be due solely to delays in differentiation, as C2C12
and primary muscle cells were fully differentiated and may indicate a direct
effect of a TNFα-dependent factor acting at the Hsd11b1
gene promoter to regulate the suppression of 11β-HSD1 expression.
TNFα suppresses 11β-HSD1 at the level of transcription
To establish if the downregulation of 11β-HSD1 occurred through a
transcriptional mechanism, C2C12 myotubes were treated with TNFα in the
presence and absence of anisomycin to inhibit protein synthesis. Accordingly,
the suppression of 11β-HSD1 mRNA transcription in response to TNFα is
unchanged in the presence of anisomycin, suggesting that the effect is primarily
at the level of transcription and not the consequence of secondary protein
synthesis (Fig. 4). We used dexamethasone
as a control, as it is well known to induce 11β-HSD1 mRNA (Fig. 4). However, in the presence of
anisomycin, the Dex-induced 11β-HSD1 increase is attenuated, indicating a
requirement of secondary protein synthesis to elicit the response.
Figure 4
TNFα reduces 11β-HSD1 mRNA independent of the presence of
anisomycin. Myotubes were treated with TNFα or dexamethasone in the
presence and absence of the protein synthesis inhibitor anisomycin.
11β-HSD1 mRNA was measured by RT-PCR using ribosomal 18S as a standard
(*P<0.05).
These data demonstrate that TNFα initiates activation of a factor not
requiring protein synthesis that can act directly at the 11β-HSD1 promoter,
and we hypothesised that this would most likely be the TNFα target
NF-κB.
The Hsd11b1 P1 promoter contains a P65-binding site
Transcription of the Hsd11b1 gene is regulated by two promoter
regions: P1 and P2 (Bruley ), and we confirmed that both promoters were
active in our differentiated C2C12 cells, with promoter P2 usage preferential to
promoter P1 (Fig. 5A). As we hypothesised
that NF-κB binding may be associated with 11β-HSD1 suppression, we
conducted ChIP analysis on C2C12 cells treated with TNFα, assessing p65
binding at putative response elements in the Hsd11b1 P1 and P2
promoters. In silico analysis revealed three candidate
sequences with resemblance to a consensus NF-κB-binding site (GGGACTTTCC),
two of which occur within close proximity to each other and are located in the
P1 promoter, upstream of exon 1a transcription start site, with all three
depicted in Fig. 5B. ChIP analysis of
samples amplified with primers for the putative p65-binding regions following
p65 pull down indicated no enrichment of p65 binding in putative regions 1 and 3
in comparison with control IgG. However, putative region 2 demonstrates that
TNFα induces an increase in the p65-binding levels in comparison with
control and suggests active recruitment of the p65 protein to the
Hsd11b1 P1 promoter. As a positive control,
TNFα-treated C2C12 cells were analysed by ChIP for enrichment of p65 to a
well-validated IkBα-binding site, and confirmatory of NF-κB
activation, further endorsing the finding of TNFα-mediated
NF-κB-binding associated with suppression of 11β-HSD1 expression and
activity (Fig. 5B). Additionally, a
10 kb upstream sequence of Hsd11b1 was used to validate
the absence of p65 as a negative control region and no TNFα enrichment was
observed for this sequence (Fig. 5B).
Figure 5
The NF-κB transcription factor p65 is recruited to the
Hsd11b1 P1 promoter upon stimulation by TNFα. (A)
RNA isolated from C2C12 myotubes was assessed for the expression of
Hsd11b1 promoter 1 (P1), promoter 2 (P2), total and
GAPDH transcripts by semi-quantitative RT-PCR. (B) Putative binding of p65
was measured using ChIP assays carried out on C2C12 myotubes. Fixed
chromatin lysates were immuno-precipitated with p65 antibody and recovered
DNA subject to PCR with primers containing putative p65-binding sites. Total
chromatin served as input and IgG was used as a negative control, images are
representative of biological triplicate experiments. (C) As a positive
control a region for binding of p65 was assessed using an established
NF-κB-binding site for IκBα. As an additional
negative-control site a region 10 kb upstream was chosen to confirm
the absence of specific binding.
Discussion
Stimulation of 11β-HSD1 activity following TNFα exposure has been
described for early progenitor cells of the mesenchymal lineage, particularly in
cells of human origin (Zhang ). Similarly, in differentiated cells such as
osteoblasts and adipocytes, TNFα increases 11β-HSD1 activity to enhance
local GC generation (Cooper , Tomlinson ). Indeed, a range of cytokines and molecules, including IL1β
and lipopolysaccharide (LPS), can stimulate 11β-HSD1 (Ishii-Yonemoto ), suggesting that
increasing 11β-HSD1 is a mechanism to initiate the process of inflammatory
resolution through increased local GC generation. GCs are well documented to
stimulate 11β-HSD1 expression and activity in most cell types including
myocytes (Morgan ). However, following muscle cell TNFα exposure, 11β-HSD1
activity is suppressed, with the effect mediated through p65 signalling and
independent of secondary protein synthesis.The best-established transcriptional regulators of Hsd11b1 gene
expression for a range of human and murine cell types are the members of
CCAATT/enhancer-binding protein (C/EBP) family. Hsd11b1 P1 promoter
regulation of C/EBPα and C/EBPβ has been described previously (Balazs ) and
C/EBPα is regarded as a positive regulator of 11β-HSD1 transcription in
hepatocytes with C/EBPβ acting as a repressor (Ignatova ). However, in adipocyte
and adipose tissue, C/EBPβ is an activator required to mediate the GC induction
and cytokine regulation of 11β-HSD1 (Sai
). More recently it has been established
that an elevated ratio of C/EBPβ-liver enriched inhibitor protein and
liver-enriched activator protein isoforms can downregulate 11β-HSD1 expression
(Esteves ).
These data collectively represent an evidence for both the positive and negative
regulation of 11β-HSD1 through transcriptional mechanisms in mature cells.Here, we demonstrate that in both a murine skeletal muscle cell line and primary
cultured myotubes 11β-HSD1 expression and activity are suppressed following
TNFα exposure, with anisomycin experiments attributing this effect at the
level of transcriptional regulation. This led us to search for potential
TNFα-stimulated-NF-κB-binding motifs in the Hsd11b1 P1
and P2 promoters, using the cis-regulatory element database (Robertson ).
Taking the three strongest targets from the in silico analysis, we
used ChIP to identify a p65-binding sequence in the sequence motif located in the P2
promoter region (Fig. 5B) and associated this
with the down-regulation of 11β-HSD1.In contrast to our findings in muscle, adipocytes from p65 overexpression transgenic
mice had elevated 11β-HSD1 at the mRNA and protein level, but show no evidence
for direct gene regulation (Lee ). In this context, NF-κB was acting as a
positive regulator in a model of chronic systemwide p65 activation, indicating that
11β-HSD1 regulation is complex, with a number of tissue- and context-specific
factors requiring consideration.With this in mind, these data presented here represent the effects mediated following
a single acute dose of TNFα, so biological interpretation in the context of
that seen in another tissue type subjected to chronic TNFα stimulation should
be cautious. TNFα-mediated regulation of 11β-HSD1 is part of a cellular
response within muscle that targets a diverse set of transcriptionally regulated
genes (Li ). It
may be that the suppressive effect observed is coordinated with the general
suppression of myogenic differentiation, and dependent on interacting transcription
factor and co-regulator availability. We have previously shown that in myoblasts
response to TNFα by 11β-HSD1 is positively regulated, but in mature
myotubes 11β-HSD1 is negatively regulated. This shift in regulation could in
part be controlled at the level of Hsd11b1 P1 and P2 promoters
utilisation during commitment and progression through myogenic differentiation that
ultimately determines overall 11β-HSD1 expression and activity.We demonstrate that 11β-HSD1 suppression is observed in differentiated C2C12 and
primary myotubes and emphasise the important role of coordinated
Hsd11b1 P1 and P2 promoters usage to control
TNFα-regulated 11β-HSD1 activity. Further experiments are now required to
expand this novel TNFα/NF-κB-mediated transcriptional suppression of
11β-HSD1 activity in the context of inflammatory disorders that can severely
impact upon muscle structure and function.
Author contribution statement
C L D, J B and A E Z conducted the work. P M S and G G L conceived and designed the
research. C L D, M S C, P M S and G G L wrote the manuscript.
Authors: Irena D Ignatova; Radina M Kostadinova; Christopher E Goldring; Andrea R Nawrocki; Felix J Frey; Brigitte M Frey Journal: Am J Physiol Endocrinol Metab Date: 2008-12-16 Impact factor: 4.310
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Authors: R Hardy; E H Rabbitt; A Filer; P Emery; M Hewison; P M Stewart; N J Gittoes; C D Buckley; K Raza; M S Cooper Journal: Ann Rheum Dis Date: 2008-04-17 Impact factor: 19.103
Authors: Stuart A Morgan; Mark Sherlock; Laura L Gathercole; Gareth G Lavery; Carol Lenaghan; Iwona J Bujalska; David Laber; Alice Yu; Gemma Convey; Rachel Mayers; Krisztina Hegyi; Jaswinder K Sethi; Paul M Stewart; David M Smith; Jeremy W Tomlinson Journal: Diabetes Date: 2009-08-12 Impact factor: 9.461