Functional heartburn has more in common with functional dyspepsia than with non-erosive reflux disease

INTRODUCTION: Functional dyspepsia and non-erosive reflux disease (NERD) are prevalent gastrointestinal conditions with accumulating evidence regarding an overlap between the two. Still, patients with NERD represent a very heterogeneous group and limited data on dyspeptic symptoms in various subgroups of NERD are available. AIM: To evaluate the prevalence of dyspeptic symptoms in patients with NERD subclassified by using 24 h impedance-pH monitoring (MII-pH). METHODS: Patients with typical reflux symptoms and normal endoscopy underwent impedance-pH monitoring off proton pump inhibitor treatment. Oesophageal acid exposure time (AET), type of acid and non-acid reflux episodes, and symptom association probability (SAP) were calculated. A validated dyspepsia questionnaire was used to quantify dyspeptic symptoms prior to reflux monitoring. RESULTS: Of 200 patients with NERD (105 female; median age, 48 years), 81 (41%) had an abnormal oesophageal AET (NERD pH-POS), 65 (32%) had normal oesophageal AET and positive SAP for acid and/or non-acid reflux (hypersensitive oesophagus), and 54 (27%) had normal oesophageal AET and negative SAP (functional heartburn). Patients with functional heartburn had more frequent (p<0.01) postprandial fullness, bloating, early satiety and nausea compared to patients with NERD pH-POS and hypersensitive oesophagus. CONCLUSION: The increased prevalence of dyspeptic symptoms in patients with functional heartburn reinforces the concept that functional gastrointestinal disorders extend beyond the boundaries suggested by the anatomical location of symptoms. This should be regarded as a further argument to test patients with symptoms of gastro-oesophageal reflux disease in order to separate patients with functional heartburn from patients with NERD in whom symptoms are associated with gastro-oesophageal reflux.

[New insights into diagnosis and management of gestational diabetes mellitus: recommendations of the Swiss Society for Endocrinology and Diabetes]

Physiology and current knowledge about gestational diabetes which led to the adoption of new diagnostic criterias and blood glucose target levels during pregnancy by the Swiss Society for Endocrinology and Diabetes are reviewed. The 6th International Workshop Conference on Gestational Diabetes mellitus in Pasedena (2008) defined new diagnostic criteria based on the results of the HAPO-Trial. These criteria were during the ADA congress in New Orleans in 2009 presented. According to the new criteria there is no need for screening, but all pregnant women have to be tested with a 75 g oral glucose tolerance test between the 24th and 28th week of pregnancy. The new diagnostic values are very similar to the ones previously adopted by the ADA with the exception that only one out of three values has to be elevated in order to make the diagnosis of gestational diabetes. Due to this important difference it is very likely that gestational diabetes will be diagnosed more frequently in the future. The diagnostic criteria are: Fasting plasma glucose > or = 5.1 mmol/l, 1-hour value > or = 10.0 mmol/l or 2-hour value > or = 8.5 mmol/l. Based on current knowledge and randomized trials it is much more difficult to define glucose target levels during pregnancy. This difficulty has led to many different recommendations issued by diabetes societies. The Swiss Society of Endocrinology and Diabetes follows the arguments of the International Diabetes Federation (IDF) that self-blood glucose monitoring itself lacks precision and that there are very few randomized trials. Therefore, the target levels have to be easy to remember and might be slightly different in mmol/l or mg/dl. The Swiss Society for Endocrinology and Diabetes adopts the tentative target values of the IDF with fasting plasma glucose values < 5.3 mM and 1- and 2-hour postprandial (after the end of the meal) values of < 8.0 and 7.0 mmol/l, respectively. The last part of these recommendations deals with the therapeutic options during pregnancy (nutrition, physical exercise and pharmaceutical treatment). If despite lifestyle changes the target values are not met, approximately 25 % of patients have to be treated pharmaceutically. Insulin therapy is still the preferred treatment option, but metformin (and as an exception glibenclamide) can be used, if there are major hurdles for the initiation of insulin therapy.

Liraglutide once a day versus exenatide twice a day for type 2 diabetes: a 26-week randomised, parallel-group, multinational, open-label trial (LEAD-6)

BACKGROUND: Unlike most antihyperglycaemic drugs, glucagon-like peptide-1 (GLP-1) receptor agonists have a glucose-dependent action and promote weight loss. We compared the efficacy and safety of liraglutide, a human GLP-1 analogue, with exenatide, an exendin-based GLP-1 receptor agonist. METHODS: Adults with inadequately controlled type 2 diabetes on maximally tolerated doses of metformin, sulphonylurea, or both, were stratified by previous oral antidiabetic therapy and randomly assigned to receive additional liraglutide 1.8 mg once a day (n=233) or exenatide 10 microg twice a day (n=231) in a 26-week open-label, parallel-group, multinational (15 countries) study. The primary outcome was change in glycosylated haemoglobin (HbA(1c)). Efficacy analyses were by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00518882. FINDINGS: Mean baseline HbA(1c) for the study population was 8.2%. Liraglutide reduced mean HbA(1c) significantly more than did exenatide (-1.12% [SE 0.08] vs -0.79% [0.08]; estimated treatment difference -0.33; 95% CI -0.47 to -0.18; p<0.0001) and more patients achieved a HbA(1c) value of less than 7% (54%vs 43%, respectively; odds ratio 2.02; 95% CI 1.31 to 3.11; p=0.0015). Liraglutide reduced mean fasting plasma glucose more than did exenatide (-1.61 mmol/L [SE 0.20] vs -0.60 mmol/L [0.20]; estimated treatment difference -1.01 mmol/L; 95% CI -1.37 to -0.65; p<0.0001) but postprandial glucose control was less effective after breakfast and dinner. Both drugs promoted similar weight losses (liraglutide -3.24 kg vs exenatide -2.87 kg). Both drugs were well tolerated, but nausea was less persistent (estimated treatment rate ratio 0.448, p<0.0001) and minor hypoglycaemia less frequent with liraglutide than with exenatide (1.93 vs 2.60 events per patient per year; rate ratio 0.55; 95% CI 0.34 to 0.88; p=0.0131; 25.5%vs 33.6% had minor hypoglycaemia). Two patients taking both exenatide and a sulphonylurea had a major hypoglycaemic episode. INTERPRETATION: Liraglutide once a day provided significantly greater improvements in glycaemic control than did exenatide twice a day, and was generally better tolerated. The results suggest that liraglutide might be a treatment option for type 2 diabetes, especially when weight loss and risk of hypoglycaemia are major considerations.

Reduction in total plasma ghrelin levels following catecholamine depletion: relation to bulimic and depressive symptoms

There is increasing preclinical and clinical evidence of the important role played by the gastric peptide hormone ghrelin in the pathogenesis of symptoms of depression and eating disorders. To investigate the role of ghrelin and its considered counterpart, peptide tyrosine tyrosine (PYY), in the development of bulimic and depressive symptoms induced by catecholamine depletion, we administered the tyrosine hydroxylase inhibitor alpha-methyl-paratyrosine (AMPT) in a randomized, double-blind, placebo-controlled crossover, single-site experimental trial to 29 healthy controls and 20 subjects with fully recovered bulimia nervosa (rBN). We found a decrease between peprandial and postprandial plasma ghrelin levels (p < 0.0001) and a postprandial rise in plasma PYY levels (p < 0.0001) in both conditions in the entire study population. Plasma ghrelin levels decreased in the entire study population after treatment with AMPT compared to placebo (p < 0.006). AMPT-induced changes in plasma ghrelin levels were negatively correlated with AMPT-induced depressive symptoms (p < 0.004). Plasma ghrelin and plasma PYY levels were also negatively correlated (p < 0.05). We did not observe a difference in ghrelin or PYY response to catecholamine depletion between rBN subjects and healthy controls, and there was no correlation between plasma ghrelin and PYY levels and bulimic symptoms induced by catecholamine depletion. These findings suggest a relationship between catecholamines and ghrelin with depressive symptoms.

Short-term feed intake is regulated by macronutrient oxidation in lactating Holstein cows

In addition to plasma metabolites and hormones participating as humoral signals in the control of feed intake, oxidative metabolic processes in peripheral organs also generate signals to terminate feeding. Although the degree of oxidation over longer periods is relatively constant, recent work suggests that the periprandial pattern of fuel oxidation is involved in regulating feeding behavior in the bovine. However, the association between periprandial oxidative metabolism and feed intake of dairy cows has not yet been studied. Therefore, the aim of this study was to elucidate possible associations existing between single feed intake events and whole-body net fat and net carbohydrate oxidation as well as their relation to plasma metabolite concentrations. To this end, 4 late-lactating cows equipped with jugular catheters were kept in respiratory chambers with continuous and simultaneous recording of gas exchange and feed intake. Animals were fed ad libitum (AL) for 24h and then feed restricted (RE) to 50% of the previous AL intake for a further 24h. Blood samples were collected hourly to analyze β-hydroxybutyrate (BHBA), glucose, nonesterified fatty acids (NEFA), insulin, and acylated ghrelin concentrations. Cross-correlation analysis revealed an offset ranging between 30 and 42 min between the maximum of a feed intake event and the lowest level of postprandial net fat oxidation (FOX(net)) and the maximum level of postprandial net carbohydrate oxidation (COX(net)), respectively. During the AL period, FOX(net) did not increase above -0.2g/min, whereas COX(net) did not decrease below 6g/min before the start of the next feed intake event. A strong inverse cross-correlation was obtained between COX(net) and plasma glucose concentration. Direct cross-correlations were observed between COXnet and insulin, between heat production and BHBA, between insulin and glucose, and between BHBA and ghrelin. We found no cross-correlation between FOX(net) and NEFA. During RE, FOX(net) increased with an exponential slope, exceeded the threshold of -0.2g/min as indicated by increasing plasma NEFA concentrations, and approached a maximum rate of 0.1g/min, whereas COX(net) decayed in an exponential manner, approaching a minimal COX(net) rate of about 2.5 g/min in all cows. Our novel findings suggest that, in late-lactating cows, postprandial increases in metabolic oxidative processes seem to signal suppression of feed intake, whereas preprandially an accelerated FOX(net) rate and a decelerated COX(net) rate initiate feed intake.

Effect of meal ingestion on liver stiffness in patients with cirrhosis and portal hypertension.

BACKGROUND AND AIMS Liver stiffness is increasingly used in the non-invasive evaluation of chronic liver diseases. Liver stiffness correlates with hepatic venous pressure gradient (HVPG) in patients with cirrhosis and holds prognostic value in this population. Hence, accuracy in its measurement is needed. Several factors independent of fibrosis influence liver stiffness, but there is insufficient information on whether meal ingestion modifies liver stiffness in cirrhosis. We investigated the changes in liver stiffness occurring after the ingestion of a liquid standard test meal in this population. METHODS In 19 patients with cirrhosis and esophageal varices (9 alcoholic, 9 HCV-related, 1 NASH; Child score 6.9±1.8), liver stiffness (transient elastography), portal blood flow (PBF) and hepatic artery blood flow (HABF) (Doppler-Ultrasound) were measured before and 30 minutes after receiving a standard mixed liquid meal. In 10 the HVPG changes were also measured. RESULTS Post-prandial hyperemia was accompanied by a marked increase in liver stiffness (+27±33%; p<0.0001). Changes in liver stiffness did not correlate with PBF changes, but directly correlated with HABF changes (r = 0.658; p = 0.002). After the meal, those patients showing a decrease in HABF (n = 13) had a less marked increase of liver stiffness as compared to patients in whom HABF increased (n = 6; +12±21% vs. +62±29%,p<0.0001). As expected, post-prandial hyperemia was associated with an increase in HVPG (n = 10; +26±13%, p = 0.003), but changes in liver stiffness did not correlate with HVPG changes. CONCLUSIONS Liver stiffness increases markedly after a liquid test meal in patients with cirrhosis, suggesting that its measurement should be performed in standardized fasting conditions. The hepatic artery buffer response appears an important factor modulating postprandial changes of liver stiffness. The post-prandial increase in HVPG cannot be predicted by changes in liver stiffness.

A Dose-Response Strategy Reveals Differences between Normal-Weight and Obese Men in Their Metabolic and Inflammatory Responses to a High-Fat Meal.

A dose-response strategy may not only allow investigation of the impact of foods and nutrients on human health but may also reveal differences in the response of individuals to food ingestion based on their metabolic health status. In a randomized crossover study, we challenged 19 normal-weight (BMI: 20-25 kg/m(2)) and 18 obese (BMI: >30 kg/m(2)) men with 500, 1000, and 1500 kcal of a high-fat (HF) meal (60.5% energy from fat). Blood was taken at baseline and up to 6 h postprandially and analyzed for a range of metabolic, inflammatory, and hormonal variables, including plasma glucose, lipids, and C-reactive protein and serum insulin, glucagon-like peptide-1, interleukin-6 (IL-6), and endotoxin. Insulin was the only variable that could differentiate the postprandial response of normal-weight and obese participants at each of the 3 caloric doses. A significant response of the inflammatory marker IL-6 was only observed in the obese group after ingestion of the HF meal containing 1500 kcal [net incremental AUC (net iAUC) = 22.9 ± 6.8 pg/mL × 6 h, P = 0.002]. Furthermore, the net iAUC for triglycerides significantly increased from the 1000 to the 1500 kcal meal in the obese group (5.0 ± 0.5 mmol/L × 6 h vs. 6.0 ± 0.5 mmol/L × 6 h, P = 0.015) but not in the normal-weight group (4.3 ± 0.5 mmol/L × 6 h vs. 4.8 ± 0.5 mmol/L × 6 h, P = 0.31). We propose that caloric dose-response studies may contribute to a better understanding of the metabolic impact of food on the human organism. This study was registered at clinicaltrials.gov as NCT01446068.

Computer Vision-Based Carbohydrate Estimation for Type 1 Diabetic Patients Using Smartphones

Background: Individuals with type 1 diabetes (T1D) have to count the carbohydrates (CHOs) of their meal to estimate the prandial insulin dose needed to compensate for the meal’s effect on blood glucose levels. CHO counting is very challenging but also crucial, since an error of 20 grams can substantially impair postprandial control. Method: The GoCARB system is a smartphone application designed to support T1D patients with CHO counting of nonpacked foods. In a typical scenario, the user places a reference card next to the dish and acquires 2 images with his/her smartphone. From these images, the plate is detected and the different food items on the plate are automatically segmented and recognized, while their 3D shape is reconstructed. Finally, the food volumes are calculated and the CHO content is estimated by combining the previous results and using the USDA nutritional database. Results: To evaluate the proposed system, a set of 24 multi-food dishes was used. For each dish, 3 pairs of images were taken and for each pair, the system was applied 4 times. The mean absolute percentage error in CHO estimation was 10 ± 12%, which led to a mean absolute error of 6 ± 8 CHO grams for normal-sized dishes. Conclusion: The laboratory experiments demonstrated the feasibility of the GoCARB prototype system since the error was below the initial goal of 20 grams. However, further improvements and evaluation are needed prior launching a system able to meet the inter- and intracultural eating habits.

GoCARB in the Context of an Artificial Pancreas

Background: In an artificial pancreas (AP), the meals are either manually announced or detected and their size estimated from the blood glucose level. Both methods have limitations, which result in suboptimal postprandial glucose control. The GoCARB system is designed to provide the carbohydrate content of meals and is presented within the AP framework. Method: The combined use of GoCARB with a control algorithm is assessed in a series of 12 computer simulations. The simulations are defined according to the type of the control (open or closed loop), the use or not-use of GoCARB and the diabetics’ skills in carbohydrate estimation. Results: For bad estimators without GoCARB, the percentage of the time spent in target range (70-180 mg/dl) during the postprandial period is 22.5% and 66.2% for open and closed loop, respectively. When the GoCARB is used, the corresponding percentages are 99.7% and 99.8%. In case of open loop, the time spent in severe hypoglycemic events (<50 mg/dl) is 33.6% without the GoCARB and is reduced to 0.0% when the GoCARB is used. In case of closed loop, the corresponding percentage is 1.4% without the GoCARB and is reduced to 0.0% with the GoCARB. Conclusion: The use of GoCARB improves the control of postprandial response and glucose profiles especially in the case of open loop. However, the most efficient regulation is achieved by the combined use of the control algorithm and the GoCARB.

The Association Between Triglyceride and Leptin Levels in Obese Subjects Following a Low-Carbohydrate or Low-Fat Diet

Obesity has been cited as the second leading preventable cause of death in the United States. Studies have determined that at risk overweight and obese individuals have high circulating levels of leptin indicative of leptin resistance as well as elevated levels of plasma triglycerides. Postulates have been formed that link elevated levels of triglycerides with the inhibition of leptin across the blood-brain barrier. If a method of lowering triglycerides is achieved, leptin should be able to cross the blood-brain barrier and reach the ypothalamus, thus regulating body weight through a decrease in appetite and increase in energy expenditure. The primary aim of this study was to compare the effects of both carbohydrate and fat restricted diets on plasma triglycerides and leptin concentrations in overweight and obese subjects with hypertriglyceridemia. Forty subjects were randomly assigned to either the low carbohydrate or low fat diet group for a 12 wk period. Plasma triglyceride and leptin concentrations in the blood were analyzed before and after the 12 wk period to assess diet-induced changes. Both groups had a significant reduction in body weight, though the effect was much greater in the carbohydrate restricted diet group. Fasting and postprandial plasma triglycerides also decreased to a greater extent in the low carbohydrate diet group. Similarly, leptin levels decreased to a greater extent in the carbohydrate restricted diet group. The changes in leptin levels were directly related to the changes in both fasting and postprandial triglyceride levels. The results from this study provide preliminary evidence of diet-induced triglyceride reductions as an underlying mechanism in lowering plasma leptin and improving leptin sensitivity. Further, they provide evidence that an increase in triglyceride levels is at least partially responsible for leptin resistance and reduced leptin sensitivity in obese hypertriglyceridemic individuals. This novel discovery is important as it raises the possibility that other methods of lowering triglycerides may improve the efficiency of leptin transport and ultimately improve fat metabolism in overweight and obese individuals.

Mejora del valor proteico para rumiantes de la harina de girasol mediante tratamientos combinados con ácidos (málico y fosfórico) y calor = Improvement of the protein value for ruminants of sunflower meal by combined treatments with acids (malic and orthophosphoric) and heat

El objetivo principal de esta tesis fue incrementar el valor proteico para rumiantes de la harina de girasol mediante tratamientos combinados con ácidos y calor para proteger sus proteínas frente a la degradación ruminal. Estos estudios comprenden dos experimentos realizados sobre ovinos mediante tecnologías in vitro (experimento 1) o in situ e in vivo (experimento 2), empleando siempre dos ácidos: málico u ortofosfórico. Aprovechando este último experimento, también se consideraron otros objetivos de carácter metodológico con el fin de mejorar la precisión de las estimas de i) la degradabilidad ruminal y la digestibilidad intestinal de la proteína y los aminoácidos (AAs) de los alimentos y ii) la síntesis microbiana ruminal y su contribución al flujo post-ruminal de nutrientes al animal. En el experimento 1 (capítulo 2) se efectuaron cuatro ensayos in vitro para estudiar la influencia de distintos factores que puedan afectar la eficacia de estos tratamientos. En cada ensayo se utilizó una réplica por tratamiento (dos para el tratamiento control) y dos bolsas vacías (empleadas para corregir la contaminación microbiana) en cada una de las cuatro botellas del incubador (ANKOM Daisy II). Cada botella contenía 2 l de medio de incubación, saturado con CO2 para asegurar la anaerobiosis. Este medio consistió en una mezcla de solución McDougall y liquido ruminal filtrado en relación 4:1. El liquido ruminal fue obtenido de 2 corderos canulados en rumen, utilizándose bien solo o mezclado con el del otro cordero en una relación 3:1. Así, cada botella de incubación contenía un inoculo ruminal diferente. Las incubaciones se realizaron a 39 ºC durante 20 h, siendo las bolsas lavadas con agua corriente y almacenadas a -20 ºC. Tras ser descongeladas, se lavaron 3 veces durante 5 min en una mini-lavadora de turbina, se desecaron a 80 ºC durante 48 h y se destinaron íntegras al análisis de N-Kjeldahl. En el ensayo 1 se estudió el efecto del volumen de disolución de dos dosis de ácido ortofosfórico (0,4 y 1,2 equivalentes gramo (eq)/kg de harina de girasol), testando cinco volúmenes de disolución (80, 160, 240, 320 and 400 ml/kg de harina) para cada dosis, desecándose las harinas a 60 ºC hasta sequedad al tacto. La proteína bruta (PB) indegradada se incremento con la dosis de ácido empleada y también (como tendencia, P < 0,1) con el volumen de dilución. En base a ello en los siguientes ensayos se utilizo el volumen de dilución mayor (400 ml/kg). En el ensayo 2 se estudió el efecto de la dosis y del tipo de ácido a cuatro dosis (1,2; 2,4; 3,6 y 4,8 eq/kg), secándose igualmente las muestras tratadas a 60 ºC. La PB indegradada aumentó con la dosis de ácido, siendo también mayor para el ácido málico, tanto en este ensayo como en los posteriores. En el ensayo 3 se estudiaron los efectos de los dos ácidos, cuatro concentraciones (0,6; 1,2; 1,8 y 2,4 eq/kg) y tres tratamientos térmicos para el secado de las muestras (100, 150 and 200 ºC durante 60, 30 y 20 minutos, respectivamente). Con los tratamientos térmicos a 100 y 150 ºC no hubo un incremento de protección para concentraciones superiores a 0,8 eq/kg para ambos ácidos. Para incrementar la protección fue necesario aumentar la temperatura a 200 ºC y la dosis a 1,2 eq/kg, no observándose un aumento de protección a dosis mayores. En el ensayo 4 se estudiaron los efectos sobre la lisina disponible, la solubilidad de la PB en saliva artificial de McDougall y la PB indegradada in vitro de tratar la harina solo con agua o con disoluciones de ambos ácidos a dosis de 0,8 eq/kg y temperaturas de secado de 100 ó 150 ºC en las mismas condiciones que en el ensayo 3. No se apreciaron efectos sobre la lisina disponible para ninguno de los tratamientos. El efecto específico de los ácidos quedo demostrado tanto por la fuerte reducción de la solubilidad de la PB como por el aumento de la PB indegradada frente al tratamiento con agua. En conjunto, los resultados de este experimento mostraron que la eficacia de estos tratamientos depende del tipo y dosis de ácido y de su dilución, así como de las condiciones de secado. Como tratamiento de mayor interés a aplicar posteriormente en el experimento 2 se consideró una dosis de 0,8 eq/kg de harina, aplicada en un volumen de 400 ml/kg (correspondiente a soluciones 1 M y 0,67 M para los ácidos málico y ortofosfórico, respectivamente) y desecación a 150 ºC. El experimento 2 (capítulos 3 a 7) se realizó con un diseño en cuadrado latino 3x3, empleando tres corderos canulados en rumen y duodeno y tres dietas isoproteicas: U, M y P, que incluían harinas de girasol sin tratar (control) y tratadas con acido málico u ortofosfórico, respectivamente. La harina de girasol se trató en las condiciones ya indicadas siendo necesarias 6 horas para su secado en estufa. Las dietas incluían 40% de heno de raigrás italiano y 60% de concentrado a base de harina de girasol (tratada y/o sin tratar), trigo y corrector vitamínico-mineral, siendo suministradas a 75 g/kg P0.75 (equivalente a 2,3 × mantenimiento). La relación harina de girasol sin tratar y tratada fue de 100:0 en la dieta U y entorno a 40:60 en las dietas M y P. Tras 10 días de adaptación a la dieta, se estudiaron sucesivamente: i) el tránsito hasta el duodeno de las partículas del heno (solo en la dieta control) y de la harina de girasol marcadas previamente con europio e iterbio, respectivamente; ii) la fermentación ruminal durante el periodo postprandial, iii) la degradación ruminal in situ de la harina de girasol específica de cada dieta (y del trigo y el heno en la dieta control) y iv) la magnitud y composición del contenido ruminal mediante el vaciado manual del rumen-retículo. Durante todo el periodo experimental se infundio de forma continua una solución de sulfato amónico enriquecido en 15N (98 átomos %) para corregir la contaminación microbiana ruminal en los estudios in situ y para establecer las diferencias de composición química entre las bacterias libres (BAL) y adherentes (BAS) del rumen. Esta solución incluyó en los dos últimos días Li-Cr- EDTA para determinar la tasa de dilución ruminal. Posteriormente, y tras un periodo de al menos 10 días para eliminar el enriquecimiento en 15N de la digesta, se estudió la digestibilidad intestinal de los distintos alimentos mediante la técnica de bolsas móviles. La determinación del bypass (BP) o de la degradabilidad efectiva (DE) de la materia seca (MS) y de la PB se realizó por el método tradicional de integración matemática; estos valores se obtuvieron también para la PB y los AAs generando una muestra representativa del flujo post-ruminal del alimento en estudio en cada animal. Ello se realizó mediante la mezcla de los distintos residuos de incubación en base a la función que describe el flujo de alimento indegradado que abandona el rumen. Todos estos trabajos se realizaron considerando la tasa de salida de partículas del rumen (kp) y, según casos, considerando también la tasa de conminución y mezcla de las partículas en este compartimento (kc). Para este último caso se ha desarrollado también el modelo matemático que describe este flujo y permite este cálculo. Los valores no corregidos por la contaminación microbiana del BP (o de DE) de la PB resultantes de ambos métodos se han comparado tanto en las harinas de girasol como en los restantes alimentos de la dieta, obteniéndose valores similares, sin apreciarse desviaciones sistemáticas. Sobre las muestras compuestas representativas de la composición química del BP se determino la digestibilidad intestinal efectiva (DIE) de la MS, PB y AAs. Todos los valores resultantes de esta técnica fueron corregidos para la contaminación microbiana de las partículas que tiene lugar en el rumen. Los estudios de transito digestivo se realizaron tras suministrar en el comedero a los corderos una dosis simple de los alimentos marcados, seguida de la toma de muestras de la digesta duodenal durante 82 h. En la dieta testigo se suministraron simultáneamente el heno de raigrás y la harina de girasol, mientras que en las otras dietas solo se suministró esta última. La harina de girasol mostro un mayor valor para kc frente al heno (0,5766 v. 0,0892, /h), mientras que no hubo diferencias entre los dos alimentos para kp (0,0623 v. 0,0609, /h). Para la harina de girasol no se apreciaron diferencias entre dietas para kc, pero si se redujo de manera moderada la tasa kp con los tratamientos, siendo ésta también menor al utilizar ácido ortofosfórico frente al uso de ácido malico (0,0577 v. 0,0600, /h). El empleo de las harinas tratadas no modifico los parámetros de fermentación ruminal, la composición de los contenidos ruminales o la tasa de dilución del rumen. Los valores efectivos del BP y de DIE de la MS, PB y AAs de las harinas de girasol se obtuvieron considerando kc y kp, conjuntamente. Los tratamientos de protección incrementaron el BP de MS y PB en 48,5 y 268% de media, respectivamente. Estos incrementos se debieron principalmente al descenso de la fracción soluble y de la velocidad de degradación, pero también al aumento de la fracción indegradable, especialmente usando ácido ortofosfórico. Con los tratamientos se incrementó también la DIE de la MS (108% de media) y de la PB con gran diferencia entre los ácidos málico y ortofosfórico (20,7 v. 11,8%). Como consecuencia de estos cambios la protección aumentó la fracción realmente digerida en el intestino en 211% (MS) y 325% (PB), sin efectos entre ambos ácidos. Considerando la reducción del suministro de energía fermentable para los microorganismos ruminales asociada a la protección y los parámetros indicados por el sistema PDI francés para la síntesis de proteína microbiana digestible, la eficacia de conversión de PB en proteína metabolizable aumentó de 0,244 a 0,559 y 0,515 con el tratamiento con acido málico y ortofosfórico, respectivamente. El contenido en aminoácidos (AAs) fue similar en todas las harinas salvo por una disminución de lisina en las harinas tratadas. De forma análoga a la PB, los tratamientos de protección incrementaron el BP y la DIE de la mayoría de AAs. El aporte de AAs metabolizabes de la harina se multiplico en 3,87 para los AAs azufrados y en menor medida (2,5 veces) para la lisina, como consecuencia de las pérdidas sufridas a consecuencia del tratamiento térmico. Estos tratamientos se muestran, por tanto, útiles para incrementar el valor proteico de la harina de girasol, si bien su empleo junto con concentrados proteicos ricos en lisina bypass digestible mejoraría el perfil de la proteína metabolizable. La corrección de la contaminación microbiana de las partículas que tiene lugar en el rumen se asoció en todos los alimentos testados y, de forma general, con reducciones del BP y de su DIE en todas las fracciones estudiadas. Estas reducciones fueron pequeñas en todos los concentrados, de forma acorde con los muy pequeños niveles de contaminación registrados tanto en las harinas de girasol como en el grano de trigo. Por el contrario, esta contaminación, al igual que los efectos de su corrección, fueron muy importantes en el heno de raigrás. Esta contaminación aumentó al tener en cuenta kc. Así, para la proporción de PB de origen microbiano existente en las muestras compuestas representativas del BP, este aumento fue significativo para el heno de raigrás (0,463 v. 0,706) y solo numérico para la harina de girasol (0,0170 v. 0,0208). La reducción de las estimas de DIE al corregir esta contaminación fue consecuencia de la eliminación de forma casi completa de los microorganismos adherentes en todos los residuos testados. Así, esta biomasa se redujo en 96,1% como media de 7x3 observaciones. Como resultado de las diferencias acumulativas a nivel del rumen e intestino, la no corrección de la contaminación microbiana junto con la no consideración de kc condujo a fuertes sobrestimaciones de la PB digerida en el intestino. Ésta fue de 39% en la harina de girasol (0,146 v. 0,105) y de 761% en el heno de raigrás (0,373 v. 0,0433). Estos resultados muestran que es necesario considerar tanto kc como corregir la contaminación microbiana para obtener estimas in situ precisas en forrajes, mientras que en concentrados, siempre que la contaminación microbiana sea pequeña, es más importante considerar kc. La elevada contaminación microbiana observada en el heno de raigrás se asoció también con importantes errores a nivel del N asociado a la fibra neutro (FND) y ácido (FAD) detergente (NDIN y ADIN, respectivamente) e incluso de estas fracciones de fibra, evidenciándose que estos métodos no eliminan completamente la contaminación microbiana que sufren los alimentos en su paso por el retículorumen. Así, en la muestra compuesta representativa de la composición química del flujo postruminal antes descrita, la sobrevaloración por no corregir la contaminación microbiana fue de 99,8; 24,2; 3,34 y 0,48% para NDIN, ADIN, FND y FAD, respectivamente. Las subvaloraciones asociadas para su DE fueron 34,1; 8,79; 4,41 y 0,51%, respectivamente. La DE corregida del NDIN y ADIN (0,743 y 0,728, respectivamente) mostró un aprovechamiento ruminal elevado de estos compuestos, si bien menor al de la PB total (0,85). El estudio de este aprovechamiento sobre los residuos de incubación ruminal a 6 y 72 h demostró, además, una más rápida degradación del ADIN frente al NDIN, así como un mayor potencial de degradación de este último en este alimento. Para comprobar si la digestión en el abomaso eliminaba la contaminación microbiana en la FND y FAD se estudio esta contaminación y sus posibles errores en muestras liofilizadas de contenidos ruminales y duodenales correspondientes a una dieta mixta de similar composición a la utilizada en el experimento 2, comparándose, además, las diferencias entre la extracción secuencial o directa de la FAD. Utilizando como referencia las BAS se apreciaron elevadas contaminaciones en la FND y FAD y su N asociado tanto en las muestras ruminales como en las duodenales. Sin embargo, los resultados de enriquecimiento en 15N de las partículas fueron intermedios entre los correspondientes a BAS y BAL lo que evidencia una elevada contaminación con BAL en estas muestras probablemente durante el proceso de liofilización. Ello conlleva una sobrevaloración de esta estimación. El método de extracción directa de FAD se mostró, por otra parte, marcadamente menos eficaz en la eliminación de la contaminación microbiana. Los resultados muestran la necesidad de corregir la contaminación microbiana para obtener estimaciones precisas de la degradabilidad de las proteínas de las paredes celulares vegetales. Estos errores deberían ser también considerados para FND y FAD en estudios in situ e in vivo. La elevada tasa fraccional de degradación del grano de trigo (60,9 y 42,0%/h para MS y PB, respectivamente) implico que su flujo de material indegradado (calculado solo en base a la kp obtenida para la harina de girasol) se redujera muy rápidamente, de forma que es casi nulo a 8 h tras la ingestión. Los valores corregidos de PB digerida en el intestino (0,15) representan solo el 18,7% de la proteína metabolizable, lo que muestra que el valor proteico del grano de trigo está estrechamente ligado a la síntesis de proteína microbiana derivada de su fermentación. En el experimento 2 se observaron menores concentraciones para materia orgánica, lípidos y PB, así como en la proporción N-AAs/N total en BAL que en BAS, siendo, por el contrario, mayor su enriquecimiento en 15N. Estos últimos resultados se utilizaron (junto con los de otros trabajos previos de este equipo) para validar una predicción preexistente del enriquecimiento en 15N de las BAS a partir de este valor en las BAL. Esta ecuación, de muy alta precisión (R2 = 0.995), permite calcular la subvaloración que se comete en los aportes de nutrientes correspondientes a las BAS al usar las BAL como muestra de referencia. Esta subvaloración representa aproximadamente 21, 32,5 y 60% para PB, proteína verdadera y lípidos.

Artificial pancreas using a personalized rule-based controller achieves overnight normoglycemia in patients with type 1 diabetes

Objective: This study assessed the efficacy of a closed-loop (CL) system consisting of a predictive rule-based algorithm (pRBA) on achieving nocturnal and postprandial normoglycemia in patients with type 1 diabetes mellitus (T1DM). The algorithm is personalized for each patient’s data using two different strategies to control nocturnal and postprandial periods. Research Design and Methods: We performed a randomized crossover clinical study in which 10 T1DM patients treated with continuous subcutaneous insulin infusion (CSII) spent two nonconsecutive nights in the research facility: one with their usual CSII pattern (open-loop [OL]) and one controlled by the pRBA (CL). The CL period lasted from 10 p.m. to 10 a.m., including overnight control, and control of breakfast. Venous samples for blood glucose (BG) measurement were collected every 20 min. Results: Time spent in normoglycemia (BG, 3.9–8.0 mmol/L) during the nocturnal period (12 a.m.–8 a.m.), expressed as median (interquartile range), increased from 66.6% (8.3–75%) with OL to 95.8% (73–100%) using the CL algorithm (P<0.05). Median time in hypoglycemia (BG, <3.9 mmol/L) was reduced from 4.2% (0–21%) in the OL night to 0.0% (0.0–0.0%) in the CL night (P<0.05). Nine hypoglycemic events (<3.9 mmol/L) were recorded with OL compared with one using CL. The postprandial glycemic excursion was not lower when the CL system was used in comparison with conventional preprandial bolus: time in target (3.9–10.0 mmol/L) 58.3% (29.1–87.5%) versus 50.0% (50–100%). Conclusions: A highly precise personalized pRBA obtains nocturnal normoglycemia, without significant hypoglycemia, in T1DM patients. There appears to be no clear benefit of CL over prandial bolus on the postprandial glycemia

Glucose-Insulin regulator for type 1 diabetes using high order neural networks

In this paper a Glucose-Insulin regulator for Type 1 Diabetes using artificial neural networks (ANN) is proposed. This is done using a discrete recurrent high order neural network in order to identify and control a nonlinear dynamical system which represents the pancreas? beta-cells behavior of a virtual patient. The ANN which reproduces and identifies the dynamical behavior system, is configured as series parallel and trained on line using the extended Kalman filter algorithm to achieve a quickly convergence identification in silico. The control objective is to regulate the glucose-insulin level under different glucose inputs and is based on a nonlinear neural block control law. A safety block is included between the control output signal and the virtual patient with type 1 diabetes mellitus. Simulations include a period of three days. Simulation results are compared during the overnight fasting period in Open-Loop (OL) versus Closed- Loop (CL). Tests in Semi-Closed-Loop (SCL) are made feedforward in order to give information to the control algorithm. We conclude the controller is able to drive the glucose to target in overnight periods and the feedforward is necessary to control the postprandial period.

Mejora postpradial de un controlador basado en reglas

La Diabetes mellitus es una enfermedad caracterizada por la insuficiente o nula producción de insulina por parte del páncreas o la reducida sensibilidad del organismo a esta hormona, que ayuda a que la glucosa llegue a los tejidos y al sistema nervioso para suministrar energía. La Diabetes tiene una mayor prevalencia en los países desarrollados debido a múltiples factores, entre ellos la obesidad, la vida sedentaria, y disfunciones en el sistema endocrino relacionadas con el páncreas. La Diabetes Tipo 1 es una enfermedad crónica e incurable, en la que son destruidas las células beta del páncreas, que producen la insulina, haciéndose necesaria la administración de insulina de forma exógena para controlar los niveles de glucosa en sangre. El paciente debe seguir una terapia con insulina administrada por vía subcutánea, que debe estar adaptada a sus necesidades metabólicas y a sus hábitos de vida. Esta terapia intenta imitar el perfil insulínico de un páncreas sano. La tecnología actual permite abordar el desarrollo del denominado “páncreas endocrino artificial” (PEA), que aportaría precisión, eficacia y seguridad en la aplicación de las terapias con insulina y permitiría una mayor independencia de los pacientes frente a su enfermedad, que en la actualidad están sujetos a una constante toma de decisiones. El PEA consta de un sensor continuo de glucosa, una bomba de infusión de insulina y un algoritmo de control, que calcula la insulina a infusionar utilizando los niveles de glucosa del paciente como información principal. Este trabajo presenta una modificación en el método de control en lazo cerrado propuesto en un proyecto previo. El controlador del que se parte está compuesto por un controlador basal booleano y un controlador borroso postprandial basado en reglas borrosas heredadas del controlador basal. El controlador postprandial administra el 50% del bolo manual (calculado a partir de la cantidad de carbohidratos que el paciente va a consumir) en el instante del aviso de la ingesta y reparte el resto en instantes posteriores. El objetivo es conseguir una regulación óptima del nivel de glucosa en el periodo postprandial. Con el objetivo de reducir las hiperglucemias que se producen en el periodo postprandial se realiza un transporte de insulina, que es un adelanto de la insulina basal del periodo postprandial que se suministrará junto con un porcentaje variable del bolo manual. Este porcentaje estará relacionado con el estado metabólico del paciente previo a la ingesta. Además se modificará la base de conocimiento para adecuar el comportamiento del controlador al periodo postprandial. Este proyecto está enfocado en la mejora del controlador borroso postprandial previo, modificando dos aspectos: la inferencia del controlador postprandial y añadiendo una toma de decisiones automática sobre el % del bolo manual y el transporte. Se ha propuesto un controlador borroso con una nueva inferencia, que no hereda las características del controlado basal, y ha sido adaptado al periodo postprandial. Se ha añadido una inferencia borrosa que modifica la cantidad de insulina a administrar en el momento del aviso de ingesta y la cantidad de insulina basal a transportar del periodo postprandial al bolo manual. La validación del algoritmo se ha realizado mediante experimentos en simulación utilizando una población de diez pacientes sintéticos pertenecientes al Simulador de Padua/Virginia, evaluando los resultados con estadísticos para después compararlos con los obtenidos con el método de control anterior. Tras la evaluación de los resultados se puede concluir que el nuevo controlador postprandial, acompañado de la toma de decisiones automática, realiza un mejor control glucémico en el periodo postprandial, disminuyendo los niveles de las hiperglucemias. ABSTRACT. Diabetes mellitus is a disease characterized by the insufficient or null production of insulin from the pancreas or by a reduced sensitivity to this hormone, which helps glucose get to the tissues and the nervous system to provide energy. Diabetes has more prevalence in developed countries due to multiple factors, including obesity, sedentary lifestyle and endocrine dysfunctions related to the pancreas. Type 1 Diabetes is a chronic, incurable disease in which beta cells in the pancreas that produce insulin are destroyed, and exogenous insulin delivery is required to control blood glucose levels. The patient must follow a therapy with insulin administered by the subcutaneous route that should be adjusted to the metabolic needs and lifestyle of the patient. This therapy tries to imitate the insulin profile of a non-pathological pancreas. Current technology can adress the development of the so-called “endocrine artificial pancreas” (EAP) that would provide accuracy, efficacy and safety in the application of insulin therapies and will allow patients a higher level of independence from their disease. Patients are currently tied to constant decision making. The EAP consists of a continuous glucose sensor, an insulin infusion pump and a control algorithm that computes the insulin amount that has to be infused using the glucose as the main source of information. This work shows modifications to the control method in closed loop proposed in a previous project. The reference controller is composed by a boolean basal controller and a postprandial rule-based fuzzy controller which inherits the rules from the basal controller. The postprandial controller administrates 50% of the bolus (calculated from the amount of carbohydrates that the patient is going to ingest) in the moment of the intake warning, and distributes the remaining in later instants. The goal is to achieve an optimum regulation of the glucose level in the postprandial period. In order to reduce hyperglycemia in the postprandial period an insulin transport is carried out. It consists on a feedforward of the basal insulin from the postprandial period, which will be administered with a variable percentage of the manual bolus. This percentage would be linked with the metabolic state of the patient in moments previous to the intake. Furthermore, the knowledge base is going to be modified in order to fit the controller performance to the postprandial period. This project is focused on the improvement of the previous controller, modifying two aspects: the postprandial controller inference, and the automatic decision making on the percentage of the manual bolus and the transport. A fuzzy controller with a new inference has been proposed and has been adapted to the postprandial period. A fuzzy inference has been added, which modifies both the amount of manual bolus to administrate at the intake warning and the amount of basal insulin to transport to the prandial bolus. The algorithm assessment has been done through simulation experiments using a synthetic population of 10 patients in the UVA/PADOVA simulator, evaluating the results with statistical parameters for further comparison with those obtained with the previous control method. After comparing results it can be concluded that the new postprandial controller, combined with the automatic decision making, carries out a better glycemic control in the postprandial period, decreasing levels of hyperglycemia.

Normal hepatic glucose production in the absence of GLUT2 reveals an alternative pathway for glucose release from hepatocytes

Glucose production by liver is a major physiological function, which is required to prevent development of hypoglycemia in the postprandial and fasted states. The mechanism of glucose release from hepatocytes has not been studied in detail but was assumed instead to depend on facilitated diffusion through the glucose transporter GLUT2. Here, we demonstrate that in the absence of GLUT2 no other transporter isoforms were overexpressed in liver and only marginally significant facilitated diffusion across the hepatocyte plasma membrane was detectable. However, the rate of hepatic glucose output was normal. This was evidenced by (i) the hyperglycemic response to i.p. glucagon injection; (ii) the in vivo measurement of glucose turnover rate; and (iii) the rate of release of neosynthesized glucose from isolated hepatocytes. These observations therefore indicated the existence of an alternative pathway for hepatic glucose output. Using a [14C]-pyruvate pulse-labeling protocol to quantitate neosynthesis and release of [14C]glucose, we demonstrated that this pathway was sensitive to low temperature (12°C). It was not inhibited by cytochalasin B nor by the intracellular traffic inhibitors brefeldin A and monensin but was blocked by progesterone, an inhibitor of cholesterol and caveolae traffic from the endoplasmic reticulum to the plasma membrane. Our observations thus demonstrate that hepatic glucose release does not require the presence of GLUT2 nor of any plasma membrane glucose facilitative diffusion mechanism. This implies the existence of an as yet unsuspected pathway for glucose release that may be based on a membrane traffic mechanism.