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

Automatic physical activity pattern recognition and meal intake modelling in type 1 diabetes for their inclusion in artificial pancreas systems

La diabetes comprende un conjunto de enfermedades metabólicas que se caracterizan por concentraciones de glucosa en sangre anormalmente altas. En el caso de la diabetes tipo 1 (T1D, por sus siglas en inglés), esta situación es debida a una ausencia total de secreción endógena de insulina, lo que impide a la mayoría de tejidos usar la glucosa. En tales circunstancias, se hace necesario el suministro exógeno de insulina para preservar la vida del paciente; no obstante, siempre con la precaución de evitar caídas agudas de la glucemia por debajo de los niveles recomendados de seguridad. Además de la administración de insulina, las ingestas y la actividad física son factores fundamentales que influyen en la homeostasis de la glucosa. En consecuencia, una gestión apropiada de la T1D debería incorporar estos dos fenómenos fisiológicos, en base a una identificación y un modelado apropiado de los mismos y de sus sorrespondientes efectos en el balance glucosa-insulina. En particular, los sistemas de páncreas artificial –ideados para llevar a cabo un control automático de los niveles de glucemia del paciente– podrían beneficiarse de la integración de esta clase de información. La primera parte de esta tesis doctoral cubre la caracterización del efecto agudo de la actividad física en los perfiles de glucosa. Con este objetivo se ha llevado a cabo una revisión sistemática de la literatura y meta-análisis que determinen las respuestas ante varias modalidades de ejercicio para pacientes con T1D, abordando esta caracterización mediante unas magnitudes que cuantifican las tasas de cambio en la glucemia a lo largo del tiempo. Por otro lado, una identificación fiable de los periodos con actividad física es un requisito imprescindible para poder proveer de esa información a los sistemas de páncreas artificial en condiciones libres y ambulatorias. Por esta razón, la segunda parte de esta tesis está enfocada a la propuesta y evaluación de un sistema automático diseñado para reconocer periodos de actividad física, clasificando su nivel de intensidad (ligera, moderada o vigorosa); así como, en el caso de periodos vigorosos, identificando también la modalidad de ejercicio (aeróbica, mixta o de fuerza). En este sentido, ambos aspectos tienen una influencia específica en el mecanismo metabólico que suministra la energía para llevar a cabo el ejercicio y, por tanto, en las respuestas glucémicas en T1D. En este trabajo se aplican varias combinaciones de técnicas de aprendizaje máquina y reconocimiento de patrones sobre la fusión multimodal de señales de acelerometría y ritmo cardíaco, las cuales describen tanto aspectos mecánicos del movimiento como la respuesta fisiológica del sistema cardiovascular ante el ejercicio. Después del reconocimiento de patrones se incorpora también un módulo de filtrado temporal para sacar partido a la considerable coherencia temporal presente en los datos, una redundancia que se origina en el hecho de que en la práctica, las tendencias en cuanto a actividad física suelen mantenerse estables a lo largo de cierto tiempo, sin fluctuaciones rápidas y repetitivas. El tercer bloque de esta tesis doctoral aborda el tema de las ingestas en el ámbito de la T1D. En concreto, se propone una serie de modelos compartimentales y se evalúan éstos en función de su capacidad para describir matemáticamente el efecto remoto de las concetraciones plasmáticas de insulina exógena sobre las tasas de eleiminación de la glucosa atribuible a la ingesta; un aspecto hasta ahora no incorporado en los principales modelos de paciente para T1D existentes en la literatura. Los datos aquí utilizados se obtuvieron gracias a un experimento realizado por el Institute of Metabolic Science (Universidad de Cambridge, Reino Unido) con 16 pacientes jóvenes. En el experimento, de tipo ‘clamp’ con objetivo variable, se replicaron los perfiles individuales de glucosa, según lo observado durante una visita preliminar tras la ingesta de una cena con o bien alta carga glucémica, o bien baja. Los seis modelos mecanísticos evaluados constaban de: a) submodelos de doble compartimento para las masas de trazadores de glucosa, b) un submodelo de único compartimento para reflejar el efecto remoto de la insulina, c) dos tipos de activación de este mismo efecto remoto (bien lineal, bien con un punto de corte), y d) diversas condiciones iniciales. ABSTRACT Diabetes encompasses a series of metabolic diseases characterized by abnormally high blood glucose concentrations. In the case of type 1 diabetes (T1D), this situation is caused by a total absence of endogenous insulin secretion, which impedes the use of glucose by most tissues. In these circumstances, exogenous insulin supplies are necessary to maintain patient’s life; although caution is always needed to avoid acute decays in glycaemia below safe levels. In addition to insulin administrations, meal intakes and physical activity are fundamental factors influencing glucose homoeostasis. Consequently, a successful management of T1D should incorporate these two physiological phenomena, based on an appropriate identification and modelling of these events and their corresponding effect on the glucose-insulin balance. In particular, artificial pancreas systems –designed to perform an automated control of patient’s glycaemia levels– may benefit from the integration of this type of information. The first part of this PhD thesis covers the characterization of the acute effect of physical activity on glucose profiles. With this aim, a systematic review of literature and metaanalyses are conduced to determine responses to various exercise modalities in patients with T1D, assessed via rates-of-change magnitudes to quantify temporal variations in glycaemia. On the other hand, a reliable identification of physical activity periods is an essential prerequisite to feed artificial pancreas systems with information concerning exercise in ambulatory, free-living conditions. For this reason, the second part of this thesis focuses on the proposal and evaluation of an automatic system devised to recognize physical activity, classifying its intensity level (light, moderate or vigorous) and for vigorous periods, identifying also its exercise modality (aerobic, mixed or resistance); since both aspects have a distinctive influence on the predominant metabolic pathway involved in fuelling exercise, and therefore, in the glycaemic responses in T1D. Various combinations of machine learning and pattern recognition techniques are applied on the fusion of multi-modal signal sources, namely: accelerometry and heart rate measurements, which describe both mechanical aspects of movement and the physiological response of the cardiovascular system to exercise. An additional temporal filtering module is incorporated after recognition in order to exploit the considerable temporal coherence (i.e. redundancy) present in data, which stems from the fact that in practice, physical activity trends are often maintained stable along time, instead of fluctuating rapid and repeatedly. The third block of this PhD thesis addresses meal intakes in the context of T1D. In particular, a number of compartmental models are proposed and compared in terms of their ability to describe mathematically the remote effect of exogenous plasma insulin concentrations on the disposal rates of meal-attributable glucose, an aspect which had not yet been incorporated to the prevailing T1D patient models in literature. Data were acquired in an experiment conduced at the Institute of Metabolic Science (University of Cambridge, UK) on 16 young patients. A variable-target glucose clamp replicated their individual glucose profiles, observed during a preliminary visit after ingesting either a high glycaemic-load or a low glycaemic-load evening meal. The six mechanistic models under evaluation here comprised: a) two-compartmental submodels for glucose tracer masses, b) a single-compartmental submodel for insulin’s remote effect, c) two types of activations for this remote effect (either linear or with a ‘cut-off’ point), and d) diverse forms of initial conditions.

Raft association of SNAP receptors acting in apical trafficking in Madin–Darby canine kidney cells

We have investigated the relationships between the apical sorting mechanism using lipid rafts and the soluble N-ethyl maleimide-sensitive factor attachment protein receptor (SNARE) machinery, which is involved in membrane docking and fusion. We first confirmed that anti-alpha-SNAP antibodies inhibit the apical pathway in Madin– Darby canine kidney (MDCK) cells; in addition, we report that a recombinant SNAP protein stimulates the apical transport whereas a SNAP mutant inhibits this transport step. Based on t-SNARE overexpression experiments and the effect of botulinum neurotoxin E, syntaxin 3 and SNAP-23 have been implicated in apical membrane trafficking. Here, we show in permeabilized MDCK cells that antisyntaxin 3 and anti-SNAP-23 antibodies lower surface delivery of an apical reporter protein. Moreover, using a similar approach, we show that tetanus toxin-insensitive, vesicle-associated membrane protein (TI-VAMP; also called VAMP7), a recently described apical v-SNARE, is involved. Furthermore, we show the presence of syntaxin 3 and TI-VAMP in isolated apical carriers. Polarized apical sorting has been postulated to be mediated by the clustering of apical proteins into dynamic sphingolipid-cholesterol rafts. We provide evidence that syntaxin 3 and TI-VAMP are raft-associated. These data support a raft-based mechanism for the sorting of not only apically destined cargo but also of SNAREs having functions in apical membrane-docking and fusion events.

Generation of Functional Beta-Like Cells from Human Exocrine Pancreas

Funding: This work was supported by a grant from the Medical Research Council MR/J015277/1. The Scottish National Islet Transplant Programme is funded by the National Services Division of NHS Scotland. KRM was funded by a Fellowship from the Wellcome Trust / Scottish Translational Medicine and Therapeutics Initiative 85664. Acknowledgments This work was supported by a grant from the Medical Research Council MR/J015277/1. The Scottish National Islet Transplant Programme is funded by the National Services Division of NHS Scotland. KRM was funded by a Fellowship from the Wellcome Trust/ Scottish Translational Medicine and Therapeutics Initiative 85664. We thank Joanna Sweetman for assistance in optimisation of the immunogold staining.

Na,K-ATPase transport from endoplasmic reticulum to Golgi requires the Golgi spectrin–ankyrin G119 skeleton in Madin Darby canine kidney cells

Spectrin (βIΣ∗) and ankyrin (AnkG119) associate with Golgi membranes and the dynactin complex, but their role in vesicle trafficking remains uncertain. We find that the actin-binding domain and membrane-association domain 1 (MAD1) of βI spectrin together form a constitutive Golgi targeting signal in transfected MDCK cells. Expression of this signal in transfected cells disrupts the endogenous Golgi spectrin skeleton and blocks transport of α- and β-Na,K-ATPase and vesicular stomatitis virus-G protein from the endoplasmic reticulum (ER) but does not disrupt the formation of Golgi stacks, the distribution of β-COP, or the transport and surface display of E-cadherin. The Golgi spectrin skeleton is thus required for the transport of a subset of membrane proteins from the ER to the Golgi. We postulate that together with polyfunctional adapter proteins such as AnkG119, Golgi spectrin forms a docking complex that acts prior to the cis-Golgi, presumably with vesicular–tubular clusters (VTCs or ERGIC), to sequester specific membrane proteins into vesicles transiting between the ER and Golgi, and subsequently (probably involving other isoforms of spectrin and ankyrin) to mediate cargo transport within the Golgi and to other membrane compartments. We hypothesize that this vesicular spectrin–ankyrin adapter-protein trafficking (or tethering) system (SAATS) mediates the capture and transport of many membrane proteins and acts in conjunction with vesicle-targeting molecules to effect the efficient transport of cargo proteins.

Pancreas development is promoted by cyclopamine, a Hedgehog signaling inhibitor

Exposure to cyclopamine, a steroid alkaloid that blocks Sonic hedgehog (Shh) signaling, promotes pancreatic expansion in embryonic chicks. Heterotopic development of pancreatic endocrine and exocrine structures occurs in regions adjacent to the pancreas including stomach and duodenum, and insulin-producing islets in the pancreas are enlarged. The homeodomain transcription factor PDX1, required for pancreas development, is expressed broadly in the posterior foregut but pancreas development normally initiates only in a restricted region of PDX1-expressing posterior foregut where endodermal Shh expression is repressed. The results suggests that cyclopamine expands the endodermal region where Shh signaling does not occur, resulting in pancreatic differentiation in a larger region of PDX1-expressing foregut endoderm. Cyclopamine reveals the capacity of a broad region of the posterior embryonic foregut to form pancreatic cells and provides a means for expanding embryonic pancreas development.

Association of Rab25 and Rab11a with the Apical Recycling System of Polarized Madin–Darby Canine Kidney Cells

Recent evidence suggests that apical and basolateral endocytic pathways in epithelia converge in an apically located, pericentriolar endosomal compartment termed the apical recycling endosome. In this compartment, apically and basolaterally internalized membrane constituents are thought to be sorted for recycling back to their site of origin or for transcytosis to the opposite plasma membrane domain. We report here that in the epithelial cell line Madin–Darby Canine Kidney (MDCK), antibodies to Rab11a label an apical pericentriolar endosomal compartment that is dependent on intact microtubules for its integrity. Furthermore, this compartment is accessible to a membrane-bound marker (dimeric immunoglobulin A [IgA]) internalized from either the apical or basolateral pole, functionally defining it as the apical recycling endosome. We have also examined the role of a closely related epithelial-specific Rab, Rab25, in the regulation of membrane recycling and transcytosis in MDCK cells. When cDNA encoding Rab25 was transfected into MDCK cells, the protein colocalized with Rab11a in subapical vesicles. Rab25 transfection also altered the distribution of Rab11a, causing the coalescence of immunoreactivity into multiple denser vesicular structures not associated with the centrosome. Nevertheless, nocodazole still dispersed these vesicles, and dimeric IgA internalized from either the apical or basolateral membrane was detected in endosomes labeled with antibodies to both Rab11a and Rab25. Overexpression of Rab25 decreased the rate of IgA transcytosis and of apical, but not basolateral, recycling of internalized ligand. Conversely, expression of the dominant-negative Rab25T26N did not alter either apical recycling or transcytosis. These results indicate that both Rab11a and Rab25 associate with the apical recycling system of epithelial cells and suggest that Rab25 may selectively regulate the apical recycling and/or transcytotic pathways.

Urokinase-Type Plasminogen Activator Receptor Is Internalized by Different Mechanisms in Polarized and Nonpolarized Madin–Darby Canine Kidney Epithelial Cells

Accumulated data indicate that endocytosis of the glycosylphosphatidyl-inositol-anchored protein urokinase plasminogen activator receptor (uPAR) depends on binding of the ligand uPA:plasminogen activator inhibitor-1 (PAI-1) and subsequent interaction with internalization receptors of the low-density lipoprotein receptor family, which are internalized through clathrin-coated pits. This interaction is inhibited by receptor-associated protein (RAP). We show that uPAR with bound uPA:PAI-1 is capable of entering cells in a clathrin-independent process. First, HeLaK44A cells expressing mutant dynamin efficiently internalized uPA:PAI-1 under conditions in which transferrin endocytosis was blocked. Second, in polarized Madin–Darby canine kidney (MDCK) cells, which expressed human uPAR apically, the low basal rate of uPAR ligand endocytosis, which could not be inhibited by RAP, was increased by forskolin or phorbol ester (phorbol 12-myristate 13-acetate), which selectively up-regulate clathrin-independent endocytosis from the apical domain of epithelial cells. Third, in subconfluent nonpolarized MDCK cells, endocytosis of uPA:PAI-1 was only decreased marginally by RAP. At the ultrastructural level uPAR was largely excluded from clathrin-coated pits in these cells and localized in invaginated caveolae only in the presence of cross-linking antibodies. Interestingly, a larger fraction of uPAR in nonpolarized relative to polarized MDCK cells was insoluble in Triton X-100 at 0°C, and by surface labeling with biotin we also show that internalized uPAR was mainly detergent insoluble, suggesting a correlation between association with detergent-resistant membrane microdomains and higher degree of clathrin-independent endocytosis. Furthermore, by cryoimmunogold labeling we show that 5–10% of internalized uPAR in nonpolarized, but not polarized, MDCK cells is targeted to lysosomes by a mechanism that is regulated by ligand occupancy.

Distinct Actions and Cooperative Roles of ROCK and mDia in Rho Small G Protein-induced Reorganization of the Actin Cytoskeleton in Madin–Darby Canine Kidney Cells

Rho, a member of the Rho small G protein family, regulates the formation of stress fibers and focal adhesions in various types of cultured cells. We investigated here the actions of ROCK and mDia, both of which have been identified to be putative downstream target molecules of Rho, in Madin–Darby canine kidney cells. The dominant active mutant of RhoA induced the formation of parallel stress fibers and focal adhesions, whereas the dominant active mutant of ROCK induced the formation of stellate stress fibers and focal adhesions, and the dominant active mutant of mDia induced the weak formation of parallel stress fibers without affecting the formation of focal adhesions. In the presence of C3 ADP-ribosyltransferase for Rho, the dominant active mutant of ROCK induced the formation of stellate stress fibers and focal adhesions, whereas the dominant active mutant of mDia induced only the diffuse localization of actin filaments. These results indicate that ROCK and mDia show distinct actions in reorganization of the actin cytoskeleton. The dominant negative mutant of either ROCK or mDia inhibited the formation of stress fibers and focal adhesions, indicating that both ROCK and mDia are necessary for the formation of stress fibers and focal adhesions. Moreover, inactivation and reactivation of both ROCK and mDia were necessary for the 12-O-tetradecanoylphorbol-13-acetate–induced disassembly and reassembly, respectively, of stress fibers and focal adhesions. The morphologies of stress fibers and focal adhesions in the cells expressing both the dominant active mutants of ROCK and mDia were not identical to those induced by the dominant active mutant of Rho. These results indicate that at least ROCK and mDia cooperatively act as downstream target molecules of Rho in the Rho-induced reorganization of the actin cytoskeleton.

Selective Perturbation of Apical Membrane Traffic by Expression of Influenza M2, an Acid-activated Ion Channel, in Polarized Madin–Darby Canine Kidney Cells

The function of acidification along the endocytic pathway is not well understood, in part because the perturbants used to modify compartmental pH have global effects and in some cases alter cytoplasmic pH. We have used a new approach to study the effect of pH perturbation on postendocytic traffic in polarized Madin–Darby canine kidney (MDCK) cells. Influenza M2 is a small membrane protein that functions as an acid-activated ion channel and can elevate the pH of the trans-Golgi network and endosomes. We used recombinant adenoviruses to express the M2 protein of influenza virus in polarized MDCK cells stably transfected with the polymeric immunoglobulin (Ig) receptor. Using indirect immunofluorescence and immunoelectron microscopy, M2 was found to be concentrated at the apical plasma membrane and in subapical vesicles; intracellular M2 colocalized partly with internalized IgA in apical recycling endosomes as well as with the trans-Golgi network marker TGN-38. Expression of M2 slowed the rate of IgA transcytosis across polarized MDCK monolayers. The delay in transport occurred after IgA reached the apical recycling endosome, consistent with the localization of intracellular M2. Apical recycling of IgA was also slowed in the presence of M2, whereas basolateral recycling of transferrin and degradation of IgA were unaffected. By contrast, ammonium chloride affected both apical IgA and basolateral transferrin release. Together, our data suggest that M2 expression selectively perturbs acidification in compartments involved in apical delivery without disrupting other postendocytic transport steps.

Modulation of Endocytic Traffic in Polarized Madin-Darby Canine Kidney Cells by the Small GTPase RhoA

Efficient postendocytic membrane traffic in polarized epithelial cells is thought to be regulated in part by the actin cytoskeleton. RhoA modulates assemblies of actin in the cell, and it has been shown to regulate pinocytosis and phagocytosis; however, its effects on postendocytic traffic are largely unexplored. To this end, we expressed wild-type RhoA (RhoAWT), dominant active RhoA (RhoAV14), and dominant inactive RhoA (RhoAN19) in Madin-Darby canine kidney (MDCK) cells expressing the polymeric immunoglobulin receptor. RhoAV14 expression stimulated the rate of apical and basolateral endocytosis, whereas RhoAN19 expression decreased the rate from both membrane domains. Polarized basolateral recycling of transferrin was disrupted in RhoAV14-expressing cells as a result of increased ligand release at the apical pole of the cell. Degradation of basolaterally internalized epidermal growth factor was slowed in RhoAV14-expressing cells. Although apical recycling of immunoglobulin A (IgA) was largely unaffected in cells expressing RhoAV14, transcytosis of basolaterally internalized IgA was severely impaired. Morphological and biochemical analyses demonstrated that a large proportion of IgA internalized from the basolateral pole of RhoAV14-expressing cells remained within basolateral early endosomes and was slow to exit these compartments. RhoAN19 and RhoAWT expression had little effect on these postendocytic pathways. These results indicate that in polarized MDCK cells activated RhoA may modulate endocytosis from both membrane domains and postendocytic traffic at the basolateral pole of the cell.

neurogenin3 is required for the development of the four endocrine cell lineages of the pancreas

In the mammalian pancreas, the endocrine cell types of the islets of Langerhans, including the α-, β-, δ-, and pancreatic polypeptide cells as well as the exocrine cells, derive from foregut endodermal progenitors. Recent genetic studies have identified a network of transcription factors, including Pdx1, Isl1, Pax4, Pax6, NeuroD, Nkx2.2, and Hlxb9, regulating the development of islet cells at different stages, but the molecular mechanisms controlling the specification of pancreatic endocrine precursors remain unknown. neurogenin3 (ngn3) is a member of a family of basic helix–loop–helix transcription factors that is involved in the determination of neural precursor cells in the neuroectoderm. ngn3 is expressed in discrete regions of the nervous system and in scattered cells in the embryonic pancreas. We show herein that ngn3-positive cells coexpress neither insulin nor glucagon, suggesting that ngn3 marks early precursors of pancreatic endocrine cells. Mice lacking ngn3 function fail to generate any pancreatic endocrine cells and die postnatally from diabetes. Expression of Isl1, Pax4, Pax6, and NeuroD is lost, and endocrine precursors are lacking in the mutant pancreatic epithelium. Thus, ngn3 is required for the specification of a common precursor for the four pancreatic endocrine cell types.

Canine sexual dimorphism in Egyptian Eocene anthropoid primates: Catopithecus and Proteopithecus

Two very small late Eocene anthropoid primates, Catopithecus browni and Proteopithecus sylviae, from Fayum, Egypt show evidence of substantial sexual dimorphism in canine teeth. The degree of dimorphism suggests that these early anthropoids lived in social groups with a polygynous mating system and intense male–male competition. Catopithecus and Proteopithecus are smaller in estimated body size than any living primates showing canine dimorphism. The origin of canine dimorphism and polygyny in anthropoids was not associated with the evolution of large body size.

Signaling through fibroblast growth factor receptor 2b plays a key role in the development of the exocrine pancreas

The development of the pancreas depends on epithelial-mesenchymal interactions. Fibroblast growth factors (FGFs) and their receptors (FGFRs 1–4) have been identified as mediators of epithelial-mesenchymal interactions in different organs. We show here that FGFR-2 IIIb and its ligands FGF-1, FGF-7, and FGF-10 are expressed throughout pancreatic development. We also show that in mesenchyme-free cultures of embryonic pancreatic epithelium FGF-1, FGF-7, and FGF-10 stimulate the growth, morphogenesis, and cytodifferentiation of the exocrine cells of the pancreas. The role of FGFs signaling through FGFR-2 IIIb was further investigated by inhibiting FGFR-2 IIIb signaling in organocultures of pancreatic explants (epithelium + mesenchyme) by using either antisense FGFR-2 IIIb oligonucleotides or a soluble recombinant FGFR-2 IIIb protein. Abrogation of FGFR-2 IIIb signaling resulted in a considerable reduction in the size of the explants and in a 2-fold reduction of the development of the exocrine cells. These results demonstrate that FGFs signaling through FGFR-2 IIIb play an important role in the development of the exocrine pancreas.