Histological validation of a type 1 diabetes clinical diagnostic model for classification of diabetes

AIMS

Misclassification of diabetes is common due to an overlap in the clinical features of type 1 and type 2 diabetes. Combined diagnostic models incorporating clinical and biomarker information have recently been developed that can aid classification, but they have not been validated using pancreatic pathology. We evaluated a clinical diagnostic model against histologically defined type 1 diabetes.

METHODS

We classified cases from the Network for Pancreatic Organ donors with Diabetes (nPOD) biobank as type 1 (n = 111) or non-type 1 (n = 42) diabetes using histopathology. Type 1 diabetes was defined by lobular loss of insulin-containing islets along with multiple insulin-deficient islets. We assessed the discriminative performance of previously described type 1 diabetes diagnostic models, based on clinical features (age at diagnosis, BMI) and biomarker data [autoantibodies, type 1 diabetes genetic risk score (T1D-GRS)], and singular features for identifying type 1 diabetes by the area under the curve of the receiver operator characteristic (AUC-ROC).

RESULTS

Diagnostic models validated well against histologically defined type 1 diabetes. The model combining clinical features, islet autoantibodies and T1D-GRS was strongly discriminative of type 1 diabetes, and performed better than clinical features alone (AUC-ROC 0.97 vs. 0.95; P = 0.03). Histological classification of type 1 diabetes was concordant with serum C-peptide [median < 17 pmol/l (limit of detection) vs. 1037 pmol/l in non-type 1 diabetes; P < 0.0001].

CONCLUSIONS

Our study provides robust histological evidence that a clinical diagnostic model, combining clinical features and biomarkers, could improve diabetes classification. Our study also provides reassurance that a C-peptide-based definition of type 1 diabetes is an appropriate surrogate outcome that can be used in large clinical studies where histological definition is impossible. Parts of this study were presented in abstract form at the Network for Pancreatic Organ Donors Conference, Florida, USA, 19-22 February 2019 and Diabetes UK Professional Conference, Liverpool, UK, 6-8 March 2019.

Estrogen receptor alpha and beta expression in upper gastrointestinal tract with regulation of trefoil factor family 2 mRNA levels in ovariectomized rats

This study compared expression of two estrogen receptor (ER alpha and ER beta) genes in the rat upper gastrointestinal tract and the effects of 17 beta-estradiol administration on gastric trefoil factor family (TFF) mRNA steady-state levels in ovariectomized rats. Estrogen receptor alpha and beta cDNA fragments from fundic mucosa were cloned by reverse transcriptase polymerase chain reaction (RT-PCR) and sequenced. Both ER subtypes were detected in fundus, antrum and duodenum by RT-PCR. Northern analysis of poly(A)+ mRNA from fundic mucosa showed that ER alpha mRNA is expressed as a single transcript at 6.5 kb and ER beta is expressed as multiple transcripts with major transcripts ranging from 1.1-4.7 kb. ER beta mRNA was expressed in greater abundance than ER alpha mRNA. Fundic TFF2 mRNA steady-state levels were increased by 17 beta-estradiol administration in ovariectomized rats with no significant change in TFF1 mRNA levels. These studies show expression of both ER subtypes in the rat upper gastrointestinal tract with regulation of TFF2 mRNA by 17 beta-estradiol. These results suggest that estrogens, probably acting via ER beta, have a direct role in regulating gastric physiology.

In situ hybridization of H-K-ATPase beta-subunit mRNA in rat and rabbit kidney

Through a variety of techniques, several investigators have demonstrated the presence of an H-K-adenosinetriphosphatase (H-K-ATPase) enzyme in the renal collecting duct, suggesting that this enzyme serves an important physiological role in the regulation of acid-base balance and potassium excretion by the kidney. The present study was designed to localize cells expressing H-K-ATPase beta-subunit mRNA in rat and rabbit kidney by nonradioactive in situ hybridization. A 570-bp DNA fragment of rabbit renal H-K-ATPase beta-subunit was used to produce digoxigenin-labeled riboprobes by in vitro transcription. Northern blot hybridization demonstrated transcripts in rat gastric oxyntic mucosa and kidney. In situ hybridization on kidney tissue sections demonstrated H-K-ATPase beta-subunit mRNA localization in epithelial cells, including intercalated cells in the connecting segment and cortical and medullary collecting duct, principal cells in the inner stripe of the outer medullary collecting duct, and inner medullary collecting duct cells in both the rat and the rabbit. These observations provide evidence that H-K-ATPase beta-subunit mRNA is present throughout the collecting duct of the kidney. The distribution of this message is consistent with a role for H-K-ATPase in bicarbonate absorption in both the outer and inner medullary collecting duct.

Basal and pentagastrin-stimulated gastric secretion in young horses

Equine gastric secretion was studied using a gastric cannula model after fasting (basal) and pentagastrin infusion. Gastric secretory rate, pH, osmolality, and electrolyte concentrations and outputs were determined over a 5-h period. Dose-response tests estimated that the maximally effective intravenous dose of pentagastrin was between 3 and 6 micrograms.kg-1.h-1. Basal secretory rate was 278 +/- 29 (SE) ml/15 min, and the pH was 2.00 +/- 0.31. Pentagastrin infusion at 6 micrograms.kg-1.h-1 increased secretory rate to 533 +/- 60 ml/15 min and decreased pH to 1.41 +/- 0.11. Basal gastric acid concentration and output were 38 +/- 5 meq/l and 211 +/- 36 mu eg.kg-1.h-1, respectively. Pentagastrin increased acid concentration to 60 +/- 5 meq/l and acid output to 474 +/- 61 mu eq.kg-1.h-1. Gastric fluid osmolality remained hypotonic during both basal and pentagastrin conditions. Sodium concentration remained high in comparison with hydrogen ion concentration, and sodium output increased during pentagastrin infusion. Equine gastric secretion did not attain maximal acid concentrations nor the marked drop in pH, which has been reported for other monogastric species. These data suggest that in the horse a large nonparietal component exists that modifies parietal secretions and is increased by pentagastrin stimulation.

Effect of butorphanol on equine antroduodenal motility

Six healthy six to eight-month-old horses were surgically prepared with Ag bipolar electrodes sutured to the gastric antrum and duodenum. Leads from the electrodes were exteriorised through a stab incision in the flank. During experimental sessions the horses were lightly restrained in stocks and electrode leads were connected to a physiograph to record antroduodenal myoelectrical activity. Intravenous (i.v.) injection of 0.05 mg/kg bodyweight (bwt) of the opioid agonist/antagonist, butorphanol was followed within 2 to 3 mins by a normal appearing period of repetitive spike activity, or phase III, of the migrating motor complex (MMC) on the duodenum. This was followed by a period of no spike activity, or phase I, of the MMC and then resumption of intermittent spike activity, or phase II, of normal duration. Pre-treatment with 15 micrograms/kg bwt of the non-selective opioid antagonist, naloxone, or with 1 mg/kg bwt of the alpha 2-adrenergic antagonist, tolazoline, did not block the myoelectrical response to butorphanol. It was concluded that a dose of butorphanol that has effective analgesic effects in a colicky horse resets the antroduodenal MMC without causing undesirable effects on antroduodenal motility. This particular effect of butorphanol might not be mediated by either a2-adrenergic or opioid receptors, although the latter question needs further investigation.

Effect of xylazine treatment on equine proximal gastrointestinal tract myoelectrical activity

Five 5 to 6 month old horses were surgically prepared with silver electrodes sutured to the serosa of gastric antrum, duodenum and proximal portions of the jejunum. Normal migrating motility complex (MMC) periodicity was determined during daytime hours in horses that were fed and horses from which food was withheld for 24 hours. Periodicity was defined as time span from the end of one period of regular spike activity (RSA) to the end of the next RSA in the MMC. The periodicity was 120.5 +/- 9.5 (SEM) minutes in horses from which food was withheld, and was 125.7 +/- 20.3 minutes in horses fed hay free choice. Coincident with each duodenal RSA, antral spike activity ceased. Xylazine (0.25 and 0.5 mg/kg), given IV during the period of intermittent spike activity of the MMC to either fed or unfed horses induced, within 2 minutes, a RSA complex in the duodenum that migrated to the proximal portion of the jejunum. This was followed by a period of no spike activity of normal duration, which proceeded on to a period of intermittent spike activity of varying duration to complete the MMC cycle. Pretreatment IV administration of an alpha 2-adrenergic antagonist, tolazoline (1 mg/kg) also provoked a RSA complex, but blocked the xylazine effect. The results indicated that xylazine resets the duodenal MMC in the horse, but does not seriously disrupt proximal gastrointestinal tract motility, and that control of MMC periodicity in this region probably involves more than alpha 2-adrenergic receptors.

Effect of ranitidine on gastric acid secretion in young male horses

Gastric cannulas were placed surgically in 5 young male horses. After a 2-week recovery period, horses were studied once a week. Horses were fasted for 24 hours, and gastric fluid output was collected for 5 continuous hours. Volumes were recorded every 15 minutes, and pH and hydrogen ion concentration were determined in an aliquot from each period. In 10 basal experiments, using 5 horses, volume, pH, and hydrogen ion concentration were continuously variable. Mean acid output was 45.1 +/- 2.02 microEq/15 min/kg (mean +/- SEM). In 6 experiments, using 3 horses, 0.5 mg of ranitidine/kg of body weight, given as an IV bolus after a 1-hour basal collection, significantly (P less than 0.02) inhibited hourly total acid output for 4 hours, but did not significantly change pH. The cannulation technique was done without complications, and horses tolerated the cannula for several months. Seemingly, the horse has a continuously variable gastric acid secretion, and histamine type-2 receptors have a role in this process.

Gastroenterostomy for treatment of gastroduodenal ulcer disease in 14 foals

Gastroenterostomy was performed in 14 foals to treat gastric outflow obstruction caused by advanced gastroduodenal ulcer disease. The onset of excessive salivation and teeth grinding, without response to medical treatment, combined with endoscopic and radiographic evidence of gastric outflow obstruction, were indications for surgical intervention. Successful outcome in 5 foals was attributed to early diagnosis, patient stabilization, early surgical correction, and postoperative management including antibiotics and antiulcer medication.