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<!-- Do not remove the above header on your project page. You can replace the "Your Cell Title Here" with the topic your group has selected.-->
 
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[[File:Beta_Cells_Title_Image.png||thumb|1100px|centre|Figure caption|]]
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[[File:Beta_Cells_Title_Image.png|1100px|centre]]
 
 
 
 
=='''Introduction'''==
 
  
 +
''Note:'' Throughout this page, terms marked with an Astericks (*) will be found in the glossary.
 +
=='''Introduction'''==
 
==='''Background'''===
 
==='''Background'''===
  
Beta cells (β cells) are one of the four major cells of the endocrine portion of the human pancreas. The human pancreas is a composite organ, which extends from the distal foregut endoderm and contains an exocrine and an endocrine portion. While the exocrine tissue consists of numerous acinar cells that discharge digestive fluid and a complementary duct complex through which the secreted fluid drains into the intestine, the endocrine portion of the pancreas comprises islets of Langerhans, or pancreatic islets (as reviewed by <ref name="PMID26395141"><pubmed>26395141</pubmed></ref>). The islets of Langerhans constitute approximately 1-2% of the pancreas and are dispersed throughout it <ref name="Brissova2008">Brissova, M. & Powers, A. C. (2008). Architecture of Pancreatic Islets. ''Pancreatic Beta Cell in Health and Disease'' (pp. 3-4).</ref>. They contain multiple endocrine cells; alpha, beta, delta, gamma and epsilon cells, which secrete different hormones; glucagon, insulin, somatostatin, pancreatic polypeptides and ghrelin, respectively <ref name="PMID26395141"><pubmed>26395141</pubmed></ref>. The pancreatic islets also host several endothelial cells, nerves and fibroblasts hence deeming them highly vascularised structures, which vary in size from small clusters to larger clusters containing up to several thousand islets and reaching diameters of 300-400 μm. As the majority of pancreatic islets are typically less than 160 μm in diameter, islets which exceed this diameter are considered to be responsible for the majority of the total islet mass <ref name="Bell2008">Bell, G., Seino, S., & SpringerLink. (2008). ''Pancreatic Beta Cell in Health and Disease.''</ref>.  
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Beta cells, abbreviated as β-cells, are one of the four major cells found within the endocrine* portion of the human pancreas*. The human pancreas is a composite organ, which extends from the distal foregut endoderm and is composed of an exocrine* and endocrine portion. The exocrine tissue consists of copious amounts of acinar cells, that discharge digestive fluid, and a complementary duct complex through which the secreted fluid drains into the intestine. The endocrine portion of the pancreas is composed of islets of Langerhans*, or pancreatic islets (reviewed in<ref name="PMID26395141"><pubmed>26395141</pubmed></ref>). These islets of Langerhans constitute approximately 1-2% of the pancreas and are dispersed throughout it<ref name="Brissova2008">Brissova, M. & Powers, A. C. (2008). Architecture of Pancreatic Islets. ''Pancreatic Beta Cell in Health and Disease'' (pp. 3-4).</ref>. They contain multiple endocrine cells; alpha, beta, delta, gamma and epsilon cells, which secrete the hormones; glucagon, insulin, somatostatin, pancreatic polypeptides and ghrelin, respectively<ref name="PMID26395141"><pubmed>26395141</pubmed></ref>. The pancreatic islets also host several endothelial cells, nerves and fibroblasts hence deeming them highly vascularised structures, which vary in size from small clusters to larger clusters, containing up to several thousand islets and reaching diameters of 300-400 μm. As the majority of pancreatic islets are typically less than 160 μm in diameter, islets which exceed this diameter are considered to be responsible for the majority of islet's total mass<ref name="Bell2008">Bell, G., Seino, S., & SpringerLink. (2008). ''Pancreatic Beta Cell in Health and Disease.''</ref>.  
  
Currently, it is predicted that adult humans have approximately 2 million islets of Langerhans, contributing to 2% of total pancreatic weight <ref name="PMID14687913"><pubmed>14687913</pubmed></ref>. Within these pancreatic islets, approximately 60-70% of the total islet-cell population can be attributed to beta cells <ref name="PMID 5333806 "><pubmed> 5333806 </pubmed></ref>. Beta cells, or insulin-secreting cells, are thus key cells within the pancreas and are predominately responsible for preserving normoglycaemia by neutralizing blood glucose levels with appropriate quantities of insulin secretion <ref name="PMID22460761"><pubmed>22460761</pubmed></ref>. The hormone insulin is also synthesised and secreted by beta cells in response to other factors aside from glucose, including nervous stimuli, other hormones and multiple nutrients <ref name="PMID14687913"><pubmed>14687913</pubmed></ref>.
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Currently, it is predicted that adult humans have approximately 2 million islets of Langerhans, which contributes to 2% of their total pancreatic weight<ref name="PMID14687913"><pubmed>14687913</pubmed></ref>. Within these islets, approximately 60-70% of the total islet-cell population can be attributed to beta cells<ref name="PMID5333806"><pubmed>5333806</pubmed></ref>. Beta cells, or insulin-secreting cells, are thus key cells within the pancreas and are predominately responsible for preserving normoglycaemia* by neutralizing blood glucose levels with appropriate quantities of insulin secretion<ref name="PMID22460761"><pubmed>22460761</pubmed></ref>. While glucose levels are the chief driver, insulin secretion and synthesis by beta cells may occasionally occur in response to other factors such as nervous stimuli, hormones and nutrients<ref name="PMID14687913"><pubmed>14687913</pubmed></ref>.
  
 
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{| class="wikitable" style="background: #EECCCC;"
 
{| class="wikitable" style="background: #EECCCC;"
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! colspan="2"  style="background: #EEAAAA;" | '''Table 1. History of Pancreatic and Beta Cell Development'''
 
|-
 
|-
 
! style="background: #EEAAAA;" | Year
 
! style="background: #EEAAAA;" | Year
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|-
 
|-
 
| style="background: #EEAAAA;" | '''1869'''
 
| style="background: #EEAAAA;" | '''1869'''
| The Islets of Langerhans, or Pancreatic Islets, are first discovered by German anatomist Paul Langerhans within rabbits as anatomical formations with no direct connection to the duct but are not given any function. <ref name="PMID6993583"><pubmed>6993583</pubmed></ref> Previous to the discovery, solely recognised as an exocrine organ. <ref name="PMID4192603"><pubmed><4192603></pubmed></ref>
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| The islets of Langerhans, or pancreatic islets, were first discovered by German anatomist Paul Langerhans, within rabbits, as anatomical formations with no direct connection to the duct. At that moment, no function was attributed to them<ref name="PMID6993583"><pubmed>6993583</pubmed></ref>. Prior to the discovery, the pancreas was solely recognised as an exocrine organ<ref name="PMID4192603"><pubmed><4192603></pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1889'''
 
|  style="background: #EEAAAA;" | '''1889'''
| Joseph Von Mering and Oskar Minkowski successfully completed the first pancreatectomy in a dog. Through this, they discovered the removal of the pancreas induced diabetes in the dog thus irrevocable establighing the connection with the pancreas and diabetes. <ref name="PMID19765178"><pubmed>19765178</pubmed></ref>
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| Joseph Von Mering and Oskar Minkowski successfully completed the first pancreatectomy* in a dog. Through this, they discovered that the removal of the pancreas induced diabetes in the dog . This discovery was paramount as it irrevocably established that the pancreas and diabetes were affiliated <ref name="PMID19765178"><pubmed>19765178</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1893'''
 
|  style="background: #EEAAAA;" | '''1893'''
| Edouard Laguesse who discovered the islets in the human pancreas suggested that they were responsible for the internal secretions that regulate glycemia, and named them after their discoverer Langerhans. <ref name="PMID26216133"><pubmed>26216133</pubmed></ref>  
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| Edouard Laguesse, who located islets in the human pancreas, suggested that they were responsible for the internal secretions that regulate glycemia*, and named them Langerhans, after their discoverer <ref name="PMID26216133"><pubmed>26216133</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1907 and 1911'''
 
|  style="background: #EEAAAA;" | '''1907 and 1911'''
| Lane and Bensley developed staining techniques to analyse the structure of the pancreas at a cellular level. these stains revealed at least two different granular cell types; A cells which contained granules preserved by alcohol and B cells which contained granules preserved by chrome sublimate. <ref name="PMID19765178"><pubmed>19765178</pubmed></ref>
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| Lane and Bensley developed staining techniques to analyse the structure of the pancreas at a cellular level. These stains revealed at least two different granular cell types; A cells, which contained granules preserved by alcohol, and B cells, which contained granules preserved by chrome sublimate*<ref name="PMID19765178"><pubmed>19765178</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1914'''
 
|  style="background: #EEAAAA;" | '''1914'''
| Homans noticed that B-cells are involved in experimental diabetes and attributed the sugar regulating function to B-cells.  <ref name="PMID4192603"><pubmed><4192603></pubmed></ref>
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| Homans noticed that B-cells were involved in experimental diabetes and thus attributed the sugar regulating function to them<ref name="PMID4192603"><pubmed><4192603></pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1921'''
 
|  style="background: #EEAAAA;" | '''1921'''
| Best and Banting isolated insulin from the canine pancreas after ductal ligation. Their discovery of insulin was awarded the Nobel Prize in Medicine in 1923. <ref name="PMID19765178"><pubmed>19765178</pubmed></ref>
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| Best and Banting isolated insulin from the canine pancreas after ductal ligation. Their discovery of insulin was awarded the Nobel Prize in Medicine in 1923<ref name="PMID19765178"><pubmed>19765178</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1943'''
 
|  style="background: #EEAAAA;" | '''1943'''
| Dunn et al. selectively destroyed beta cells by administration of alloxan, which led to diabetes. <ref name="PMID4192603"><pubmed><4192603></pubmed></ref>
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| Dunn et al. selectively destroyed beta cells by administration of alloxan*, which led to diabetes<ref name="PMID4192603"><pubmed><4192603></pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1957-1974'''
 
|  style="background: #EEAAAA;" | '''1957-1974'''
| morphopligical features of the islet cell types were established through multiple studies utilising electron microscopy, including the structure and apppearance of their cytoplasmic secretory granules. <ref name="PMID26216133"><pubmed>26216133</pubmed></ref>  
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| Morphological features of the islet cell types were established through multiple studies utilising electron microscopy. Their structure and the appearance of their cytoplasmic secretory granules were observed<ref name="PMID26216133"><pubmed>26216133</pubmed></ref>.
 
|-
 
|-
 
|  style="background:#EEAAAA;" | '''1966'''
 
|  style="background:#EEAAAA;" | '''1966'''
| First case of insulin independence by pancreas transplantation by William Kelly and Richard Lillehei into a 28 year old uremic woman at University of Minnesota. <ref name="PMID5338113"><pubmed>5338113</pubmed></ref>
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| First case of insulin independence by pancreas transplantation by William Kelly and Richard Lillehei into a 28 year old uremic* woman at the University of Minnesota<ref name="PMID5338113"><pubmed>5338113</pubmed></ref>.
 
|-
 
|-
 
|  style="background:#EEAAAA;" | '''1972'''
 
|  style="background:#EEAAAA;" | '''1972'''
| Pictet and Rutter analysed the ultrastructural development of the pancreas by transmission electron microscopy and found both the endocrine and exocrine cells of the pancreas derived from a common progenitor; alpha cells were the first endocrine cells to differentiate. <ref name="PMID19765178"><pubmed>19765178</pubmed></ref>
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| Pictet and Rutter analysed the ultrastructural development of the pancreas by transmission electron microscopy and found that both the endocrine and exocrine cells of the pancreas were derived from a common progenitor*; alpha cells were the first endocrine cells to differentiate<ref name="PMID19765178"><pubmed>19765178</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1977'''
 
|  style="background: #EEAAAA;" | '''1977'''
| Cudworth et al. made crucial step in the etiological classification of diabetes; reintroducing terms type 1 and type 2 diabetes. <ref name="PMID67403"><pubmed>67403</pubmed></ref>
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| Cudworth et al. made a crucial step in the etiological* classification of diabetes; introducing the terms type 1 and type 2 diabetes<ref name="PMID67403"><pubmed>67403</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''1990'''
 
|  style="background: #EEAAAA;" | '''1990'''
| Sharp et al. led further advances in transplantation achieving clinical insulin independance lasting 1 month through islet transplantation. <ref name="PMID2108071"><pubmed>2108071</pubmed></ref>
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| Sharp et al. led further advances in transplantation achieving clinical insulin independence, lasting 1 month, through islet transplantation<ref name="PMID2108071"><pubmed>2108071</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''2000'''
 
|  style="background: #EEAAAA;" | '''2000'''
| Shapiro et al. utilise "Edmonton protocol" where 7 patients with type 1 diabetes receive iselts and all recipients achieve insulin independence. Study utilised Immunosuppression drugs to prevent rejection. <ref name="PMID10911004"><pubmed>10911004</pubmed></ref>
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| Shapiro et al. utilise the "Edmonton protocol*" where 7 patients with type 1 diabetes receive islets and all recipients achieve insulin independence. The study utilised immunosuppression drugs to prevent rejection<ref name="PMID10911004"><pubmed>10911004</pubmed></ref>.
 
|-
 
|-
 
|  style="background: #EEAAAA;" | '''2014'''
 
|  style="background: #EEAAAA;" | '''2014'''
| Pagliuca et al. conduct first successful generation of functional human pancreatic beta cells in vitro, providing potentially an unprecedented cell source for drug discovery and cell transplantation therapy in diabetes. <ref name="PMID25303535 "><pubmed>25303535 </pubmed></ref>  
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| Pagliuca et al. conduct the first successful generation of functional human pancreatic beta cells in vitro*, potentially providing an unprecedented cell source for drug discovery and cell transplantation therapy in diabetes <ref name="PMID25303535 "><pubmed>25303535 </pubmed></ref>.
 
|-
 
|-
|  style="background: #EEAAAA;" | '''Continuing'''
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|  style="background: #EEAAAA;" | '''Present'''
| Research continues into stem cell therapeutics for diabetes (refer to "Current Research" below)
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| Research continues into stem cell therapeutics for diabetes (refer to "Current Research").
 
|}
 
|}
  
 
=='''Structure'''==
 
=='''Structure'''==
[[File:Microscopic structure of pancreas.JPG|thumb|left|400px|'''Figure X. Microscopic structure of pancreas''']]
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[[File:Microscopic structure of pancreas.JPG|thumb|right|300px|'''Figure 1.''' Microscopic image of the pancreas, which reveals the structure of a blood vessel, acini, pancreatic islet and duct. Image is reprinted with permission from<ref name="Gittes">Gittes, G. (2009). Developmental Biology of the Pancreas: a Comprehensive Review. Dev. Biol.: 326(1);4-35</ref>.]]
Among most species, pancreatic islets are generally characterised by an oval shape. Nevertheless, the distribution of cells within the endocrine portion of the pancreas is subject to variation. In most mammals, the pancreatic islet contains a core of beta cells, which is encircled by a mantle of non-beta cells. Yet, in humans and primates, cells are dispersed with greater complexity and deviate from the mammalian mantle-core arrangement to a composite of several mantle-core subunits. Due to such cellular organisation, pancreatic islets within humans and primates may be oval of clover-leaf shaped.  
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Among most species, pancreatic islets are generally characterised by an oval shape although the distribution of cells, within the endocrine pancreas, are subject to variation across animals. In most mammals, the islet contains a core of beta cells, which is encircled by a mantle of non-beta cells. Conversely, in humans and primates, cells are dispersed with greater complexity and deviate from the mammalian mantle-core arrangement to a composite of several mantle-core subunits. Due to such cellular organisation, pancreatic islets within humans and primates may be of oval or clover-leaf shape. Islets of Langerhans are highly vascularised structures, which contain capillaries that are lined by endothelial cells comprising of mitochondria*, ergastoplams*, a golgi complex* and a nucleus*. The peripheral extensions of the cytoplasm* of such endothelial cells are typically thinner and lack these organelles however, they contain several fenestrae or openings. While it is not confirmed whether these fenestrae vary in quantity and/or distribution, it is predicted that they represent areas for communication and allow the transfer of materials between the bloodstream and the extravascular space.  
 
 
Islets of Langerhans are highly vascularised structures, which contain capillaries that are lined by endothelial cells comprising of mitochondria, ergastoplams, a golgi complex and a nucleus. The peripheral extensions of the cytoplasm of such endothelial cells are typically thinner and lack such organelles however contain several fenestrae, or openings. While it is not confirmed whether these fenestrae are static or whether they vary in quantity and distribution, it is predicted that they represent areas for communication and the transfer of materials between the bloodstream and the extravascular space.  
 
  
The beta cell, itself, is enclosed by a continuous plasma membrane and includes, within its cytoplasm, several membrane-bound organelles such as the endoplasmic reticulum, mitochondria, a nucleus, golgi complex and secretory granules. The endoplasmic reticulum, also called the ergastoplasm, is composed of two lamellar membranes that have ribosomes attached to their exterior surface. In comparison to the mitochondria present within adjacent acinar cells, the mitochondria of the beta cells are relatively smaller in size, however they are easily identifiable by the cristae within their matrix. The golgi complex and beta granules are similarly composed of smooth membranous sacs, although the latter is sequestered from the cytoplasm by the walls of these sacs. The beta granules are additionally dispersed throughout the entire cytoplasm. The nucleus contains a double-layered nuclear membrane and also several nuclear pores, which allow continuity and interaction between the nucleoplasm and cytoplasm of the beta cell.
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The beta cell, itself, is enclosed by a continuous plasma membrane and includes, within its cytoplasm, several membrane-bound organelles such as the endoplasmic reticulum*, mitochondria, a nucleus, golgi complex and secretory granules*. The endoplasmic reticulum, also called the ergastoplasm, is composed of two lamellar membranes that have ribosomes attached to their exterior surface. In comparison to the mitochondria present within adjacent acinar cells, the mitochondria of the beta cells are relatively smaller in size. However they are easily identifiable by the cristae within their matrix. The golgi complex and beta granules are similarly composed of smooth membranous sacs, although the latter is sequestered from the cytoplasm by the walls of these sacs. The beta granules are additionally dispersed throughout the entire cytoplasm. The nucleus contains a double-layered nuclear membrane and also several nuclear pores, which allow continuity and interaction between the nucleoplasm and cytoplasm of the beta cell.
  
Adjacent beta cells are connected to each other at distributed focal points, called desmosomes, along their plasma membrane. Between two successive desmosomes, an intercellular space exists and its size is reliant upon the respective activity of the cells. The capillaries present within the islets of Langerhans are detached from the beta cells by two basement membranes; one related to the endothelium and the other to the capillary surface. Typically, between these two basement membranes, cross-sections of fibroblasts and unmyelinated nerve fibres can be detected. In some instances, unmyelinated nerve fibres have additionally been spotted beneath the basement membrane and in close contact with the cell’s plasma membrane. Although presently unconfirmed, this is considered to indicate synapses between the nerve fibres and the beta cell <ref name="PMID 5333806 "><pubmed> 5333806 </pubmed></ref>.
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Adjacent beta cells are connected to each other at distributed focal points, termed desmosomes, along their plasma membrane. Between two successive desmosomes, an intercellular space exists and its size is reliant upon the respective activity of the cells. The capillaries present within the islets of Langerhans are detached from the beta cells by two basement membranes; one related to the endothelium and the other to the capillary surface. Typically, between these two basement membranes, cross-sections of fibroblasts* and unmyelinated* nerve fibres can be detected. In some instances, unmyelinated nerve fibres have also been identified beneath the basement membrane and in close contact with the cell’s plasma membrane. Although presently unconfirmed, this is considered to indicate synapses between the nerve fibres and the beta cell<ref name="PMID5333806"><pubmed>5333806</pubmed></ref>.  
  
 
==='''Structural Modifications with Age'''===
 
==='''Structural Modifications with Age'''===
 
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Extensive studies conducted on human pancreases, from the prenatal period through to adulthood, have revealed that the anatomical architecture of pancreatic islets resemble their adult form by the age of 2. As a direct result of this, the pancreas experiences substantial beta cell proliferation* during the first 2 years after its conception, which enables significant increases in beta cell mass and area. Increased beta cell production thus manifests as an increase in the diameter of existing pancreatic islets, rather than the formation of new islets. In fact, while 10% of beta cell mass increase during early life can be attributed to islet development, a sizeable 90% can be linked to an increase in islet size. Although, beta cell replication continues throughout life, the replication rate notably decreases after adolescence and hereafter beta cell mass remains relatively constant between the ages of 20 – 100 (reviewed in<ref name="PMID26030186"><pubmed>26030186</pubmed></ref>).  
Extensive studies conducted on human pancreases from the prenatal period through to adulthood, have revealed that the anatomical architecture of pancreatic islets resemble their adult form, by the age of 2. As a direct result of this, the pancreas experiences substantial beta cell proliferation during the first 2 years after birth therefore enabling significant increases in beta cell mass and area. Increased beta cell production thus manifests as an increase in the diameter of existing pancreatic islets rather than the formation of new islets. In fact, while 10% of beta cell mass increase, during early life, can be attributed to islet development, a sizeable 90% can be linked to an increase in islet size. Although, beta cell replication continues throughout life, the replication rate notably decreases after adolescence and hereafter beta cell mass remains relatively constant between the ages of 20 – 100, as reviewed by <ref name="PMID26030186"><pubmed>26030186</pubmed></ref>.
 
  
 
==='''Structural Comparison between Humans and Mice'''===
 
==='''Structural Comparison between Humans and Mice'''===
 +
Consequential of the clinical importance of pancreas-associated disease (refer to "Pathology"), the structure of the pancreas is studied extensively within medical science. Studies of the human pancreas, nevertheless, are restricted due to the inherent ethical and medical limitations present in obtaining pancreatic samples at specific and intermittent intervals. As a result of scarce human pancreatic samples, animal models are increasingly used in scientific studies. Within current pancreatic research, mice are the most frequently studied animal models. As a sizeable portion of scientific knowledge concerning the human pancreas is derived from studies conducted on mice, it is thereby imperative to identify and understand the distinction between the human and mouse pancreas<ref name="PMID26030186"><pubmed>26030186</pubmed></ref>.
  
Consequential of the clinical importance of pancreas-associated disease, such as diabetes, endocrine tumours and pancreatic cancer, the structure of the pancreas is studied extensively within medical science. Studies of the human pancreas, however, are restricted due to the inherent ethical and medical limitations present in obtaining pancreatic samples at specific and intermittent intervals. As a direct result of scarce human pancreatic samples, animal models are increasingly used in studies. Within current pancreatic research, mice are the most frequently studied animal models. As a sizeable portion of scientific knowledge concerning the cellular architecture of the human pancreas is derived from studies conducted on mice, it is thereby imperative to identify and understand the distinction between the human and mouse pancreas.  
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[[File:Pancreatic_Anatomy_Comparison.png|thumb|400px|right|'''Figure 2.''' Comparison of the macroscopic architecture of the human pancreas (A) against the mouse pancreas (B). Image is reprinted with permission from <ref name="PMID26030186"><pubmed>26030186</pubmed></ref>.]]
  
[[File:Pancreatic_Anatomy_Comparison.png|thumb|400px|right|'''Fig 1. Comparison of the macroscopic anatomy of the human pancreas (A) against the mouse pancreas (B).''']]
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[[File:Pancreas_Drawings.png|thumb|500px|right|'''Figure 3.''' Hand-drawn illustration (by user z5158862) comparing the pancreas of the human embryo and the mouse embryo. Image is appropriated with permission from <ref name="PMID26030186"><pubmed>26030186</pubmed></ref>.]]
  
[[File:Pancreas drawings.png|thumb|500px|right|'''Hand-drawn illustration by user z5158862 comparing the pancreas of the human embryo and the pig embryo.''']]
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===='''Macroscopic Comparison'''====
 +
At a macroscopic level, the human pancreas is a well-defined organ, which contains three key structural components: the anterior and posterior head, body and tail (reviewed in<ref name="PMID16547676"><pubmed>16547676</pubmed></ref>). The left border of the superior mesenteric artery borders the head and body of the pancreas, while the midpoint of the pancreatic body and tail, combined, is understood as the border between the body and the tail. Reflecting a C-shape, the pancreatic head is continuous with the upper curvature of duodenum whereas the pancreatic tail touches the hilum of the spleen. The narrow and flat pancreatic body locates itself underneath the stomach and extends in such a manner that it crosses with the superior mesenteric artery and vein, abdominal aorta, inferior vena cava and portal vein.  
  
 +
Contradictorily, the mouse pancreas is less defined than its human counterpart, see Figure 2. and Figure 3., and in a dendritic manner, is uniquely diffused along the mesentery of the proximal small intestine of mice. Analogous to the human pancreas, it can also be distinguished into three key structural components. However, these are termed ‘lobes’ and are identified as the duodenal, splenic and gastric lobe. The largest lobe, the splenic lobe, extends between the duodenum and the spleen and is homologous to the body and the tail of the human pancreas. The second largest lobe, the duodenal lobe, is located within the mesentery, that surrounds the duodenum, and is homologous to the human pancreatic head. Additionally, the gastric lobe, which is the smallest observable lobe, is considered to be a component of the splenic lobe, from which it originally develops, and is homologous to the auricle of the human pancreas. Characteristically, patches of adipose*, connective and lymphatic tissue separate these three main pancreatic lobes in mice<ref name="PMID26030186"><pubmed>26030186</pubmed></ref>.
  
  
===='''Macroscopic Comparison'''====
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===='''Microscopic Comparison'''====
At a macroscopic level, the human pancreas is a well-defined organ, which contains three key structural components: the head, body and tail. The left border of the superior mesenteric artery borders the head and body of the pancreas, while the midpoint of the pancreatic body and tail combined is understood as the border between the body and the tail. Reflecting a C-shape, the pancreatic head is continuous with the upper curvature of duodenum whereas the pancreatic touches the hilum of the spleen and the narrow and flat pancreatic body locates itself underneath the stomach and extends in such a manner that it crosses with the superior mesenteric artery and vein, abdominal aorta, inferior vena cava and portal vein.  
+
Microscopically analysed, each lobe of the pancreas contains numerous smaller lobules, which vary in size respective to the organism and measure 1-10 mm in diameter in humans and 0.5-1.5 mm in diameter in mice. Dome-resembling clusters of pyramidal acinar cells are dispersed throughout these pancreatic lobules. They secrete various digestive enzymes, which are ultimately released into the duodenum by successive movement through intercalated ducts, intralobular ducts, interlobar ducts and finally the pancreatic duct, thus forming the exocrine pancreas. The endocrine portion of the pancreas, predominately constituting islets of Langerhans, is embedded within the exocrine tissue. Notably, the size and distribution of pancreatic islets is congruous between humans and mice. With distinctly irregular cross-sections, they are home to thousands of hormone-secreting endocrine cells, which may also be singularly and randomly scattered across acinar and ductal tissues. While a minimum of five different polypeptide endocrine cells can be identified within the islets, beta cells, which synthesize and secrete insulin, form the majority and account for 60-70% of the islet cell population in humans and 60-80% in mice.  
  
Conversely, the mouse pancreas is less defined than its human counterpart and in a dendritic manner, is uniquely diffused along the mesentery of the proximal small intestine of mice (See Fig. 2.). Analogous to the human pancreas, it can also be distinguished into three key structural components. However, these are called ‘globes’ and are recognized as the duodenal, splenic and gastric lobe. Identified as the largest lobe, the splenic lobe extends between the duodenum and the spleen and is homologous to the body and the tail of the human pancreas. The second largest lobe, the duodenal lobe, is located within the mesentery that surrounds the duodenum and is homologous to the human pancreatic head. Additionally, the gastric lobe, which is the smallest observable lobe, is considered a component of the splenic lobe, from which it originally develops, and is homologous to the auricle of the human pancreas. Typically, patches of adipose, connective, and lymphatic tissue separate these three main pancreatic lobes in mice.
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The spatial organization of beta cells has continuous focus for scientific research. In mice, the mantle component of pancreatic islets contain non-beta cells while the core component exclusively comprises beta cells. In humans, it was initially perceived that, alongside a similar mantle-core pattern, beta cells additionally formed ribbon-like clusters and were scattered throughout islets in an unorganised manner. However, consequential of recent studies, the current scientific consensus is that human pancreatic islets form trilmainar plates, which are folded into a U- or O-shape, and within which there are two layers of alpha cells that enclose a single beta cell layer. The reason for this specific organisation is considered to be the promotion of heterologous contact between both endocrine cells. Alternatively, in mice, there is homologous contact among alpha cells within the mantle of the islet and beta cells within the core of the islet. It is proposed that this specific type of spatial arrangement promotes alpha-cell-stimulation of beta cell functional activity<ref name="PMID26030186"><pubmed>26030186</pubmed></ref>.
  
===='''Microscopic Comparison'''====
 
Microscopically observed, each lobe of the pancreas contains numerous lobules, which vary in size respective to the organism and measure 1-10 mm in diameter in humans and 0.5-1.5 mm in diameter in mice. Dome-resembling clusters of pyramidal acinar cells are dispersed throughout the pancreatic lobules. They secrete various digestive enzymes, which are ultimately released into the duodenum by successive movement through intercalated ducts, intralobular ducts, interlobar ducts and finally the pancreatic duct, thus forming the exocrine pancreas. The endocrine portion of the pancreas, predominately constituting Islets of Langerhans, is embedded within the exocrine tissue. The size and distribution of pancreatic islets is congruous between humans and mice. With notably irregular cross-sections, they are home to thousands of hormone-secreting endocrine cells, which may also be singularly and randomly scattered across acinar and ductal tissues. While a minimum of 5 different polypeptide endocrine cells can be identified within the islets, beta cells, which synthesize and secrete insulin, form the majority and account for 60-70% of islet cell population in humans, and 60-80% in mice. The spatial organization of beta cells has continuous focus for scientific research. In mice, the mantle component of pancreatic islets contain non-beta cells while the core component exclusively comprise beta cells. In humans, it was originally perceived that alongside a similar mantle-core pattern, beta cells additionally formed ribbon-like clusters and were scattered throughout islets in an unorganised manner. As a consequence of recent studies, however, the current scientific consensus is that human pancreatic islets form trilmainar plates, which are folded into a U- or O-shape, and within which there are two layers of alpha cells that enclose a single beta cell layer. The reason for this specific organisation is considered to be the promotion of heterologous contact between both endocrine cells. Alternatively, in mice, there is homologous contact among alpha cells within the mantle of the islet and beta cells within the core of the islet. It is proposed that this specific type of spatial arrangement promotes alpha cell stimulation of beta cell functional activity.
 
  
 
{| class="wikitable mw-collapsible mw-" style="background: #EECCCC;"
 
{| class="wikitable mw-collapsible mw-" style="background: #EECCCC;"
! colspan="3"  style="background: #EEAAAA;" | '''Summary Table of Key Comparisons between Humans and Mice'''
+
! colspan="3"  style="background: #EEAAAA;" | '''Table 2. Summary Table of Key Comparisons between Human and Mice Pancreas'''
 
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|-
 
! style="background: #EEAAAA;" | Property
 
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== Pancreatic and Beta Cell Development==
+
=='''Pancreatic and Beta Cell Development'''==
The ultimate architecture of the complete adult pancreas is the outcome of several necessary embryologic events (reviewed in <ref name="PMID19013144"><pubmed>19013144</pubmed></ref>). During embryonic day 8.5 and 9, the emerging embryo turns from a lordotic position to a fetal position<ref name="PMID3420142"><pubmed>3420142</pubmed></ref>, which causes the endoderm layer to fold on itself and form a primitive gut tube that is divided into the foregut, midgut and the hind-gut. Upon the establishment of the gut tube, the development of the dorsal pancreas is hereafter controlled by the notochord <ref name="PMID19013144"><pubmed>19013144</pubmed></ref>, which is the source of permissive signals that enables the differentiation of the foregut endoderm into a pancreas. The removal of the notochord is scientifically evidenced to eliminate the expression of pancreatic genes thus inhibiting pancreatic development and preventing the formation of all pancreatic cells, including beta cells<ref name="PMID9334273"><pubmed>9334273</pubmed></ref>).   
+
The ultimate architecture of the complete adult pancreas is the outcome of several necessary embryologic events (reviewed in<ref name="PMID19013144"><pubmed>19013144</pubmed></ref>). During embryonic days 8.5 and 9, the emerging embryo moves from a lordotic position to a fetal position<ref name="PMID3420142"><pubmed>3420142</pubmed></ref>, which causes the endoderm layer to fold on itself and form a primitive gut tube that is divided into the foregut, midgut and hind-gut. Upon the establishment of the gut tube, the development of the dorsal pancreas is hereafter controlled by the notochord<ref name="PMID19013144"><pubmed>19013144</pubmed></ref>, which is the source of permissive signals that enable the differentiation of the foregut endoderm into a pancreas. The removal of the notochord is scientifically evidenced to eliminate the expression of pancreatic genes thus inhibiting pancreatic development and preventing the formation of all pancreatic cells, including beta cells<ref name="PMID9334273"><pubmed>9334273</pubmed></ref>).   
 
 
Of the three divisions of the gut tube, the foregut is the most essential <ref name=”PMID17185316"><pubmed>17185316</pubmed></ref> as the first morphological process in pancreatic formation, and beta cell development, is a condensation of mesenchyme covering the dorsal aspect of the endodermal gut tube in the foregut. Succeeding this condensation, at 26 days post-conception, the endoderm envaginates into the mesenchyme and the dorsal and ventral buds arise from the foregut. The buds are marked by transcription factors, such as pancreatic and duodenal homeobox factor 1 (PDX1) <ref name=”PMID17185316"><pubmed>17185316</pubmed></ref>, sex-determining region Y (SRY) - box9 (SOX9), and GATA binding protein 4 (GATA4), which are all necessary for pancreatic growth<ref name=”PMID26395141"><pubmed>26395141</pubmed></ref>. The epithelium, which constructs the mesenchyme surrounding the pancreas, coelomic epithelium, also begins to compartmentalize the pancreas away from non-gut structures and a substantial increase in the proliferation of mesenchymal cells, between the coelomic epithelium and pancreatic epithelium, is seen <ref name="PMID19013144"><pubmed>19013144</pubmed></ref>.
 
  
[[File:Pancreas development.JPG|thumb|centre|600px|caption]]
+
Of the three divisions of the gut tube, the foregut is the most essential<ref name=”PMID17185316"><pubmed>17185316</pubmed></ref> as the first morphological process in pancreatic formation, and beta cell development, is a condensation of the mesenchyme covering the dorsal aspect of the endodermal gut tube in the foregut. Succeeding this condensation, at 26 days post-conception, the endoderm evaginates into the mesenchyme and dorsal and ventral buds arise from the foregut. The buds are marked by transcription factors, such as pancreatic and duodenal homeobox factor 1 (PDX1) <ref name=”PMID17185316"><pubmed>17185316</pubmed></ref>, SRY (sex-determining region Y)-box 9 (SOX9) and GATA binding protein 4 (GATA4), which are all necessary for pancreatic growth<ref name=”PMID26395141"><pubmed>26395141</pubmed></ref>. The epithelium, which constructs the mesenchyme surrounding the pancreas, coelomic epithelium, also begins to compartmentalise the pancreas away from non-gut structures and a substantial increase in the proliferation of mesenchymal cells, between the coelomic epithelium and pancreatic epithelium, is seen<ref name="PMID19013144"><pubmed>19013144</pubmed></ref>.  
  
At approximately 37 to 42 days after gestation, the proximal portion of the dorsal bud form small accessory ducts called ducts of Santorini, while the remainder of the dorsal bud and ventral bud fuse to form the duct of Wirsung, which runs across the entire pancreas. Hereafter, the cellular architecture of the pancreas undergoes significant change and a major amplification in the amount of endocrine cells, particularly β-cells, is observed. Pancreatic acinar cells also undergo cell differentiation, acinar enzyme gene expression exponentially increases and the rough endoplasmic reticulum and zymogen granules begin forming, consequently causing the pancreas to become opaque to the naked-eye due to high zymogen granule concentrations.
+
At approximately 37 to 42 days after gestation, the proximal portion of the dorsal bud form small accessory ducts called ducts of Santorini, while the remainder of the dorsal bud and ventral bud fuse to form the duct of Wirsung, which runs across the entire pancreas. Hereafter, the cellular architecture of the pancreas undergoes significant change and a major amplification in the amount of endocrine cells, particularly β-cells, is observed. Pancreatic acinar cells also undergo cell differentiation and gene expression for acinar enzymes increase in an exponential manner. The rough endoplasmic reticulum and zymogen granules also begin forming, consequently causing the pancreas to become opaque to the naked-eye due to high zymogen granule concentrations.
  
 +
Although pancreatic alpha cells are differentiated and observed before beta cells, the earliest endocrine cells of the pancreas are collectively found in an admixture of endocrine, exocrine and epithelial cells, which all maintain close contact with the lumen. Eventual morphological transitions, however, allow endocrine cells to become distinct from epithelial cells and lose connection with the lumen<ref name="PMID19013144"><pubmed>19013144</pubmed></ref>. At this stage in development, a down regulation of PDX1, which marks pluripotent precursor cells, is detected in endocrine progenitor cells as they become non-epithelial. Throughout pancreatic maturation, PDX1 remains principally expressed in the beta cells of the pancreas population<ref name="PMID PMC232449"><pubmed> PMC232449</pubmed></ref>, which is considered to be necessary for proper endocrine differentiation<ref name="PMID3420142"><pubmed>3420142</pubmed></ref>. As the developmental process nears conclusion, endocrine cells aggregate in pancreatic ducts, as shown in Figure 4., and form islets of Langerhans<ref name="PMID19013144"><pubmed>19013144</pubmed></ref>.
  
Although pancreatic alpha cells are observed before beta cells, the earliest endocrine cells of the pancreas are collectively found in an admixture of endocrine, exocrine and epithelial cells, which all maintain close contact with the lumen. Eventual morphological transitions, however, allow endocrine cells to become distinct from epithelial cells and lose connection with the lumen <ref name="PMID19013144"><pubmed>19013144</pubmed></ref>. At this stage in development, a down regulation of Pdx1 (pancreatic and duodenal homeobox 1), which marks pluripotent precursor cells, is detected in endocrine progenitor cells as they become non-epithelial. Throughout pancreatic maturation, Pdx1 remains principally expressed in the beta cells of the pancreas population, <ref name="PMID PMC232449"><pubmed> PMC232449</pubmed></ref>, which is considered to be necessary for proper endocrine differentiation<ref name="PMID3420142"><pubmed>3420142</pubmed></ref>. As the developmental process nears conclusion, endocrine cells aggregate in pancreatic ducts and form islets of Langerhans<ref name="PMID19013144"><pubmed>19013144</pubmed></ref>.
+
[[File:Pancreas development.JPG|thumb|centre|800px|'''Figure 4.''' Endocrine cells captured, at mid-gestation, showing periductal accumulations of cells. (A) Whole-mount insulin-staining of mouse pancreas displaying insulin cells. (B) Histologic sections with insulin in yellow, ducts in green and amylase in blue displaying the distribution of endocrine cells. (C) A TGF-β receptor II mutant mouse with amplification of periductal cord-like distribution of cells shown for emphasis. Image is reprinted with permission from <ref name="PMID19013144"><pubmed>19013144</pubmed></ref>.]]
  
On a hormonal level, at around 52 days after the conception of the human pancreas, Neurogenin3 (NGN3), a regulator of pancreatic islet differentiation and regeneration is first detected in the pancreas <ref name=”PMID23630303"><pubmed>23630303</pubmed></ref>. Although the expression of the transcription factor Pdx-1 precedes them <ref name="PMID PMC232449"><pubmed> PMC232449</pubmed></ref>, insulin, glucagon, and somatostatin are the first expressed pancreatic hormones expressed. Pancreatic polypeptide is not detected until about 10 weeks post-conception. At the point where pancreatic islet formation reaches its peak, around 12 weeks into the gestation period, all four hormones are been expressed and the total number of hormone expressing cells, present within the islets, has increased <ref name=”PMID15072563"><pubmed>15072563</pubmed></ref>.
+
On a hormonal level, at around 52 days after the conception of the human pancreas, Neurogenin-3 (NGN3), a regulator of pancreatic islet differentiation and regeneration is first detected in the pancreas<ref name=”PMID23630303"><pubmed>23630303</pubmed></ref>. Although the expression of the transcription factor PDX1 precedes them<ref name="PMID PMC232449"><pubmed> PMC232449</pubmed></ref>, insulin, glucagon and somatostatin are the first pancreatic hormones expressed. Pancreatic polypeptide is not detected until about 10 weeks post-conception. At around 12 weeks into the gestation period, at the point where pancreatic islet formation reaches its peak, all four hormones are expressed and thus the total number of hormone expressing cells, present within the islets, is increased<ref name=”PMID15072563"><pubmed>15072563</pubmed></ref>.
  
 
=='''Function'''==
 
=='''Function'''==
The overall function of the pancreas is to maintain glucose levels within the blood and beta cells play a specialised role within this process. The insulin gene, which provides instructions for the manufacture of the hormone insulin, is solely expressed in the endocrine portion of the pancreas within the beta cells of pancreatic islets. Insulin, a polypeptide hormone, is a key regulator of metabolism as it promotes the storage of excess glucose, amino acids and fatty acids, by acting on the liver, muscles and adipose tissue. Insulin release into the bloodstream predominantly occurs as a consequence of increased blood glucose levels. Glucose phosphorylation, by glucokinase, is currently understood to act as the glucose sensor, as it adjusts the rate of metabolic activity to the extracellular concentration of glucose. Glucose metabolism generates intracellular signals in beta cells, which subsequently initiates insulin secretion, insulin mRNA translation and insulin gene transcription.
+
The overall function of the pancreas is to maintain glucose levels within the blood and beta cells play a specialised role within this process. The insulin gene, which provides instructions for the manufacture of insulin, is solely expressed in the endocrine portion of the pancreas within the beta cells of pancreatic islets. Insulin, a polypeptide hormone, is a key regulator of metabolism as it promotes the storage of excess glucose, amino acids and fatty acids by acting on the liver, muscle and adipose tissue. Insulin release into the bloodstream predominantly occurs as a consequence of increased glucose levels detected in the blood. Glucose phosphorylation, by glucokinase, is currently understood to act as the glucose sensor as it adjusts the rate of cellular metabolic activity to the extracellular concentration of glucose. Glucose metabolism generates intracellular signals in beta cells, which subsequently initiates insulin secretion, insulin mRNA translation and insulin gene transcription<ref name="Artner2008">Artner, I. & Stein, R. (2008).
 +
Transcriptional Regulation of Insulin Gene. ''Pancreatic Beta Cell in Health and Disease'' (pp. 13-16).</ref>.
  
 
{| class="wikitable mw-collapsible mw-"
 
{| class="wikitable mw-collapsible mw-"
!Video 2. Video elucidating the function of insulin in the human body: &nbsp;
+
!Video 2. Video Elucidating the Function of Insulin in the Human Body: &nbsp;
 
|-
 
|-
 
|<html5media>https://www.youtube.com/watch?v=OYH1deu7-4E</html5media>
 
|<html5media>https://www.youtube.com/watch?v=OYH1deu7-4E</html5media>
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==='''Insulin Gene Expression'''===  
 
==='''Insulin Gene Expression'''===  
In the late 1980s, the 5’ flanking region of the insulin gene was identified in transgenic mice. This proved to be an extraordinary breakthrough as it allowed the general location of binding sites, for transcription factors, to be discovered. The transcription factor binding sites, which direct beta-cell-specific expression, were eventually located to be between −520 and +1 base pairs relative to the transcription initiation site. In later studies, congruous expression data was collected for the human insulin gene. Both results thus collectively indicate that there are sequences conserved between mammalian insulin genes, which lie within 350bp of the transcription start site and control the specific cell-type expressions. The enhancer region in mammalian insulin genes is located between nucleotides -340 and -91. While the transcription factors that bind onto this region principally determine the glucose-regulated expression properties of the gene, the activity of the enhancer can be additionally up-regulated and/or down-regulated by cellular activity. For example, through autocrine signalling, the insulin secreted from beta cells may increase insulin transcription in the same beta cells, by positively influencing enhancer-mediated activation <ref name="Artner2008">Artner, I. & Stein, R. (2008). 
Transcriptional Regulation of Insulin Gene. ''Pancreatic Beta Cell in Health and Disease'' (pp. 13-16).</ref>.
+
In the late 1980s, the 5’ flanking region of the insulin gene was identified in transgenic mice. This proved to be an extraordinary breakthrough in science as it allowed the general location of binding sites, for transcription factors, to be discovered. The transcription factor binding sites, which direct beta-cell-specific expression, were eventually located to be between −520 and +1 base pairs relative to the transcription initiation site. In later studies, congruous expression data was collected for the human insulin gene. Both results thus collectively indicate that there are sequences conserved between mammalian insulin genes, which lie within 350bp of the transcription start site and control the specific cell-type expressions. The enhancer region in mammalian insulin genes is located between nucleotides -340 and -91. While the transcription factors that bind onto this region principally determine the glucose-regulated expression properties of the gene, the activity of the enhancer can be additionally up-regulated and/or down-regulated by cellular activity. For example, through autocrine signalling, the insulin secreted from beta cells may increase insulin transcription in the same beta cells, by positively influencing enhancer-mediated activation<ref name="Artner2008">Artner, I. & Stein, R. (2008).  
 +
Transcriptional Regulation of Insulin Gene. ''Pancreatic Beta Cell in Health and Disease'' (pp. 13-16).</ref>.
 +
 
 +
 
  
 
==='''Insulin Biosynthesis'''===
 
==='''Insulin Biosynthesis'''===
In the 1950s, insulin (as show in Fig. x) became the first protein to have its structure clearly revealed. The discovery exposed insulin as a two-chain hormone and consequently triggered widespread speculation in the scientific community on the underlying mechanisms contributing to such a structure. Succeeding the discovery of single-chain precursor proteins, which occurred in 1967, insulin synthesis was finally understood to occur through several reactions with multiple single-chained precursor proteins, including preproinsulin and proinsulin.  
+
In the 1950s, insulin, as show in Figure. 5, became the first protein to have its structure clearly revealed. The discovery exposed insulin as a two-chain hormone and consequently triggered widespread speculation in the scientific community on the underlying mechanisms contributing to such a structure. Succeeding the discovery of single-chain precursor proteins, which occurred in 1967, insulin synthesis was finally understood to occur through several reactions with multiple single-chained precursor proteins, including preproinsulin and proinsulin.  
  
During insulin biosynthesis, the initial product formed instantaneously after insulin mRNA translation is preproinsulin, which contains a hydrophobic N-terminal 24 residue signal peptide. The signal peptide engages with the signal recognition particle (SRP), a ribonucleoprotein particle that is located within the cytosol, which enables the separation of the preproinsulin polypeptide chain from the cytosolic compartment into the secretory pathway. From here, the preprohormone is translocated across the membrane of the rough endoplasmic retiticulum (RER) and into its lumen, via a peptide-conducting channel. A specialized signal peptidase, situated on the surface of the RER membrane, cleaves and rapidly degrades the signal sequence. Inside the RER, several chaperone proteins, catalyse the folding of proinsulin and facilitate its manufacture of three disulfide bonds, which largely contribute to the development of its native structure.  
+
[[File:Proinsulin to Insulin.JPG|thumb|left|350px|'''Figure 5.'''Diagrammatic representation of proinsulin conversion to insulin. The image reveals the two-chain structure of insulin. Image is reprinted with permission from <ref name=”PMID26216140"><pubmed>26216140</pubmed></ref>.]]
  
[[File:Proinsulin to Insulin.JPG|Thumb|left|400px|'''Figure X. Diagrammatic representation of proinsulin to insulin''']]
+
During insulin biosynthesis, the initial product formed instantaneously after insulin mRNA translation is preproinsulin, which contains a hydrophobic N-terminal 24 residue signal peptide. The signal peptide engages with the signal recognition particle (SRP), a ribonucleoprotein particle that is located within the cytosol, which enables the separation of the preproinsulin polypeptide chain from the cytosolic compartment into the secretory pathway. From here, the preprohormone is translocated across the membrane of the rough endoplasmic reticulum (RER) and into its lumen, via a peptide-conducting channel. A specialized signal peptidase, situated on the surface of the RER membrane, cleaves and rapidly degrades the signal sequence. Inside the RER, several chaperone proteins catalyse the folding of proinsulin and facilitate its manufacture of three disulfide bonds, which largely contribute to the development of its native structure.
  
Within a time period of ~10-20 minutes, proinsulin is rapidly transported from the RER to the Golgi apparatus. Here, proinsulin is packaged into immature secretory vesicles [REF] and cleaved to form equimolar amounts of insulin and connecting polypeptide (C-peptide) <ref name="Steiner2008">Steiner, D. (2008). The Biosynthesis of Insulin. ''Pancreatic Beta Cell in Health and Disease'' (pp. 31-37).</ref>. The predominant route for proinsulin processing is via cleavage at the junctions resulting in a 32,33 proinsulin peptide split, followed by the removal of 2 amino acids resulting in Des-31,32 proinsulin which finally becomes mature C-peptide and insulin with the action of pro-protein convertase-2 (PC2) and carboxypeptide-E (CPE). The alternative pathway which occurs less commonly is where the 2 amino acids are removed first (see Figure X)  <ref name=”PMID26216140"><pubmed>26216140</pubmed></ref>.  
+
Within a time period of ~10-20 minutes, proinsulin is rapidly transported from the RER to the Golgi apparatus. Here, proinsulin is packaged into immature secretory vesicles and cleaved to form equimolar amounts of insulin and connecting polypeptide (C-peptide) <ref name="Steiner2008">Steiner, D. (2008). The Biosynthesis of Insulin. ''Pancreatic Beta Cell in Health and Disease'' (pp. 31-37).</ref>. The predominant route for proinsulin processing is via cleavage at the junctions resulting in a 32,33 proinsulin peptide split, followed by the removal of 2 amino acids resulting in Des-31,32 proinsulin which finally forms mature C-peptide and insulin by the action of pro-protein convertase-2 (PC2) and carboxypeptide-E (CPE), see Figure. 5. The alternative pathway, which occurs less commonly, involves the removal of 2 amino acids are first<ref name=”PMID26216140"><pubmed>26216140</pubmed></ref>. The formation of insulin from its precursor, proinsulin, is initiated approximately 20 minutes after the synthesis of preproinsulin and typically lasts for 1-2 hours, independent of additional protein synthesis.  
  
While proinsulin and insulin have a direct biological effect, C-peptide has no effect on homologous or heterologous tissue and no ability to influence the concentration or action of beta cell hormones (reviewed in <ref name=”PMID403392"><pubmed>403392</pubmed></ref>). Although small volumes of proinsulin and its immediate cleavage forms, C-peptide and insulin are collectively stored in the secretion granules of beta cells, insulin is the predominant hormone released after signalling.
+
While proinsulin and insulin have a direct biological effect, C-peptide has no effect on homologous or heterologous tissue and no ability to influence the concentration or action of beta cell hormones (reviewed in<ref name=”PMID403392"><pubmed>403392</pubmed></ref>). Although small volumes of proinsulin and its immediate cleavage forms, C-peptide and insulin, are collectively stored in the secretion granules of beta cells, insulin is the predominant hormone released after signalling. Notably, proinsulin and insulin share similarities with respect to many of their properties, including solubility, isoelectric point, self-associative properties and relative reactivity with insulin antiserum<ref name="Artner2008"></ref>. The insulin moiety found within proinsulin is also highly similar to the one present in insulin itself, thus making their overall conformation highly similar<ref name=”PMID2252901"><pubmed>2252901</pubmed></ref>.
  
The formation of insulin from its precursor, proinsulin, is initiated approximately 20 minutes after the synthesis of preproinsulin and typically lasts for 1-2 hours, independent of additional protein synthesis.
 
  
Notably, proinsulin and insulin share similarities with respect to many of their properties, including solubility, isoelectric point, self-associative properties and relative reactivity with insulin antiserum. The insulin moiety found within proinsulin is also highly similar to the one present in insulin itself, as indicated by nuclear magnetic resonance (NMR) imaging.  
+
==='''Cell Biology of Insulin Biosynthesis'''===
 +
Congruous to other neurosecretory cells, the Golgi apparatus plays a substantial role in the formation of secretory granules in beta cells. However, its dynamic nature and the underlying mechanisms, which facilitate the transport and sorting of secretory products within it, is currently only partially understood. With further research, new models for Golgi progression are continuously proposed. Currently, a scientifically favoured model presents a form of the Golgi apparatus wherein individual cisternae, containing their secretory contents, migrate from cis to trans while small, coated vesicles transport various Golgi resident proteins and enzymes in an opposite manner from trans to cis. Relative to this model, while secretory products mature, they are kept in the same compartment and only exit from it as they dissipate into the trans Golgi network into immature secretory granules. Recent immunocyto-chemical studies have established that newly synthesized clathrin-clad granules in the trans Golgi cisternal network (TGN) are rich in proinsulin, which confirms the proposal that proinsulin conversion to insulin occurs principally during the maturation of the secretory granules. The proteolytic processing of proinsulin may be prevented by energy poisons, which block their transfer into secretory vesicles. Nevertheless, once newly manufactured proinsulin has reached the trans Golgi, energy is no longer required to convert it to insulin. While proinsulin conversion may begin in the trans compartment of the Golgi apparatus, it is now confirmed that it occurs predominantly within newly manufactured secretory vesicles as they leave the Golgi region and mature biochemically in the cytosol<ref name="Steiner2008"></ref>.
  
Image Proinsulin and Image insulin
+
===='''Quantitative Aspects of Insulin Secretion'''====
 +
In the late 1960s, the dynamics of insulin secretion, in response to glucose stimulation was studied and results demonstrated that glucose infused into the pancreas for extended amount of time, led to two different phases of insulin release. The first phase was characterised by rapid insulin release for 2 minutes, while the latter phase involved the continuous release of insulin, which slowly increased in rate until the termination of the glucose stimulus<ref name="PMID4877098"><pubmed>4877098</pubmed></ref>. 
  
==='''Cell Biology of Insulin Biosynthesis'''===
+
This was the first indication that insulin release from beta cells follows a biphasic pattern<ref name="PMID12879249"><pubmed>12879249</pubmed></ref>. Insulin release in the initial phase is due to ATP-dependent potassium channels, which allow increased calcium influx and the discharge of ready and releasable insulin-containing granules. The second phase involves preparing granules for release and is thought to include the translocation of granules and checks to ensure that they are competent for exocytosis. Insulin secretion in the second phase therefore occurs over a greater length of time. In fact, in mouse islets, of the 13 000 granules present in beta cells, only ~100 are ready for release in phase one and thus the others must be finalized in phase two<ref name="PMID11815463"><pubmed>11815463</pubmed></ref>. Quantitative comparisons can be made between both phases of insulin release by reports, which state that first and second phase insulin secretion in mouse islets occur at a rate of 0.14%/min and 0.05%/min, respectively<ref name="PMID12879249"><pubmed>12879249</pubmed></ref>.
Congruous to other neurosecretory cells, the Golgi apparatus plays a substantial role in the formation of secretory granules in beta cells. However, its dynamic nature and the underlying mechanisms, which facilitate the transport and sorting of secretory products within it, is currently only partly understood. With further research, new models for Golgi progression are continuously proposed. Currently, a scientifically favoured model presents a form of the Golgi apparatus wherein individual cisternae, containing their secretory contents, migrate from cis to trans while small, coated vesicles transport various Golgi resident proteins and enzymes in an opposite manner from trans to cis. Relative to this model, while secretory products mature, they are kept in the same compartment and only exit from it as they dissipate into the trans Golgi network into immature secretory granules. Recent immunocyto-chemical studies have established that newly synthesized clathrin-clad granules in the trans Golgi cisternal network (TGN) are rich in proinsulin, which confirms the proposal that conversion to insulin occurs principally during the maturation of the secretory granules. The proteolytic processing of proinsulin may be prevented by energy poisons, which block their transfer into secretory vesicles. Nevertheless, once newly manufactured proinsulin has reached the trans Golgi, energy is no longer required to convert it to insulin. While proinsulin conversion may begin in the trans compartment of the Golgi apparatus, it is now confirmed that it occurs predominantly within newly manufactured secretory vesicles as they leave the Golgi region and mature biochemically in the cytosol (see Fig y.) <ref name="Steiner2008"></ref>..
 
  
 
=='''Signalling'''==
 
=='''Signalling'''==
 
 
==='''The Stimulus-Secretion Coupling Mechanism'''===
 
==='''The Stimulus-Secretion Coupling Mechanism'''===
Stimulus-secretion coupling refers to glucose-dependent insulin secretion from beta cells. Congruous to muscle cells, beta cells are also dependent on electrical activity and calcium entry in order to discharge insulin into the body. As a result, they have specific ion channels located in their plasma membrane, which enable the flow of calcium and potassium ions into and out of the cell. As these ions are electrically charged, their movement across the membrane causes action potentials, which are sharp changes in voltage <ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.  
+
Stimulus-secretion coupling refers to glucose-dependent insulin secretion from beta cells. Congruous to muscle cells, beta cells are also dependent on electrical activity and calcium entry in order to discharge insulin into the body. As a result, they have specific ion channels located in their plasma membrane, which enable the flow of calcium and potassium ions into and out of the cell. As these ions are electrically charged, their movement across the membrane causes action potentials, which are sharp changes in voltage<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.  
  
[[File:Signalling of beta-cell.JPG|thumb|centre|400px|Caption]]
+
In pancreatic beta cells, an increase in blood glucose levels block ATP-dependent potassium channels thus leading to the depolarisation of the membrane. Initially identified in ventricular myocytes, ATP-sensitive potassium channels are potassium channels that are inhibited by high intracellular concentrations of ATP (reviewed in<ref name="PMID3662377"><pubmed>3662377</pubmed></ref>. As the activation of these channels disallow the production of action potentials, their inhibition, by glucose, stimulates action potentials by triggering voltage-dependent calcium channels in the membrane to open and thus allow increased calcium influx into the cell (reviewed in<ref name="PMID1779997"><pubmed>1779997</pubmed></ref>). Within the cell, the calcium ions act on exocytotic machinery to stimulate the merging of vesicles, containing insulin, with the plasma membrane, thereby preparing them for secretion into the blood stream <ref name="PMID12879249"><pubmed>12879249</pubmed></ref>.  
  
In pancreatic beta cells, an increase in blood glucose levels blocks ATP-dependent potassium channels thus leading to the depolarisation of the membrane. Initially identified in ventricular myocytes, ATP-sensitive potassium channels are potassium channels that are inhibited by high intracellular concentrations of ATP (reviewed in<ref name="PMID3662377"><pubmed>3662377</pubmed></ref>. As the activation of these channels disallow the production of action potentials, their inhibition, by glucose, stimulates action potentials by triggering voltage-dependent calcium channels in the membrane to open and thus allow increased calcium influx into the cell (reviewed in<ref name="PMID1779997"><pubmed>1779997</pubmed></ref>). Within the cell, the calcium ions act on exocytotic machinery to stimulate the merging of vesicles, containing insulin, with the plasma membrane, thereby preparing them for secretion into the blood stream <ref name="PMID12879249"><pubmed>12879249</pubmed></ref>.  
+
Conversely, as the electrical activity induced in beta cells is mainly due to calcium ion influx <ref name="PMID1309425"><pubmed>1309425</pubmed></ref>, decreased extracellular levels of calcium ions prevent the firing of action potentials and thus, by extension, inhibit insulin secretion <ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.  
  
Conversely, as the electrical activity induced in beta cells is mainly due to calcium ion influx <ref name="PMID1309425"><pubmed>1309425</pubmed></ref>, decreased extracellular levels of calcium ions prevent the firing of action potentials and thus, by extension, inhibit insulin secretion <ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.  
+
[[File:Signalling of beta-cell.JPG|thumb|centre|600px|'''Figure 6.''' An illustration of the endocrine pancreatic cell population with focus on the beta cell and its intracellular signalling mechanisms. Image is reprinted with permission from <ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.]]
  
 
===='''Glucose Metabolism and Potassium Channels'''====
 
===='''Glucose Metabolism and Potassium Channels'''====
 +
As glucose breakdown is imperative for insulin secretion, the inhibition of mitochondrial metabolism prevents insulin from being secreted by beta cells. Adenosine triphosphate (ATP) is the major product of glucose metabolism and therefore is a key factor that links the mitochondrial metabolism of glucose and ATP-sensitive potassium channels. ATP-dependent potassium channels contain four pore-forming subunits alongside four accessory sulfonylurea receptor subunits (SUR1). These SUR1 subunits are essential components of beta cells, as they are the focus site for anti-diabetic sulphonylurea drugs, which aim to increase insulin secretion by replicating the effect of glucose in order to block ATP-sensitive potassium channels<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.
  
As glucose breakdown is imperative for insulin secretion, the inhibition of mitochondrial metabolism prevents insulin from being secreted by beta cells. Adenosine triphosphate (ATP) is the major product of glucose metabolism and therefore is a key factor that links the mitochondrial metabolism of glucose and ATP-sensitive potassium channels. ATP-dependent potassium channels contain four pore-forming subunits alongside four accessory sulfonylurea receptor subunits (SUR1). These SUR1 subunits are essential components of beta cells, as they are the focus site for anti-diabetic sulphonylurea drugs, which aim to increase insulin secretion by replication the effect of glucose in order to block ATP-sensitive potassium channels <ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.
+
While increased glucose levels generate a high cytoplasmic concentration of ATP and depolarize beta cells by blocking ATP-sensitive potassium channels<ref name="PMID2417189"><pubmed>2417189</pubmed></ref>, under low concentrations of glucose, these channels are open and enable the outward flux of potassium, causing a negative cellular membrane potential of ~ -70 mV. At this point, action potentials cease to occur and insulin exocytosis is inhibited. The membrane potential is only increased to more positive values once glucose-induced increases in ATP drive the closure of ATP-sensitive potassium channels. Hereafter, L-type voltage-dependent calcium channels, which are predominately expressed in beta cells, allow the release of insulin into the blood in order to maintain glucose homeostasis<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.  
 
 
While increased glucose levels generate a high cytoplasmic concentration of ATP and depolarize beta cells by blocking ATP-sensitive potassium channels<ref name="PMID2417189"><pubmed>2417189</pubmed></ref>, under low concentrations of glucose, these channels are open and enable the outward flux of potassium, causing a negative cellular membrane potential of ~ -70 mV. At this point, action potentials cease to occur and insulin exocytosis is inhibited. The membrane potential is only increased to more positive values once glucose-induced increases in ATP drive the closure ATP-sensitive potassium channels. Hereafter, L-type voltage-dependent calcium channels, which are predominately expressed in beta cells, allow the release of insulin into the blood in order to maintain glucose homeostasis<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.  
 
  
 
===='''Un-Coupling Glucose Metabolism and ATP Production in Beta Cells'''====
 
===='''Un-Coupling Glucose Metabolism and ATP Production in Beta Cells'''====
As mentioned above, the voltage of the cell membrane is dependent upon changes in the intracellular concentration of ATP. As a result of this, perturbations of metabolic pathways that produce ATP can, by extension, impact insulin secretion by beta cells. In all cells, ATP is generated in the mitochondria<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>, which produces approximately 95% of the cell’s energy and is therefore colloquially termed “powerhouse of the cell” <ref name="PMID22901785"><pubmed>22901785</pubmed></ref>. Within the mitochondria, the electron transport chain (ETC) is the central machinery responsible for ATP production (reviewed in <ref name="PMID24372303"><pubmed>24372303</pubmed></ref>) and is heavily reliant upon a proton gradient across the mitochondrial membrane<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.  
+
As mentioned above, the voltage of the cell membrane is dependent upon changes in the intracellular concentration of ATP. As a result of this, perturbations of metabolic pathways that produce ATP can, by extension, impact insulin secretion by beta cells. In all cells, ATP is generated in the mitochondria<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>, which produces approximately 95% of the cell’s energy and is therefore colloquially termed “(the) powerhouse of the cell”<ref name="PMID22901785"><pubmed>22901785</pubmed></ref>.  
  
The ETC is composed of four enzyme complexes that transfer electrons from donors, such as NADH, to the ultimate electron accepter, oxygen. Throughout this transfer of electron, the ETC concurrently pumps protons, or hydrogen ions (H+), into the inter-membrane space, which subsequently generates a gradient across the inner mitochondrial membrane. ATPase, an enzyme, then harnesses this gradient to drive ATP synthesis<ref name="PMID4522279
+
Within the mitochondria, the electron transport chain (ETC), as depicted in Figure 7., is the central machinery responsible for ATP production (reviewed in<ref name="PMID24372303"><pubmed>24372303</pubmed></ref>) and is heavily reliant upon a proton gradient across the mitochondrial membrane<ref name="PMID1363709"><pubmed>1363709</pubmed></ref>. The four enzyme complexes of the ETC transfer electrons from donors, such as NADH, to the ultimate electron accepter, oxygen. Throughout this transfer of electron, the ETC concurrently pumps protons, or hydrogen ions (H+), into the inter-membrane space, which subsequently generates a gradient across the inner mitochondrial membrane. ATPase, an enzyme, then harnesses this gradient to drive ATP synthesis<ref name="PMID4522279"><pubmed>4522279</pubmed></ref>. This process is additionally explained in Video 3.  
"><pubmed>4522279</pubmed></ref> (as shown in Figure. X and further explain in Video 3.).  
 
  
[[File:Electron transport chain(2).JPG|thumb|centre|600px|caption]]
+
[[File:Electron transport chain(2).JPG|thumb|centre|600px|'''Figure 7.''' Illustration of the components of the Mitochondrial Electron Transport Chain. Image is reprinted with permission from <ref name="PMID 20346106"><pubmed> 20346106 </pubmed></ref>]]
  
Specifically within beta cells, the uncoupling protein-2 (UCP2) can largely impair the generation of ATP via the mitochondrial ETC as it enables a proton leakage across the mitochondrial membrane <ref name="PMID1363709"><pubmed>1363709</pubmed></ref> and therefore inhibits the necessary formation of a proton gradient. The overexpression of UCP2 can therefore bypass the production of ATP, which is reinforced by studies that report a 50% reduction in the ATP content in the cells of UCP-2-induced pancreatic islets <ref name="PMID11375330"><pubmed>11375330</pubmed></ref>), On the other hand, a loss of UCP2 expression is hence responsible for increased intracellular ATP concentrations and glucose-stimulated insulin secretion by beta cells, which serves to decrease levels of glycemia <ref name="PMID11440717"><pubmed>11440717</pubmed></ref>). It has also been discovered that the expression of Sirt1in beta cells downregulates UCP2 expression, further enhancing insulin secretion <ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.
+
Specifically within beta cells, the uncoupling protein-2 (UCP2) can largely impair the generation of ATP via the mitochondrial ETC as it enables a proton leakage across the mitochondrial membrane<ref name="PMID1363709"><pubmed>1363709</pubmed></ref> and therefore inhibits the necessary formation of a proton gradient. The over-expression of UCP2 can therefore bypass the production of ATP, which is reinforced by studies that report a 50% reduction in ATP content in the cells of UCP-2-induced pancreatic islets<ref name="PMID11375330"><pubmed>11375330</pubmed></ref>). On the other hand, a loss of UCP2 expression is hence responsible for increased intracellular ATP concentrations and glucose-stimulated insulin secretion by beta cells, which serves to decrease levels of glycemia<ref name="PMID11440717"><pubmed>11440717</pubmed></ref>). It has also been discovered that the expression of Sirt1, in beta cells, downregulates UCP2 expression, further enhancing insulin secretion <ref name="PMID1363709"><pubmed>1363709</pubmed></ref>.
  
 
{| class="wikitable mw-collapsible mw-"
 
{| class="wikitable mw-collapsible mw-"
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[https://www.youtube.com/watch?v=6W-7FG9KlpA Youtube Link]
 
[https://www.youtube.com/watch?v=6W-7FG9KlpA Youtube Link]
 
|}
 
|}
 
===='''Quantitative Aspects of Insulin Secretion'''====
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Article on signalling: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3081169/
 
 
- development and differentiation
 
 
- how the somatic cell knows to differentiate into a beta cell
 
 
- how the body communicates to the beta cell that insulin needs to be released
 
 
- how the cell knows that there is excess insulin - ie. how it switches off?
 
 
- receptors on different cells and organs
 
 
- what initiates secretion
 
 
- receptors
 
 
- hormones - secretion, breakdown
 
  
 
=='''Role in Pathology'''==
 
=='''Role in Pathology'''==
 
+
As established above, insulin is vital in the maintenance of glucose levels in blood. Through the signalling of liver, muscle and fat cells, insulin enables glucose uptake and allows for its use as an energy source. When the body has a sufficient amount of energy, insulin signals the liver to take up excess glucose and store it as glycogen. Thus, in the absence of insulin or responsiveness to insulin, glucose remains in the blood stream resulting in a rise of blood-glucose levels, leading to diabetes. This concept is reiterated visually in Video 4.  
To reiterate the sections above, insulin is vital in the maintenance of glucose levels. Through signalling of liver, muscle and fat cells, insulin allows for the uptake of glucose, allowing for its use as an energy source. When the body has a sufficient amount of energy, insulin signals the liver to take up glucose and store it as glycogen. Thus in the absence of insulin or responsiveness to insulin, glucose remains in the blood stream resulting in a rise of blood-glucose levels. Refer to the video below for a visual conceptual explanation of the relationship between insulin, glucose and diabetes.
 
  
 
{| class="wikitable mw-collapsible mw-"
 
{| class="wikitable mw-collapsible mw-"
!Video 4. Video to understand the connection between insulin and diabetes: &nbsp;
+
!Video 4. Explanation of the relationship between insulin, glucose and diabetes: &nbsp;
 
|-
 
|-
 
|<html5media>https://www.youtube.com/watch?v=rPLjSY00JlE</html5media>
 
|<html5media>https://www.youtube.com/watch?v=rPLjSY00JlE</html5media>
Line 266: Line 231:
  
 
==='''Disease'''===
 
==='''Disease'''===
 +
The role of beta cells in disease in explained in Table 3.
  
 
{| class="wikitable" style= "text-align: top-left cell;" style="background: #EECCCC;"
 
{| class="wikitable" style= "text-align: top-left cell;" style="background: #EECCCC;"
 +
! colspan="3"  style="background: #EEAAAA;" | '''Table 3. Comparison of Type 1 and Type 2 Diabetes Mellitus'''
 
|-
 
|-
 
! style="background: #EEAAAA;" |  
 
! style="background: #EEAAAA;" |  
Line 273: Line 240:
 
! style= "width: 500px;" style="background: #EEAAAA;" | Type 2 Diabetes Mellitus (T2DM)
 
! style= "width: 500px;" style="background: #EEAAAA;" | Type 2 Diabetes Mellitus (T2DM)
 
|-
 
|-
| style="background: #EEAAAA;" | '''Epidimiology'''
+
| style="background: #EEAAAA;" | '''Epidemiology*'''
 
|  
 
|  
Type 1 diabetes is one of the most common chronic childhood diseases  
+
Type 1 diabetes is one of the most common chronic childhood diseases:
  
* It appears two peaks occur in the presentation of type 1 diabetes; between the age of 5-7 and the other occurring near puberty. <ref name="PMID18502302"><pubmed>18502302</pubmed></ref>  
+
* Two peaks in its occurrence present between the age of 5-7 and near puberty<ref name="PMID18502302"><pubmed>18502302</pubmed></ref>.
* accounts for approximately 5-10% of the diabetic population worldwide. <ref name="PMID9914216"><pubmed>9914216</pubmed></ref>  
+
* Accounts for approximately 5-10% of the diabetic population worldwide<ref name="PMID9914216"><pubmed>9914216</pubmed></ref>.
  
Type 1 diabetes varies dramatically on a global scale with more than 350-fold variation in incidence among reporting countries; overall:  
+
Type 1 diabetes varies dramatically on a global scale with >350-fold variation in incidence among reporting countries; overall:  
  
* least common in China, India and Venezuela
+
* It is the least common in China, India and Venezuela
* most common in Finland as well as Sweden, Norway, Portugal, Great Britain, Canada and New Zealand. <ref name="PMID20723815"><pubmed>20723815</pubmed></ref>
+
* It is the most common in Finland as well as Sweden, Norway, Portugal, Great Britain, Canada and New Zealand<ref name="PMID20723815"><pubmed>20723815</pubmed></ref>.
 
|  
 
|  
* The number of type 2 diabetes is increasing with 80% living in low and middle income countries.  
+
* The number of type 2 diabetes patients is currently increasing, with 80% living in low and middle income countries.  
* It is estimated that 439 million people would have type 2 diabetes by the year 2030 <ref name="PMID20622160"><pubmed>20622160</pubmed></ref>.  
+
* It is estimated that 439 million people will have type 2 diabetes by the year 2030<ref name="PMID20622160"><pubmed>20622160</pubmed></ref>.  
* The incidence varies substantially from one geographic region to the next due to environmental and lifestyle risk factors <ref name="PMID11742409"><pubmed>11742409</pubmed></ref>.
+
* Type 1 diabtes incidence varies substantially from one geographic region to the another as a result of environmental and lifestyle risk factors<ref name="PMID11742409"><pubmed>11742409</pubmed></ref>.
 
|-
 
|-
 
| style="background: #EEAAAA;" | '''Cause'''
 
| style="background: #EEAAAA;" | '''Cause'''
 
|
 
|
Type 1 diabetes results from an insulin deficiency that is caused by the loss of pancreatic beta cells
+
Type 1 diabetes results from an insulin deficiency that is caused by the loss of pancreatic beta cells. This can be consequential of:
  
* consequence of autoimmune destruction of beta cells that generally occurs over an extended period of time
+
* Autoimmune destruction of beta cells, which generally occurs over an extended period of time
* Genetic susceptibility is believed to be a prerequisite for type 1 diabetes. <ref name="PMID9914216"><pubmed>9914216</pubmed></ref> However in a study by Barnett, Leslie & Pyke (1981)
+
* Genetic susceptibility, which is believed to be a prerequisite for type 1 diabetes<ref name="PMID9914216"><pubmed>9914216</pubmed></ref> However in a study by Barnett, Leslie & Pyke (1981). However type 1 diabetes does not fit any simple inheritance pattern and is considered a complex multifactorial disease<ref name="PMID22315720"><pubmed>22315720</pubmed></ref>.
* However type 1 diabetes does not fit any simple inheritance pattern and is considered a complex multifactorial disease. <ref name="PMID22315720"><pubmed>22315720</pubmed></ref>
 
  
Early familial and twin studies supported the importance of both genetic and environmental risk factors. <ref name="PMID7193616"><pubmed>7193616</pubmed></ref>
+
Early familial and twin studies support the importance of both genetic and environmental risk factors<ref name="PMID7193616"><pubmed>7193616</pubmed></ref>:
  
* the analysis of 200 pairs of identical twins within different age groups revealed approximately half the pairs were discordant'; suggesting type 1 diabetes was not entirely genetically based.  
+
* An analysis of 200 pairs of identical twins, within different age groups, revealed that approximately half the pairs were discordant; suggesting that type 1 diabetes is not entirely genetically based.  
* An environmental or alternative non-genetic cause was suggested as twins that were living separately between the ages of 20-39 were shown to have a greater number of discordance.<ref name="PMID7193616"><pubmed>7193616</pubmed></ref>
+
* An environmental, or alternative non-genetic, cause was suggested as twins that were living separately, between the ages of 20-39, were shown to have a greater number of discordance<ref name="PMID7193616"><pubmed>7193616</pubmed></ref>.
  
 
|  
 
|  
* Pancreatic beta-cell dysfunction and failure results in the prevalence of type 2 diabetes.
+
* Pancreatic beta-cell dysfunction and failure results in the prevalence of type 2 diabetes:
 +
 
 +
 
 +
In the normal healthy body, beta-cells are able to function at a greater capacity when glucose increases, thus producing more insulin to maintain glucose homeostasis. Beta cells are able to adapt to the change by introducing in a compensatory response in insulin production. Beta-cell dysfunction is seen in Type 2 diabetes as this compensatory response results in the gradual failure of beta cells, primarily due to insulin resistance within the individual<ref name="PMID27536890"><pubmed>27536890</pubmed></ref>.
  
In the normal healthy body, beta-cells are able to function at a greater capacity when glucose increases, thus producing more insulin to maintain glucose homeostasis; beta cells are able to adapt resulting in a compensatory response in insulin production. Beta-cell dysfunction is seen inType 2 diabetes as the compsenatory response results in gradual failure of beta cells, primarily due to insulin resistance within the individual <ref name="PMID27536890"><pubmed>27536890</pubmed></ref>
+
Primarily lifestyle factors cause this insulin resistance to occur. Such factors may include:
  
Primarily lifestyle factors cause this insulin resistance to occur;
+
* Physical inactivity
 +
* Sedentary lifestyle  
 +
* Cigarette smoking and generous consumption of alcohol
 +
* Obesity contributing to 55% of cases<ref name="PMID18055651"><pubmed>18055651</pubmed></ref>.
  
* physical inactivity,
 
* sedentary lifestyle,
 
* cigarette smoking and generous consumption of alcohol;
 
* obesity contributing to 55% of cases. <ref name="PMID18055651"><pubmed>18055651</pubmed></ref>.
 
  
Recent increase in occurence of type 2 diabetes may also be attributed to environmental factors as reveiwed by Olokoba et al. (2012) <ref name="PMID23071876"><pubmed>23071876</pubmed></ref>.
+
Recent increases in the occurrence of type 2 diabetes may also be attributed to environmental factors (reveiwed in <ref name="PMID23071876"><pubmed>23071876</pubmed></ref>).
  
 
|-  
 
|-  
 
| style="background: #EEAAAA;" | '''Symptoms'''
 
| style="background: #EEAAAA;" | '''Symptoms'''
 
|  
 
|  
* Polyuria,
+
* Polyuria*
* increased thirst,
+
* Increased thirst
* unexplained weight loss,
+
* Unexplained weight loss  
* blurred vision,  
+
* Blurred vision,  
* fasting plasma glucose of >126mg/dL (7.0mmol/L) ,  
+
* Fasting plasma glucose* of >126mg/dL (7.0 mmol/L) ,  
* two hour postload plasma glucose of >200mg/dL (11.1 mmol/L) during standard oral glucose tolerance test (OGTT) <ref name="PMID9203460"><pubmed>9203460</pubmed></ref>
+
* Two hour post-load plasma glucose of >200 mg/dL (11.1 mmol/L) during standard oral glucose tolerance test (OGTT)* <ref name="PMID9203460"><pubmed>9203460</pubmed></ref>
 
|
 
|
 
* Polyuria,
 
* Polyuria,
* polydipsia,  
+
* Polydipsia*,  
* polyphagia,
+
* Polyphagia*,
* raised fasting plasma glucose >126mg/dL (7.0mmol/L),  
+
* Raised fasting plasma glucose >126mg/dL (7.0 mmol/L),  
* two hour postload plasma glucose of >200mg/dL (11.1 mmol/L) during standard oral glucose tolerance test (OGTT) ( as reviewed by Olokoba et al. 2012)  <ref name="PMID23071876"><pubmed>23071876</pubmed></ref>
+
* Two hour post-load plasma glucose of >200mg/dL (11.1 mmol/L) during standard oral glucose tolerance test (OGTT)<ref name="PMID23071876"><pubmed>23071876</pubmed></ref>
 
|-
 
|-
| style="background:#EEAAAA;" | '''Pathogeneis'''
+
| style="background:#EEAAAA;" | '''Pathogeneis*'''
 
|  
 
|  
The pathogenesis of autoimmune type 1 diabetes has been extensively studied through the use of animal models; nonobese diabetic mouse and diabetes-prone BioBreeding rat. Exact mechanisms of initiation and progression remain unclear, however through the animal studies it is generally believed that beta-cell autoantigens macrophages, dendritic cells, B lymphocytes, and T lymphocytes are involved in the beta-cell specific autoimmune process. As seen in Figure 3, the beta-cell autoantigens are processed by the macrophages, dendritic cells or B cells in the pancreatic islets, and then presented to the autoreactive CD4+ T cells in the peripheral lymphoid system. These cells are consequently activated leading to the secretion of cytokines which can activate beta-cell specific cytotoxic CD8+ T cells. Activated T cells recruit at the iselts, producing cytokines which further activate macrophages and other T cells; all contributing to the destruction of pancreatic beta-cells. <ref name="PMID16280652"><pubmed>16280652</pubmed></ref>
+
The pathogenesis of autoimmune-induced type 1 diabetes has been extensively studied through the use of animal models, such as non-obese diabetic mice and diabetes-prone BioBreeding rats. From the studies, exact mechanisms of initiation and progression remain unclear, however through the it is generally believed that beta-cell auto-antigens, macrophages, dendritic cells, B lymphocytes and T lymphocytes are involved in the beta-cell specific autoimmune process. As seen in Figure 8., the beta-cell auto-antigens are processed by the macrophages, dendritic cells or B cells in the pancreatic islets and then presented to the auto-reactive CD4+ T cells in the peripheral lymphoid system. These cells are consequently activated, thus leading to the secretion of cytokines, which may activate beta-cell specific cytotoxic CD8+ T cells. Activated T cells also recruit at the islets, producing cytokines which further activate macrophages and other T cells; all contributing to the destruction of pancreatic beta-cells<ref name="PMID16280652"><pubmed>16280652</pubmed></ref>.
  
[[File:Beta Cell Destruction.JPG|thumb|centre|300px|'''Figure 3:''' Beta-cell destruction by autoimmune processes]]
+
[[File:Beta Cell Destruction.JPG|thumb|centre|600px|'''Figure 8:''' Beta-cell destruction by autoimmune processes. Image is reprinted with permission from <ref name="PMID16280652"><pubmed>16280652</pubmed></ref>.]]
  
 
|  
 
|  
 
The evolution of beta-cell dysfunction is marked by 5 stages as identified by [https://www.ncbi.nlm.nih.gov/pubmed?cmd=Search&doptcmdl=Citation&defaultField=Title%20Word&term=Weir%5Bauthor%5D%20AND%20Five%20stages%20of%20evolving%20beta-cell%20dysfunction%20during%20progression%20to%20diabetes Weir & Bonner-Weir] (2004) <ref name="PMID15561905"><pubmed>15561905</pubmed></ref>:
 
The evolution of beta-cell dysfunction is marked by 5 stages as identified by [https://www.ncbi.nlm.nih.gov/pubmed?cmd=Search&doptcmdl=Citation&defaultField=Title%20Word&term=Weir%5Bauthor%5D%20AND%20Five%20stages%20of%20evolving%20beta-cell%20dysfunction%20during%20progression%20to%20diabetes Weir & Bonner-Weir] (2004) <ref name="PMID15561905"><pubmed>15561905</pubmed></ref>:
  
* Stage 1: Referred to as compensation; when the insulin secretion must compensate for degrees of insulin resistance for the maintenance of glucose homeostasis.
+
* '''Stage 1:''' Referred to as compensation; when the insulin secretion must compensate for degrees of insulin resistance to ensure the maintenance of glucose homeostasis.
* Stage 2: Where fasting levels range between 5-7.3mmol/L, representing 'beta-cell adaptation'. People progressing toward Type 2 diabetes may remain here for many years, however when beta-cell mass becomes insufficient glucose levels may rise to stage 4 rapidly.
+
* '''Stage 2:''' Where fasting levels range between 5-7.3 mmol/L, representing 'beta-cell adaptation'. Patients progressing towards type 2 diabetes may remain here for many years, however as beta-cell mass becomes insufficient, glucose levels may rise to stage 4 rapidly.
* Stage 3: Early decompensation: glucose levels rise beyond 7.3mmol/L
+
* '''Stage 3:''' Early decompensation: glucose levels rise beyond 7.3 mmol/L
* Stage 4: Stable decompensation: glucose levels range between 16-20mmol/L
+
* '''Stage 4:''' Stable decompensation: glucose levels range between 16-20mmol/L
*Stage 5: Severe decompensation: extreme beta cell failure; ketosis with blood glucose levels above 22mmol/L
+
* '''Stage 5:''' Severe decompensation: extreme beta cell failure; ketosis with blood glucose levels above 22 mmol/L
[[File:Evolution of beta-cell dysfunction.JPG|thumb|centre|250px|'''Figure 4:Progression of beta-cell dysfunction''']]
+
 
 +
[[File:Evolution of beta-cell dysfunction.JPG|thumb|centre|250px|'''Figure 9''': Flowchart depicting the progression of beta-cell dysfunction. This is a student-created illustration by user z5076777.]]
 
|}
 
|}
  
 
===='''Pancreatogenic (Type 3c) Diabetes'''====
 
===='''Pancreatogenic (Type 3c) Diabetes'''====
Unlike T1DM and T2DM, Type 3c Diabetes Mellitus (T3cDM) is a form of secondary mellitus that is caused by underlying pancreatic diseases such as acute or chronic pancreatitis, cystic fibrosis, pancreatic cancer or any other pancreatic trauma leading to loss of pancreatic tissue; the most common cause being chronic pancreatits (CP). CP accounts for 75-80% of T3cDM cases while pancreatic carncinoma accounts for 8%<ref name="PMID22121010"><pubmed>22121010</pubmed></ref> T3cDM was previously believed to have a lower prevalence of approximately 0.5-1.2 percent among diabetes cases in North America, however recent studies suggest higher occurences with a recent 2013 study finding a 5-10% prevalece among all diabetic subjects in Western populations<ref name="PMID 23375619"><pubmed>23375619</pubmed></ref> A review by Anderson et al. (2013) suggest previous underestimations may be attributed to the fact that it has become easier to detect exocrine pancreatic pathology with the advancements in imaging technology and noninvasive screening methods to quantify exocrine dysfunction. <ref name="PMID24152948"><pubmed> 24152948</pubmed></ref>  
+
Unlike T1DM and T2DM, Type 3c Diabetes Mellitus (T3cDM) is a form of secondary mellitus that is caused by underlying pancreatic diseases such as acute or chronic pancreatitis, cystic fibrosis, pancreatic cancer or other form of pancreatic trauma leading to loss of pancreatic tissue; the most common cause being chronic pancreatitis (CP). CP accounts for 75-80% of T3cDM cases, while pancreatic carncinoma accounts for 8%<ref name="PMID22121010"><pubmed>22121010</pubmed></ref>. T3cDM was initially believed to have a lower prevalence (approximately 0.5-1.2%) among diabetes cases in North America, however recent studies suggest higher occurrences than originally anticipated. In fact, a recent study shows a 5-10% prevalence among all diabetic subjects in Western populations<ref name="PMID 23375619"><pubmed>23375619</pubmed></ref>. A review by Anderson et al. (2013) suggests that previous underestimations may be attributed to the fact that it has become easier to detect exocrine pancreatic pathology, and quantify exocrine dysfunction, with new advancements in imaging technology and noninvasive screening methods<ref name="PMID24152948"><pubmed> 24152948</pubmed></ref>.
  
Also unlike T1DM and T2DM the endocrinopathy is far more complex in T3cDM due to additional comorbidties.  <ref name="PMID16954337"><pubmed>16954337</pubmed></ref> Due to the cross over in risk factors for T2DM and T3cDM such as obesity and the similar symptom associated with all three forms of diabetes; difficulties with glucose homeostasis, a method of discrimination between the diseases is required.  
+
Moreover, the endocrinopathy is far more complex in T3cDM, than T1DM and T2DM, due to additional comorbidities<ref name="PMID16954337"><pubmed>16954337</pubmed></ref>. As a result of the cross over in risk factors for T2DM and T3cDM, such as obesity and congruous symptoms associated with all three forms of diabetes; e.g. difficulties with glucose homeostasis, a method of discrimination between the diseases is required. The proposed criteria for this involves noting
  
Proposed criteria:
+
* Presence of exocrine pancreatic insufficiency (monoclonal fecal elastase-1 test)
* presence of exocrine pancreatic insufficency (monoclonal fecal elasttase-1 test)
 
 
* Pathological pancreatic imaging (endoscopic ultrasound, MRI, CT)
 
* Pathological pancreatic imaging (endoscopic ultrasound, MRI, CT)
 
* Absence of type 1 diabetes mellitus associated autoimmune markers
 
* Absence of type 1 diabetes mellitus associated autoimmune markers
Line 363: Line 331:
 
* Low serum levels of lipid soluable  vitamuns
 
* Low serum levels of lipid soluable  vitamuns
  
However even with these criteria in place, overlapping still occurs as people suffering from T1DM and T2DM for an extended period of time are also associated with pancreatic failure and are at risk of acute and chronic pancreatitis. Additionally, patients with pancreatitis may develop T1DM or T2DM independently. Thus the best discriminator seems to be the pancreatic polypeptide (PP) response to nutrients. <ref name="PMID23890130"><pubmed>23890130</pubmed></ref>
 
  
A study found that isolated hepatic insulin resistance coexisted with clinical studies of T3cDM <ref name="PMID 21757968"><pubmed>21757968</pubmed></ref>. This has been documentated to be due to CP, pancreatic cancer and cystic fibrosis resulting in unsuppressed hepatic glucose production. PP deficiency was also found to coincide and thus was identified as a likely mediator of the hepatic defect. Animal studies confirmed that PP deficiency results in diminished hepatic insulin receptor availability and thus PP administration reversed hepatic insulin resistance in patience with CP, resulting in improved glucose tolerance. <ref name="PMID22226275"><pubmed>22226275</pubmed></ref>
+
However, despite the implementation of the proposed criteria, overlapping still occurs as patients suffering from T1DM and T2DM, for an extended period of time, are also victims of pancreatic failure and are at risk of acute and chronic pancreatitis. Additionally, patients with pancreatitis may develop T1DM or T2DM independently. Thus, the best discriminator between all three forms of diabetes is believed to be the pancreatic polypeptide's (PP) response to nutrients <ref name="PMID23890130"><pubmed>23890130</pubmed></ref>.
  
[[File:Effect of Adrenomedulin on Insulin Secretion.JPG|thumb|600px|left|'''Figure 5: The effect of adrenomedulin on insulin secretion''']]
+
Interestingly, studies have revealed that isolated hepatic insulin resistance coexists with clinical studies of T3cDM <ref name="PMID 21757968"><pubmed>21757968</pubmed></ref>. This is documented to be consequential of CP, pancreatic cancer and/or cystic fibrosis, which results in unsuppressed hepatic glucose production. PP deficiency was also found to coincide with T3cDM and thus, is identified as a likely mediator of the hepatic defect. Animal studies indeed confirm that PP deficiency results in diminished hepatic insulin receptor availability and thus PP administration reverses hepatic insulin resistance in patients with CP, thereby improving glucose tolerance<ref name="PMID22226275"><pubmed>22226275</pubmed></ref>.
  
'''How cancer induces T3cDM'''
+
[[File:Effect of Adrenomedulin on Insulin Secretion.JPG|thumb|650px|right|'''Figure 10:''' Diagram showing the effect of adrenomedulin on insulin secretion. Image is reprinted with permission from <ref name="PMID22960655"><pubmed>22960655</pubmed></ref>.]]
  
The most likely explanation for the consequential occurence of diabetes in pancreactic ductal adenocarcinoma (PDAC) is a paraneoplastic phenomenon caused by tumor-secreted products. One such product that results in beta-cell dysfunction is adrenomedullin; a pluripotent hormone with homology to amylin, which is overexpressed in PDAC. Adrenomedullin receptors are found on beta cells, which studies have found with the external administration of adrenomedulin in animal studies cause the inhibition of insulin secretion. <ref name="PMID23528347"><pubmed>23528347</pubmed></ref> One such study performed by identified adreninedulin (AM) to impair insulin secretion from beta cell and cintributing to the insulin inhibitory effect of pancreatic cancer cells in vitro and in vivo (as seen in Figure 5) <ref name="PMID 22960655"><pubmed> 22960655</pubmed></ref>. These finding support that adrenomedulin is mediator of beta cell dysfunction in PDAC.
+
'''How cancer induces T3cDM:'''
 +
 
 +
The most likely explanation for the consequential occurence of diabetes in pancreactic ductal adenocarcinoma (PDAC) patients, is a paraneoplastic phenomenon caused by tumor-secreted products. One such product that results in beta-cell dysfunction is adrenomedullin; a pluripotent hormone with homology to amylin, which is over-expressed in PDAC. Adrenomedullin receptors are found on beta cells and therefore external administration of adrenomedulin causes the inhibition of insulin secretion, as evidenced in animal studies<ref name="PMID23528347"><pubmed>23528347</pubmed></ref> One such study performed by identified adreninedulin (AM) to impair insulin secretion from beta cell and cintributing to the insulin inhibitory effect of pancreatic cancer cells in vitro and in vivo* (as seen in Figure 10.)<ref name="PMID22960655"><pubmed>22960655</pubmed></ref>. These finding support that adrenomedulin is mediator of beta cell dysfunction in PDAC.
 
   
 
   
 
 
'''How chronic pancreatitis induces T3cDM'''
 
'''How chronic pancreatitis induces T3cDM'''
  
Development of diabetes in chronic pancreatitis mainly occurs due to the destruction of islet cells by pancreatic inflammation. Additionally maldigestion caused by pancreatitis leads to diminished insulin release. <ref name="PMID6997121"><pubmed>6997121</pubmed></ref> GLP-1 is an incretin hormone secreted by the L-cells of the distal intestine, and has the effect of stimulating insulin gene expression and proinsulin biosynthesis. GLP-1 also has proliferative and anti-apoptotic effects on the beta-cell. <ref name="PMID25401335 "><pubmed>25401335</pubmed></ref> Thus maldigestion leads to an impaired incretin secretion and therefore diminished insulin release of the remaining beta-cells. <ref name="PMID6997121"><pubmed>6997121</pubmed></ref> In contrast to auto-immune destruction of beta-cells in T1DM, gulcagon secreting alpha cells and PP cells are also subject to destruction in CP leading to a complex metabolic situation.
+
Development of diabetes in chronic pancreatitis patients mainly occurs due to the destruction of islet cells by pancreatic inflammation. Additionally maldigestion caused by pancreatitis leads to diminished insulin release<ref name="PMID6997121"><pubmed>6997121</pubmed></ref>. GLP-1 is an incretin hormone secreted by the L-cells of the distal intestine, and has the effect of stimulating insulin gene expression and proinsulin biosynthesis. GLP-1 also has proliferative and anti-apoptotic effects on the beta-cell<ref name="PMID25401335 "><pubmed>25401335</pubmed></ref>. Thus, maldigestion leads to impaired incretin secretion and therefore diminished insulin release of the remaining beta-cells<ref name="PMID6997121"><pubmed>6997121</pubmed></ref>. In contrast to the autoimmune-mediated destruction of beta-cells in T1DM, gulcagon-secreting alpha cells and PP cells are also subject to destruction in CP leading to a complex metabolic situation.
  
 
==='''Treatments'''===
 
==='''Treatments'''===
 
 
===='''Insulin Therapy'''====
 
===='''Insulin Therapy'''====
 +
Insulin injections are used in place of the insulin that would normally be produced by the body. Individualised treatment plans are suggested for patients however, generally T1DM patients take 3-4 injections per day to provide optimal glucose control, while T2DM take 2 injections per day if not in conjunction with other medication<ref name="PMID25040034"><pubmed>25040034</pubmed></ref><ref name="PMID20589066 "><pubmed>20589066 </pubmed></ref>. Insulin shots are most effective when administered when food enters the blood, such as 30 minutes before eating. Furthermore, particular sites for injections, such as the abdomen, provide better results while insulin administered at the arms and thighs take a longer period of time to enter into the blood stream<ref name="PMID20513314"><pubmed>20513314</pubmed></ref>.
  
Insulin injections are used in place of the insulin that would normally be produced by the body. Individualised treatment plans are suggested however generally T1DM patients would take 3-4 injections per day to provide optimal glucose control, while T2DM generally would take 2 injections per day if not in conjunction with medication. <ref name="PMID25040034"><pubmed>25040034</pubmed></ref><ref name="PMID20589066 "><pubmed>20589066 </pubmed></ref>
+
However, insulin vials and syringes provide an inconvenience to patients. Adverse psychological and social effects may occur to others, and to the patient, when using syringes. Incorrect insulin use and dosage could also result in risks. Insulin pens have thus been developed to counteract these issues by providing rapid, long-acting insulin<ref name="PMID17594200"><pubmed>17594200</pubmed></ref>. Nevertheless, insulin pens have a greater cost per unit of insulin compared to the insulin supplied in vials<ref name="PMID20513314"><pubmed>20513314</pubmed></ref>.
Review Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901025/#!po=72.5000 Insulin shots are most effective when administered when food enters the blood such as 30 minutes before eating. Also particular sites of injections provide better results, such as the addomen, while insulin taken at the arms and thighs take a longer period of time to arrive into the blood stream. <ref name="PMID20513314"><pubmed>20513314</pubmed></ref>
 
 
 
However insulin vial and syringes provide an inconvenience to patients, providing adverse psychological and social impact in using a syringe as well as incorrect insulin use and dosage could also result in risks. Insulin pens were thus developed to counter these issues, providing rapid, long acting insulin<ref name="PMID17594200"><pubmed>17594200</pubmed></ref> On the other hand, insulin pens become more costly per unit of insulin compared to the insulin supplied in vials. <ref name="PMID20513314"><pubmed>20513314</pubmed></ref>
 
 
 
Insulin pumps are also another alternative to provide insulin however it is in the form of continuous treatment; also known as continuous subcutaneous insulin infusion (CSII). This method is mainly utilised by patients with T1DM. Insulin pumps send insulin through tubing into an infusion set that delivers insulin to the body. A plastic tube is connected to the insulin reservour and insulin flows into the subcutaneous tissue through the infusion set. However pumps are not only costly but require commitment to self-management with frequent blood glucose checks throughout the day. Many adolescents also may feel uncomfortable with the notion of being attached to a foreign object.  
 
  
 +
Insulin pumps are another method of attaining insulin and counteracting insulin deficit, however they require frequent use as they come in the form of continuous subcutaneous insulin infusions (CSII). This method is therefore mainly utilised by patients with T1DM. Insulin pumps send insulin, through tubing, into an infusion set that delivers insulin to the body. A plastic tube is connected to the insulin reservoir and insulin flows into the subcutaneous tissue via the infusion set. The pumps are very costly and also require commitment to self-management, with frequent blood glucose checks throughout the day. Many adolescents may feel uncomfortable with the concept of being attached to a foreign object. It is also worth noting that insulin pumps do have the potential to over or under medicate patients if they are broken or used incorrectly, and thus potential complications of their use also include ketoacidoses and hypoglycemia<ref name="PMID16774616"><pubmed>16774616 </pubmed></ref>. Thus potential complications of use include ketoacidoses and hypoglycemia. <ref name="PMID16774616"><pubmed>16774616 </pubmed></ref>
  
 
===='''Pancreatic Transplantation'''====
 
===='''Pancreatic Transplantation'''====
 
+
As there is no definite cure for diabetes, much of the current research on beta cells focuses on developing new and better treatments for diabetic patients. One of the most promising treatments, that is presently being researched and monitored with experimentation, is pancreatic transplantation<ref name="PMID19196588"><pubmed>19196588</pubmed></ref>. Insulin pumps also have the potential to over or undermedicate if they are to malfunction or are used improperly.  
As there is no definite cure for diabetes, many of the current research on Beta Cells focus on developing new and better treatments for patients with diabetes. One of the most promising treatments that is still under research and experimentation is pancreatic transplantation. <ref name="PMID19196588"><pubmed>19196588</pubmed></ref> Insulin pumps also have the potential to over or undermedicate if they are to malfunction or are used improperly. Thus potential complications of use include ketoacidoses and hypoglycemia. <ref name="PMID16774616"><pubmed>16774616 </pubmed></ref>
 
 
    
 
    
The development of more physiological routes of insulin administration, use of artificial pancreas or pancreas/beta cell transplantation thus become important for ongoing research.
 
 
 
'''1. Pancreatic Islet Transplantation''' <ref name="PMID15630467"><pubmed>15630467</pubmed></ref>
 
'''1. Pancreatic Islet Transplantation''' <ref name="PMID15630467"><pubmed>15630467</pubmed></ref>
  
This method is specifically aimed to treat patients with type-1 diabetes mellitus. The pancreatic islet is responsible for the endocrine function of the pancreas. This is isolated within the donated pancreas, and the exocrine functioning part of the pancreas is removed. The isolated pancreatic islet is then transported to the liver of the patient by the blood of the vein.
+
This method is specifically aimed to treat patients with type 1 diabetes mellitus. During treatment, the pancreatic islet is isolated within the donated pancreas and the exocrine functioning part of the pancreas is removed. The isolated islet is then transported to the liver of the patient by venous blood.
  
[[File:Pancreatic islet transplantation.JPG|thumb|700px|right|'''Figure 6: Diagrammatic representation of islet transplantation''']]
+
[[File:Pancreatic islet transplantation.JPG|thumb|600px|centre|'''Figure 11:''' Diagrammatic representation of islet transplantation. Image is reprinted with permission from <ref name="PMID15630467"><pubmed>15630467</pubmed></ref>.]]
In a study performed by Shapiro et al. the Edmonton protocol was established which was taken on by  islet trancplant centers around the world and has greatly increased islet transplant. <ref name="PMID15630467"><pubmed>15630467</pubmed></ref> The protocol involves the islet transplantation in conjunction with immunosuppressive drugs in order to counteract rejection. The procedure of transplantation involves the isolation of islets with cold purified collagenase, which is then digested and purified in xenoprotein-free medium, and transplanted immediately through a catheter; a small plastic tube using ultrasound for guidance, through the upper abdomen and into the liver (see Figure 6). This procedure only requires a local anesthetic, Alternatively some surgeons will create a small incision using general anesthetics. Once implanted, the beta cells in the islet begin to make and release insulin. Ultimately the transplant succefully results in insulin independence with excellent metabolic control. <ref name="PMID10911004"><pubmed>10911004</pubmed></ref>
 
  
However currently many limitations remain with this procedure, two of which include islet rejection and supply of islets  for transplantation. Although current immunosuppressive regimens exist, they are expensive and may increase the risk or particular malignancies and opportunistic infections. Also as a contradiction, some drugs also impair normal islet function and insulin action, combined with other unwanted side effects such as anemia, weight loss, hypertension, diarrhea and fatigue. <ref name="PMID10911004"><pubmed>10911004</pubmed></ref> More importantly are the concerns of renal failure associated with umminnosuppressive agents, as renal function is a crucial factor in determining long-term outcomes for the patients. <ref name="PMID12954741"><pubmed>12954741</pubmed></ref> As for the limitation of islet donors; statistics highlight at least 1 million american have T1DM however only a few thousand pancreas donors are available each year. To resolve this issues researchers continue to look for alternative means such as growing islets, or at least cells capable of physiologically regulated insulin sectrion - in vitro.
+
In a study performed by Shapiro et al. the Edmonton protocol was established and is now used by islet transplant centres around the world, greatly increasing islet transplant effectivity <ref name="PMID15630467"><pubmed>15630467</pubmed></ref>. The protocol involves the islet transplantation in conjunction with immunosuppressive drugs in order to counteract rejection. The procedure of transplantation involves the isolation of islets with cold purified collagenase, which is then digested and purified in a xenoprotein-free medium, and transplanted immediately through a catheter; a small plastic tube using ultrasound for guidance, through the upper abdomen and into the liver (see Figure 11.). This procedure requires only a small dosage of local anaesthetic. Alternatively, some surgeons may create a small incision in patients, with use of general anesthesia. Once implanted, the beta cells in the islet begin to synthesise and release insulin. Ultimately the transplant successfully results in insulin independence with excellent metabolic control<ref name="PMID10911004"><pubmed>10911004</pubmed></ref>.
  
'''2. Transplantation using Embryonic Pig Pancreatic Tissue''' <ref name="PMID16768546"><pubmed>16768546</pubmed></ref>
+
Currently, many limitations exist with the procedure. These include islet rejection and insufficient supply of islets for transplantation. Although current immunosuppressive regimens exist, they are expensive and may increase the risk of particular malignancies and opportunistic infections. Also as a contradiction, some drugs also impair normal islet function and insulin action, combined with other unwanted side effects, including anemia, weight loss, hypertension, diarrhea and fatigue<ref name="PMID10911004"><pubmed>10911004</pubmed></ref>. Another important concern is renal failure associated with immunosuppressive agents as renal function is a crucial factor in determining the long-term outcomes of patients<ref name="PMID12954741"><pubmed>12954741</pubmed></ref>. With regards to the limitation of islet donors; statistics highlight that at least 1 million americans have T1DM however, only a few thousand pancreas donors are available each year. To resolve this issues researchers continue to look for alternative methods such as growing islets, or at least cells capable of physiologically regulated insulin secretion in vitro.
  
Instead of using human tissue or organ for transplantation, this method uses pancreatic tissue of an embryonic pig. Although previous clinical studies failed to provide successful results in treating diabetes, this study sought to examine the potential, functionality and immunogenicit of pig embryonic pancreatic tissue harvested different stages of the embryonic pig development.
+
'''2. Transplantation using Embryonic Pig Pancreatic Tissue'''
  
Through the use of implantation of the varying embryonic pancreatic tissues in SCID mice, the 42nd day of gestation (E42) enabled a substantial growth of pig islets for a prolonged period of time and restored noromoglycemia in the diabetic mice as seen in Figure 7. Also the study reveal reduced rejection was seen at this stage of embryonic tissue implantation, as opposed to E56 or later stages. Ultimately the fully immunocompetent diabetic mice with E42 implanted pancreatic tissue that were simultaneously treated with immunosuppression protocol attained normal glucose levels and elimated the need for insulin.
+
Instead of using human tissue or organ for transplantation, this method uses the pancreatic tissue of an embryonic pig. Although previous clinical studies failed to provide successful results in treating diabetes, this study has sought to examine the potential and functionality of pig embryonic pancreatic tissues, harvested at different stages of embryonic pig development, in diabetic treatment. In an experimental study, various embryonic pancreatic tissues were implanted in SCID mice and the 42nd day of gestation (E42) showed a substantial growth of pig islets for a prolonged period of time, thereby restoring normoglycemia in the diabetic mice as seen in Figure 12. The study also revealed that reduced tissue rejection was seen at this stage of embryonic tissue implantation, as opposed to E56 or at later stages. Ultimately, the fully immunocompetent diabetic mice, with E42 implanted pancreatic tissue, that were treated with the immunosuppression protocol, attained normal glucose levels<ref name="PMID16768546"><pubmed>16768546</pubmed></ref>. These results thus highlighted the therapeutic potential of E42 embryonic pig pancreatic tissues transplantation in diabetic treatment.
 
 
Thus these results highlight the theraputic potential of E42 embryonic pig pancreatic tissue transplantation in diabetes.
 
 
 
[[File:Effect of pig embryonic pancreatic tissue transplant.JPG|thumb|centre|600px|'''Figure 7: Comparing implantation of varying stages of pig embryonic pancreatic tissue on diabetic mice''']]
 
  
 +
[[File:Effect of pig embryonic pancreatic tissue transplant.JPG|thumb|centre|600px|'''Figure 12:''' Comparison of the implantation of pig embryonic pancreatic tissue, from varying developmental stages, on diabetic mice. Image is reprinted with permission from <ref name="PMID16768546"><pubmed>16768546</pubmed></ref>.]]
  
 
===='''Stem Cell Research'''====
 
===='''Stem Cell Research'''====
 
+
Another promising anti-diabetic therapeutic option is within stem cell research. Mitutsova et al. (2017) investigated the possible use of muscle-derived stem cells (MDSC), from adult mice, to differentiate into functional beta cells in vitro; consequentially compensating for beta-cell deficiency. Within their study they successfully found in vitro cultured MDSC to spontaneously differentiate into insulin-expressing, islet-like cell clusters, under the control of an insulin promoter. These differentiated clusters of beta-like cells co-expressing insulin with transcription factors were shown to secrete significant levels of insulin in response to glucose challenges. Additionally, in vivo undifferentiated MDSC injected into streptozotocin* treated mice, engrafted within 48 hours specifically, to damaged pancreatic islets and were also shown to differentiate and express insulin within 10-12 days after injection. Also to add to the successful results, injection of MDSC into hyperglycemic diabetic mice was shown to reduce blood glucose levels for 2-4 weeks. Ultimately the study successfully showed MDSC as capable of differentiating into mature pancreatic beta like cells, both in vivo and in vitro highlighting a promising avenue in stem-cell based treatment of beta-cell deficiencies<ref name="PMID28420418"><pubmed>28420418</pubmed></ref>.
Another recent endeavour into a promising anti-diabetic therapeutic is within stem cell research. has also been conducted in the search for anti-diabetic therapeutics. Mitutsova et al. (2017) investigated the possible use of muscle-derived stem cells (MDSC) from adult mice to differentiate ''in vitro'' into beta cells when transplanted as undifferentiated stem cells ''in vivo'' to compensate for beta-cell deficiency. Within their study they successfully found in vitro cultured MDSC to spontaneously differentiate into insulin-expressing islet like cell clusters under the control of an insulin promoter. Differentiated clusters of beta-like cells co-expressing insuling with transcription factors were shown to secrete significant levels of insulin in response to glucose challenges. Additionally, in vivo undifferentiated MDSC injected into ''streptozotocin'' treated mice engrafted within 48 hours specifically to damaged pancreatic islets and were also shown to differentiate and express insulin within 10-12 days after injection. Also to add to the successful results, injection of MDSC into hyperglycemic diabetic mice was shown to reduce blood glucose levels for 2-4 weeks. Ultimately the study successfully showed MDSC as capable of differenctiating into mature pancreatic beta islet-like cells, both in vivo and in vitro highlighting a promising avenue in stem-cell based treated of beta-cell deficiencies. <ref name="PMID28420418"><pubmed>28420418</pubmed></ref>
 
  
 
=='''Current Research'''==
 
=='''Current Research'''==
 
 
==='''Generation of Functional Beta-like Cells'''===
 
==='''Generation of Functional Beta-like Cells'''===
 +
In a recent study by Lima et. al. (2016), the generation of mature and functional beta-like cells from the human exocrine pancreas were assessed as a viable avenue for the treatment of type 1 diabetes. The pivotal finding of the study was that the knockdown of transcription factor, ARX, expression, combined with the over-expression of transcription factor, Pax4, considerably enhances the production of functional insulin secreting beta-like cells while suppressing of alpha cells. The beta-like cells produced were shown to efficiently exhibit glucose-responsive insulin secretion. They also showed immediate and prolonged effects in normalising blood glucose levels upon transplantation into diabetic mice.
  
In a recent study by Lima et. al. (2016) the generation of mature and functional beta-like cells from the human exocrine pancreas was assessed for being a viable avenue for treatment of type 1 diabetes. The pivotal finding of the study was that knockdown of transcription factor ARX expression combined with over expression of transcription factor Pax4 considerably enhances the production of functional insulin secreting beta-like cells with the accompanying suppression of alpha cells.The beta-like cells produced were shown to efficiently exhibit glucose responsive insulin secretion and an immediate as well as prolonged effect in normalising blood glucose levels upon transplantation into diabetic mice. The study estimated approximately 3 billion of these cells would have an immediate therapeutic effect following implantation in T1DM patients and potentially one pancreas could provide enough tissue for numerous transplants.
+
The study estimated approximately 3 billion of these cells would have an immediate therapeutic effect following implantation in T1DM patients and potentially one pancreas could provide enough tissue for numerous transplants. Thus, the ability to reprogram exocrine pancreas tissue could circumvent the necessity for multiple pancreas donors to treat a single patient. The study, although not achieving exact human islet response levels, did succeed in attaining results of 15-30% insulin levels of that of the normal human islet. This response could potentially have large therapeutic benefits for a patient with T1DMas reinstating even a fraction of the normal beta-cell mass would be beneficial.  
 
 
The ability to reprogram exocrine pancreas tissue could circumvent the necessity for multiple pancreas donors to treat a single patient, allowing one pancreas to treat several patients instead. The study although could not achieve exact human islet response levels, did succeed in attaining results of 15-30% insulin levels of that of the normal human islet. This response could potentially have therapeutic benefits for a patient with T1DM as reinstating even a fraction of the normal beta-cell mass would have a therapeutic effect.  
 
  
Ultimately this study produced functional beta-like cells that efficiently processed proinsulin to insulin, contained insulin storage granules, secreted insulin in response to glucose and rescued diabetes in a streptozotocin mouse model. Essential this inexpensive relatively simple protocol, for cell preparation could provide an avenue to bypass the obstacle of pancreas donors as one donor could provide numerous islet grafts. <ref name="PMID27243814"><pubmed>27243814</pubmed></ref>
+
The study thereby produced functional beta-like cells that efficiently processed proinsulin to insulin, contained insulin storage granules, secreted insulin in response to glucose and rescued diabetes in a streptozotocin mouse model. Essentially, this inexpensive and relatively simple protocol, for cell preparation, could provide an avenue to bypass the obstacle of pancreas donors as one donor could provide numerous islet grafts<ref name="PMID27243814"><pubmed>27243814</pubmed></ref>.
  
 
==='''Glibenclamide as Potential Prevention of Diabetes'''===
 
==='''Glibenclamide as Potential Prevention of Diabetes'''===
A study by Lamprianou et al. (2016) utilised previous study's findings in the importance of Cx35 as an enhancement factor of insulin secretion, promoting resistance of beta cells against pro-inflammatory cytokines, and furthered this by studying whether glibenclamide could protect beta cells since it is shown to promote the assembly and function of Cx36 channels. The study utilised untreated NOD mice to model type 1 diabetes, and found the glibenclamide to:
+
A study by Lamprianou et al. (2016) utilised previous findings on the importance of Cx35 as an enhancement factor for promoting beta cell insulin secretion and resistance to pro-inflammatory cytokines, and extended this research further by analysing the effect of glibenclamide on beta cells. Glibenclamide is shown to promote the assembly and function of Cx36 channels. This study utilised untreated NOD mice to model type 1 diabetes and found the glibenclamide to:
  
[[File:Effect_of_Glibenclamide_on_Diabetes.JPG|thumb|right|400px| '''Figure X: The Therapeutic Effect of Glibenclamide on NOD Mice''']]
+
[[File:Effect_of_Glibenclamide_on_Diabetes.JPG|thumb|right|400px| '''Figure 13:''' A series of images identifying the the therapeutic effect of Glibenclamide on NOD mice. Image is reprinted with permission from <ref name="PMID28006000"><pubmed>28006000</pubmed></ref>]]
  
* protect Cx36 loss in vitro usually induced by Th1 cytokines  
+
* Protect Cx36 loss in vitro usually induced by Th1 cytokines  
* prevent the development of hyperglycemia through the prevention of loss of beta cells, shown to rapidly develop in the aging untreated NOD mice
+
* Prevent the development of hyperglycemia through the prevention of beta cell loss (which was shown to rapidly develop in the aging untreated NOD mice)
* modified the proportion of CD4+ and CD8+ T cells in pancreatic draining lymph nodes
+
* Modify the proportion of CD4+ and CD8+ T cells in pancreatic draining lymph nodes
  
Figure X highlights the highly successful results, comparing the before and after of islet and beta cell mass. The images of the islets in Figure Xa highlight the substantial increase of islet number and size after dose 1 and 2 of glibenclamide compared to the control. Figure Xb and c also highlight the numerical density changes in islet and beta cells respectively emphasising a spike of approximately 66% islet density and 50% beta cell density after dose 2.
 
  
Ultimately the study establishes a plausible avenue for therapeutics as seen through the testing of the therapeutic value of glibenclamide effects. <ref name="PMID28006000"><pubmed>28006000</pubmed></ref>
+
Figure 13. highlights the study's highly successful results, comparing the before and after amounts of islet and beta cell mass. The images of the islets in Figure 13a. highlight the substantial increase in islet number and size after dose 1 and 2 of glibenclamide compared to the control. Figures 13b. and 13c. also highlight the numerical density changes in islet and beta cells respectively, emphasising a spike of approximately 66% islet density and 50% beta cell density after dose 2. The study, therefore ultimately establishes glibenclamide treatment as another plausible avenue for diabetic therapeutics<ref name="PMID28006000"><pubmed>28006000</pubmed></ref>.
  
 
==='''RA index to Determine Beta-Cell Functionality'''===
 
==='''RA index to Determine Beta-Cell Functionality'''===
This study aims to identify parameters which influence the function of beta-cells in order to potentially find markers of disease progression or targets for intervention. Although body mass index (BMI) and increased energy intake considered risk factors associated with beta-cell dysfunction, evidence of direct numerical correlation remain undefined. Thus Curran et al. (2016) recognised the necessity for identification markers to allow for beta-cell function assessment.
+
This study aims to identify parameters which influence the function of beta-cells in order to potentially find markers of disease progression or targets for intervention. Although, body mass index (BMI) and increased energy intake are commonly considered risk factors associated with beta-cell dysfunction, evidence of direct numerical correlation remain undefined. Thus, Curran et al. (2016) recognised the necessity for identification markers to allow for beta-cell function assessment.  
 
 
Beta cells were calculated as a ratio of the incremental insulin to glucose response over 30 minutes of the OGTT. Insulin sensitivity and beta-cell homeostatic assessment of insulin resistance was calculated as well as C-peptide. Ultimately after all else was accounted for a RA index was formulated as a ratio of restin to adiponectin at fasting levels. Ultimately the findings were that RA index was very strongly associated with pancreatic beta-cell function; in vitro studies correlated RA index to insulin secretion. Previous studies have found the RA index to correlate to T2DM however this study was first to make the connection to beta-cell function.
 
  
The study concluded with the venture to examine potential mechanisms for modulating the RA index which consequentially may lead to new avenues/interventions for improving beta-cell function. <ref name="PMID27536890"><pubmed>27536890</pubmed></ref>
+
Beta cells were calculated as a ratio of the incremental insulin to glucose response over 30 minutes of the OGTT. Insulin sensitivity and beta-cell homeostatic assessment of insulin resistance was calculated as well as C-peptide amount. After all else was accounted for, an RA index was formulated as a ratio of resistin to adiponectin at fasting levels. Ultimately the findings showed that the RA index was strongly associated with pancreatic beta-cell function; in vitro studies found direct correlation of RA index to insulin secretion. Previous studies have also found the RA index to coincide with T2DM however this study was the first to mark its connection to beta-cell functionality. The study concluded that there was a necessity for further future investigation into potential mechanisms for modulating the RA index which consequentially may lead to new mechanisms for improving beta-cell function<ref name="PMID27536890"><pubmed>27536890</pubmed></ref>.
  
 
=='''Review Quiz'''==
 
=='''Review Quiz'''==
Line 476: Line 427:
 
-  Type 2 diabetes is one of the most common chronic childhood diseases
 
-  Type 2 diabetes is one of the most common chronic childhood diseases
 
|| The correct statement is: The proteolytic processing of proinsulin may be prevented by energy poisons, which block their transfer into secretory vesicles. Proinsulin and insulin are actually very similar with respect to their solubility, isoelectric point, self-associative properties and relative reactivity with insulin antiserum.  
 
|| The correct statement is: The proteolytic processing of proinsulin may be prevented by energy poisons, which block their transfer into secretory vesicles. Proinsulin and insulin are actually very similar with respect to their solubility, isoelectric point, self-associative properties and relative reactivity with insulin antiserum.  
 +
 +
{How does an individual become at risk of Type 3c diabetes?
 +
| type="()"}
 +
- Through genetic predisposition leading to autoimmune attack of beta cells
 +
+ As a secondary effect from some alternative disease effecting pancreatic tissue and sub-sequentially beta cells
 +
- Through a sedentary life style
 +
|| The correct statement is: As a secondary effect from some alternative disease effecting pancreatic tissue and sub-sequentially beta cells. Autoimmune attack from genetic predisposition leads to Type 1 diabetes while a sedentary life style would likely lead to Type 2 diabetes.
 +
 +
{How can beta-like cells become useful in the future of therapetics?
 +
| type="()"}
 +
- Cost effective treatment option
 +
- Less donors required
 +
- Simple protocol
 +
+ All of the above
 +
|| The correct answer is: all of the above - beta-like cells efficiently processed proinulin to insulin and secreted insulin in response to glucose in an over all simple and cost effective protocol that can utilise a single pancreas for multiple donors.
 +
 +
{The notochord is:
 +
| type="()"}
 +
+ The source of permissive signals that enable the differentiation of the foregut endoderm
 +
- The term for the first morphological process in pancreatic formation
 +
- Another name for the endoplasmic reticulum.
 +
||The correct answer is: The source of permissive signals that enable the differentiation of the foregut endoderm. The first morphological process in pancreatic formation is a condensation of the mesenchyme, covering the dorsal aspect of the endodermal gut tube in the foregut - this process is not called the notochord. Another name from the endoplasmic reticulum is ergastoplasm.
  
 
{Polydipsia is a defining symptom of which beta-cell related disease?
 
{Polydipsia is a defining symptom of which beta-cell related disease?
Line 496: Line 469:
 
=='''Glossary'''==
 
=='''Glossary'''==
  
{| class="wikitable"
+
{| class="wikitable mw-collapsible mw-" style="background: #EECCCC;"
 +
|-
 +
!  style="background: #EEAAAA;" | '''Term'''
 +
!  style="background: #EEAAAA;" | '''Definition'''
 +
|-
 +
|  style="background: #EEAAAA;" | '''Adiponectin'''
 +
| A protein involved in regulating glucose levels as well as fatty acid breakdown.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Adipose'''
 +
| Bodily tissue which stores brown or white fat.
 +
|-
 +
| style="background: #EEAAAA;" |  '''Alloxan'''
 +
| A toxic glucose analogue which selectively destroys insulin-producing cells in the pancreas when administered in rodents and many other animal species.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Anemia'''
 +
| A deficiency of red blood cells.
 +
|-
 +
| style="background: #EEAAAA;" |  '''Autocrine'''
 +
| A cell produced substance that has an effect on the cell by which it was secreted.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Chrome sublimate'''
 +
| A staining method to identify beta-cell granules (appear as a violet colour).
 +
|-
 +
| style="background: #EEAAAA;" | '''Clathrin-clad granule'''
 +
| Clathrin is a protein that plays a major role in the formation of coated vesicles.
 +
|-
 +
| style="background: #EEAAAA;" |  '''Cytoplasm'''
 +
| The material within a living cell excluding the cell nucleus.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Edmonton Procedure'''
 +
| Researchers use specialised enzymes to remove islets from the pancreas of a deceased donor and transplant to a patient via catheter through to small incision through to the liver as treatment for type 1 diabetes.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Endocrine'''
 +
| Glands that secrete hormones directly into the blood.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Endoderm'''
 +
| The innermost layer of cells or tissue of an embryo in early development.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Endoplasmic reticulum'''
 +
| Usually has ribosomes attached and is involved in protein and lipid synthesis.
 +
|-
 +
| style="background: #EEAAAA;" | '''Epidemiology'''
 +
| The study of distribution and determinant of diseases.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Ergastoplasms'''
 +
| Ribosome-studded endoplasmic reticulum.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Etiological'''
 +
| Relating to cause or origin.
 +
|-
 +
| style="background: #EEAAAA;" |  '''Exocrine'''
 +
| Glands that secret products through ducts.
 +
|-
 +
| style="background: #EEAAAA;" |  '''Fetal position'''
 +
| Back is curved, head is bowed, limbs are bent and drawn up to torso.
 +
|-
 +
| style="background: #EEAAAA;" | '''Fibroblasts'''
 +
| Cells in connective tissue which produces collagen and other fibres.
 +
|-
 +
|  style="background: #EEAAAA;" |  '''Glucagon'''
 +
| A hormone formed in the pancreas which promotes the breakdown of glycogen to glucose in the liver.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Glucokinase'''
 +
| Recognises how high blood glucose levels are in the body.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Glycemia'''
 +
| Presence of glucose in the blood.
 
|-
 
|-
! Term
+
|  style="background: #EEAAAA;" | '''Golgi complex'''
! Definition
+
| Also known as golgi apparatus/body is a complex of vesicles and folded membranes within the cytoplasm of most eukaryotic cells, involved in secretion and intracellular transport.
 
|-
 
|-
| '''Adipose'''
+
|  style="background: #EEAAAA;" | '''Heterologous'''
| Bodily tissue which stores brown or white fat
+
| Anything other than homologous.
 
|-
 
|-
| '''Edmonton Procedure'''
+
|  style="background: #EEAAAA;" | '''Homologous'''
| Researchers use specialised enzymes to remove islets from the pancreas of a deceased donor and transplant to patient via catheter through to small incision through to liver as treatment for type 1 diabetes.
+
| Having the same relation, relative position, or structure.
 
|-
 
|-
|'''Epidemiology'''
+
|  style="background: #EEAAAA;" | '''In vitro'''
| The study of distribution and determinant of diseases
+
| Performed or taking place in a test tube, culture dish, or elsewhere outside the living organism.
 
|-
 
|-
| '''In vitro'''
+
|  style="background: #EEAAAA;" | '''In vivo'''
| Performed or taking place in a test tube, culture dish, or elsewhere outside the living organism
+
| Performed within a living organism.
 +
|-
 +
|  style="background: #EEAAAA;" |  '''Islets of Langerhans'''
 +
|  A cluster of endocrine pancreatic cells, which secrete the hormones insulin and glucagon.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Lordotic position'''
 +
| increased inward lumbar spine curvature.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Mesenchyme'''
 +
| Mucoid connective tissue consisting of loosely packed, unspecialised cells set in a gelatinous ground substance, from which connective tissue, bone, cartilage, and the circulatory and lymphatic systems develop.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Mitochondria'''
 +
| An organelle which carries out the biochemical process of respiration and energy production.
 
|-
 
|-
| '''In vivo'''
+
|  style="background: #EEAAAA;" | '''Neurosecretory'''
| Performed within a living organism
+
| Storage, synthesis and release of hormones from neurons.
 +
|-
 +
|  style="background: #EEAAAA;" | '''NOD mice'''
 +
| Non-obese diabetic mice are used as an animal model for type 1 diabetes.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Normoglycemia'''
 +
| a normal concentration of sugar in the blood
 +
|-
 +
|  style="background: #EEAAAA;" | '''Notochord'''
 +
| A cartilaginous skeletal rod supporting the body in all embryonic animals.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Nucleus'''
 +
| A dense organelle typically a single rounded double membrane structure containing genetic material.
 
|-
 
|-
| '''Islets of Langerhans'''
+
|  style="background: #EEAAAA;" | '''Oral Glucose Tolerance Test (OGTT)'''
| A cluster of endocrine pancreatic cells, which secrete the hormones insulin and glucagon
+
| Test determining the body's capacity to maintain glucose levels; results noted after overnight fasting and 4 times after administration (usually through sweet liquid) of 75g of glucose (100g for pregnant woman).
 
|-  
 
|-  
| '''Pancreas'''
+
|  style="background: #EEAAAA;" | '''Pancreas'''
| A large gland within organisms which has an exocrine portion that secretes digestive enzymes and an endocrine portion that secretes the hormones insuln and glucagon
+
| A large gland within organisms which has an exocrine portion that secretes digestive enzymes and an endocrine portion that secretes the hormones insuln and glucagon.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Pancreatectomy'''
 +
| Surgical removal of the pancreas.
 
|-  
 
|-  
| '''Pathogenesis'''
+
|  style="background: #EEAAAA;" | '''Pathogenesis'''
| The manner of development of a disease
+
| The manner of development of a disease.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Phosphorylation'''
 +
| introduction of phosphate group into an organic compound.
 
|-
 
|-
| '''Plasma glucose'''
+
|  style="background: #EEAAAA;" | '''Plasma glucose'''
 
| The concentration of glucose in blood measured in milligram per deciliter or milimole per litre. (normal fasting is >100 mg/dL (5.55 mmol/L).
 
| The concentration of glucose in blood measured in milligram per deciliter or milimole per litre. (normal fasting is >100 mg/dL (5.55 mmol/L).
 +
|-
 +
|  style="background: #EEAAAA;" | '''Pluipotent'''
 +
| Capable of giving rise to several cell types.
 +
|-
 +
| style="background: #EEAAAA;" | '''Polydipsia'''
 +
| Abnormally increased thirst symptomatic of disease.
 +
|-
 +
| style="background: #EEAAAA;" | '''Polyphagia'''
 +
| Excessive eating or appetite symptomatic of disease.
 +
|-
 +
| style="background: #EEAAAA;" | '''Polyuria'''
 +
| The production of abnormally large volumes of dilute urine ( >2.5L per day).
 +
|-
 +
| style="background: #EEAAAA;" | '''Progenitor'''
 +
| A cell that has a tendency to differentiate into a specific type of cell; like a stem cell.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Proliferation'''
 +
| Rapid increase in the number of something.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Proteolytic'''
 +
| The break down of proteins into smaller polypeptides or amino acids.
 +
|-
 +
|  style="background: #EEAAAA;" | '''Resistin'''
 +
| A cytokine secreted by adipocytes into the circulation causing resistance of peripheral tissues to insulin.
 +
|-
 +
| style="background: #EEAAAA;" | '''SCID mice'''
 +
| Mice severely deficient in functional B and T lymphocytes.
 
|-  
 
|-  
|'''Polydipsia'''
+
| style="background: #EEAAAA;" | '''Secretory granules'''
| Abnormally increased thirst symptomatic of disease
+
|Unique organelle in which neuropeptides and/or hormones are packaged and stored for secretion
 
|-  
 
|-  
|'''Polyphagia'''
+
| style="background: #EEAAAA;" | '''Somatostatin'''
| Excessive eating or appetite symptomatic of disease
+
| Hormone secreted in the pancreas and pituitary gland which inhibits gastric secretion and somatotrophin release.
 +
|-
 +
| style="background: #EEAAAA;" | '''Streptozotocin'''
 +
| A naturally occurring chemical that is particularly toxic to the insulin-producing beta cells of the pancreas in mammals.
 
|-  
 
|-  
|'''Polyuria'''
+
| style="background: #EEAAAA;" | '''Sulphonylurea'''
| The production of abnormally large volumes of dilute urine ( >2.5L per day)
+
| A class of hypoglycaemic agents taken by people with type 2 diabetes to increase the secretion of insulin by the pancreas.
 
|-  
 
|-  
| '''Oral Glucose Tolerance Test (OGTT)'''
+
| style="background: #EEAAAA;" | '''Unmyelinated'''
| Test determining the body's capacity to maintain glucose levels; results noted after overnight fasting and 4 times after administration (usually through sweet liquid) of 75g of glucose (100g for pregnant woman).
+
| Myelin is a fatty white substance that surrounds the axon of some nerve cells, forming an electrically insulating layer. When unmyelinated, the nerve does not have this surrounding layer.
 
|-  
 
|-  
| '''Streptozotocin'''
+
|style="background: #EEAAAA;" |  '''Uremic'''
| A naturally occurring chemical that is particularly toxic to the insulin-producing beta cells of the pancreas in mammals
+
| Uremia is the condition of having urea in the blood; symptomatic of chronic kidney disease.
 
|-  
 
|-  
 
+
| style="background: #EEAAAA;" | '''Zymogen'''
 
+
| Inactive forms of digestive enzymes.
 +
|-
 
|}
 
|}
  
 
==References==
 
==References==
 
<references/>
 
<references/>

Latest revision as of 11:13, 30 May 2017

2017 Projects: Group 1 - Delta | Group 2 - Duct | Group 3 - Beta | Group 4 - Alpha

Beta Cells Title Image.png

Note: Throughout this page, terms marked with an Astericks (*) will be found in the glossary.

Introduction

Background

Beta cells, abbreviated as β-cells, are one of the four major cells found within the endocrine* portion of the human pancreas*. The human pancreas is a composite organ, which extends from the distal foregut endoderm and is composed of an exocrine* and endocrine portion. The exocrine tissue consists of copious amounts of acinar cells, that discharge digestive fluid, and a complementary duct complex through which the secreted fluid drains into the intestine. The endocrine portion of the pancreas is composed of islets of Langerhans*, or pancreatic islets (reviewed in[1]). These islets of Langerhans constitute approximately 1-2% of the pancreas and are dispersed throughout it[2]. They contain multiple endocrine cells; alpha, beta, delta, gamma and epsilon cells, which secrete the hormones; glucagon, insulin, somatostatin, pancreatic polypeptides and ghrelin, respectively[1]. The pancreatic islets also host several endothelial cells, nerves and fibroblasts hence deeming them highly vascularised structures, which vary in size from small clusters to larger clusters, containing up to several thousand islets and reaching diameters of 300-400 μm. As the majority of pancreatic islets are typically less than 160 μm in diameter, islets which exceed this diameter are considered to be responsible for the majority of islet's total mass[3].

Currently, it is predicted that adult humans have approximately 2 million islets of Langerhans, which contributes to 2% of their total pancreatic weight[4]. Within these islets, approximately 60-70% of the total islet-cell population can be attributed to beta cells[5]. Beta cells, or insulin-secreting cells, are thus key cells within the pancreas and are predominately responsible for preserving normoglycaemia* by neutralizing blood glucose levels with appropriate quantities of insulin secretion[6]. While glucose levels are the chief driver, insulin secretion and synthesis by beta cells may occasionally occur in response to other factors such as nervous stimuli, hormones and nutrients[4].

Video 1. Introductory Video on the Role of the Pancreas:  

Youtube Link

History

Table 1. History of Pancreatic and Beta Cell Development
Year Historical Event
1869 The islets of Langerhans, or pancreatic islets, were first discovered by German anatomist Paul Langerhans, within rabbits, as anatomical formations with no direct connection to the duct. At that moment, no function was attributed to them[7]. Prior to the discovery, the pancreas was solely recognised as an exocrine organ[8].
1889 Joseph Von Mering and Oskar Minkowski successfully completed the first pancreatectomy* in a dog. Through this, they discovered that the removal of the pancreas induced diabetes in the dog . This discovery was paramount as it irrevocably established that the pancreas and diabetes were affiliated [9].
1893 Edouard Laguesse, who located islets in the human pancreas, suggested that they were responsible for the internal secretions that regulate glycemia*, and named them Langerhans, after their discoverer [10].
1907 and 1911 Lane and Bensley developed staining techniques to analyse the structure of the pancreas at a cellular level. These stains revealed at least two different granular cell types; A cells, which contained granules preserved by alcohol, and B cells, which contained granules preserved by chrome sublimate*[9].
1914 Homans noticed that B-cells were involved in experimental diabetes and thus attributed the sugar regulating function to them[8].
1921 Best and Banting isolated insulin from the canine pancreas after ductal ligation. Their discovery of insulin was awarded the Nobel Prize in Medicine in 1923[9].
1943 Dunn et al. selectively destroyed beta cells by administration of alloxan*, which led to diabetes[8].
1957-1974 Morphological features of the islet cell types were established through multiple studies utilising electron microscopy. Their structure and the appearance of their cytoplasmic secretory granules were observed[10].
1966 First case of insulin independence by pancreas transplantation by William Kelly and Richard Lillehei into a 28 year old uremic* woman at the University of Minnesota[11].
1972 Pictet and Rutter analysed the ultrastructural development of the pancreas by transmission electron microscopy and found that both the endocrine and exocrine cells of the pancreas were derived from a common progenitor*; alpha cells were the first endocrine cells to differentiate[9].
1977 Cudworth et al. made a crucial step in the etiological* classification of diabetes; introducing the terms type 1 and type 2 diabetes[12].
1990 Sharp et al. led further advances in transplantation achieving clinical insulin independence, lasting 1 month, through islet transplantation[13].
2000 Shapiro et al. utilise the "Edmonton protocol*" where 7 patients with type 1 diabetes receive islets and all recipients achieve insulin independence. The study utilised immunosuppression drugs to prevent rejection[14].
2014 Pagliuca et al. conduct the first successful generation of functional human pancreatic beta cells in vitro*, potentially providing an unprecedented cell source for drug discovery and cell transplantation therapy in diabetes [15].
Present Research continues into stem cell therapeutics for diabetes (refer to "Current Research").

Structure

Figure 1. Microscopic image of the pancreas, which reveals the structure of a blood vessel, acini, pancreatic islet and duct. Image is reprinted with permission from[16].

Among most species, pancreatic islets are generally characterised by an oval shape although the distribution of cells, within the endocrine pancreas, are subject to variation across animals. In most mammals, the islet contains a core of beta cells, which is encircled by a mantle of non-beta cells. Conversely, in humans and primates, cells are dispersed with greater complexity and deviate from the mammalian mantle-core arrangement to a composite of several mantle-core subunits. Due to such cellular organisation, pancreatic islets within humans and primates may be of oval or clover-leaf shape. Islets of Langerhans are highly vascularised structures, which contain capillaries that are lined by endothelial cells comprising of mitochondria*, ergastoplams*, a golgi complex* and a nucleus*. The peripheral extensions of the cytoplasm* of such endothelial cells are typically thinner and lack these organelles however, they contain several fenestrae or openings. While it is not confirmed whether these fenestrae vary in quantity and/or distribution, it is predicted that they represent areas for communication and allow the transfer of materials between the bloodstream and the extravascular space.

The beta cell, itself, is enclosed by a continuous plasma membrane and includes, within its cytoplasm, several membrane-bound organelles such as the endoplasmic reticulum*, mitochondria, a nucleus, golgi complex and secretory granules*. The endoplasmic reticulum, also called the ergastoplasm, is composed of two lamellar membranes that have ribosomes attached to their exterior surface. In comparison to the mitochondria present within adjacent acinar cells, the mitochondria of the beta cells are relatively smaller in size. However they are easily identifiable by the cristae within their matrix. The golgi complex and beta granules are similarly composed of smooth membranous sacs, although the latter is sequestered from the cytoplasm by the walls of these sacs. The beta granules are additionally dispersed throughout the entire cytoplasm. The nucleus contains a double-layered nuclear membrane and also several nuclear pores, which allow continuity and interaction between the nucleoplasm and cytoplasm of the beta cell.

Adjacent beta cells are connected to each other at distributed focal points, termed desmosomes, along their plasma membrane. Between two successive desmosomes, an intercellular space exists and its size is reliant upon the respective activity of the cells. The capillaries present within the islets of Langerhans are detached from the beta cells by two basement membranes; one related to the endothelium and the other to the capillary surface. Typically, between these two basement membranes, cross-sections of fibroblasts* and unmyelinated* nerve fibres can be detected. In some instances, unmyelinated nerve fibres have also been identified beneath the basement membrane and in close contact with the cell’s plasma membrane. Although presently unconfirmed, this is considered to indicate synapses between the nerve fibres and the beta cell[5].

Structural Modifications with Age

Extensive studies conducted on human pancreases, from the prenatal period through to adulthood, have revealed that the anatomical architecture of pancreatic islets resemble their adult form by the age of 2. As a direct result of this, the pancreas experiences substantial beta cell proliferation* during the first 2 years after its conception, which enables significant increases in beta cell mass and area. Increased beta cell production thus manifests as an increase in the diameter of existing pancreatic islets, rather than the formation of new islets. In fact, while 10% of beta cell mass increase during early life can be attributed to islet development, a sizeable 90% can be linked to an increase in islet size. Although, beta cell replication continues throughout life, the replication rate notably decreases after adolescence and hereafter beta cell mass remains relatively constant between the ages of 20 – 100 (reviewed in[17]).

Structural Comparison between Humans and Mice

Consequential of the clinical importance of pancreas-associated disease (refer to "Pathology"), the structure of the pancreas is studied extensively within medical science. Studies of the human pancreas, nevertheless, are restricted due to the inherent ethical and medical limitations present in obtaining pancreatic samples at specific and intermittent intervals. As a result of scarce human pancreatic samples, animal models are increasingly used in scientific studies. Within current pancreatic research, mice are the most frequently studied animal models. As a sizeable portion of scientific knowledge concerning the human pancreas is derived from studies conducted on mice, it is thereby imperative to identify and understand the distinction between the human and mouse pancreas[17].

Figure 2. Comparison of the macroscopic architecture of the human pancreas (A) against the mouse pancreas (B). Image is reprinted with permission from [17].
Figure 3. Hand-drawn illustration (by user z5158862) comparing the pancreas of the human embryo and the mouse embryo. Image is appropriated with permission from [17].

Macroscopic Comparison

At a macroscopic level, the human pancreas is a well-defined organ, which contains three key structural components: the anterior and posterior head, body and tail (reviewed in[18]). The left border of the superior mesenteric artery borders the head and body of the pancreas, while the midpoint of the pancreatic body and tail, combined, is understood as the border between the body and the tail. Reflecting a C-shape, the pancreatic head is continuous with the upper curvature of duodenum whereas the pancreatic tail touches the hilum of the spleen. The narrow and flat pancreatic body locates itself underneath the stomach and extends in such a manner that it crosses with the superior mesenteric artery and vein, abdominal aorta, inferior vena cava and portal vein.

Contradictorily, the mouse pancreas is less defined than its human counterpart, see Figure 2. and Figure 3., and in a dendritic manner, is uniquely diffused along the mesentery of the proximal small intestine of mice. Analogous to the human pancreas, it can also be distinguished into three key structural components. However, these are termed ‘lobes’ and are identified as the duodenal, splenic and gastric lobe. The largest lobe, the splenic lobe, extends between the duodenum and the spleen and is homologous to the body and the tail of the human pancreas. The second largest lobe, the duodenal lobe, is located within the mesentery, that surrounds the duodenum, and is homologous to the human pancreatic head. Additionally, the gastric lobe, which is the smallest observable lobe, is considered to be a component of the splenic lobe, from which it originally develops, and is homologous to the auricle of the human pancreas. Characteristically, patches of adipose*, connective and lymphatic tissue separate these three main pancreatic lobes in mice[17].


Microscopic Comparison

Microscopically analysed, each lobe of the pancreas contains numerous smaller lobules, which vary in size respective to the organism and measure 1-10 mm in diameter in humans and 0.5-1.5 mm in diameter in mice. Dome-resembling clusters of pyramidal acinar cells are dispersed throughout these pancreatic lobules. They secrete various digestive enzymes, which are ultimately released into the duodenum by successive movement through intercalated ducts, intralobular ducts, interlobar ducts and finally the pancreatic duct, thus forming the exocrine pancreas. The endocrine portion of the pancreas, predominately constituting islets of Langerhans, is embedded within the exocrine tissue. Notably, the size and distribution of pancreatic islets is congruous between humans and mice. With distinctly irregular cross-sections, they are home to thousands of hormone-secreting endocrine cells, which may also be singularly and randomly scattered across acinar and ductal tissues. While a minimum of five different polypeptide endocrine cells can be identified within the islets, beta cells, which synthesize and secrete insulin, form the majority and account for 60-70% of the islet cell population in humans and 60-80% in mice.

The spatial organization of beta cells has continuous focus for scientific research. In mice, the mantle component of pancreatic islets contain non-beta cells while the core component exclusively comprises beta cells. In humans, it was initially perceived that, alongside a similar mantle-core pattern, beta cells additionally formed ribbon-like clusters and were scattered throughout islets in an unorganised manner. However, consequential of recent studies, the current scientific consensus is that human pancreatic islets form trilmainar plates, which are folded into a U- or O-shape, and within which there are two layers of alpha cells that enclose a single beta cell layer. The reason for this specific organisation is considered to be the promotion of heterologous contact between both endocrine cells. Alternatively, in mice, there is homologous contact among alpha cells within the mantle of the islet and beta cells within the core of the islet. It is proposed that this specific type of spatial arrangement promotes alpha-cell-stimulation of beta cell functional activity[17].


Table 2. Summary Table of Key Comparisons between Human and Mice Pancreas
Property Humans Mice
Macroscopic Pancreatic Structure Well-defined organ with three structural components: the head, body and tail Less-defined structure with three lobes: duodenal, splenic and gastric lobe
Diameter of Lobules 1 - 10 mm 0.5 - 1.5 mm
Beta Cells as a % of Pancreatic Cell Population 60 - 70% 60 - 80%
Microarchitecture of Islets Trilaminar islets predominate Mantle islets predominate
Contact between Alpha and Beta Cells Heterologous contact between endocrine cells as two layers of alpha cells enclose a single beta cell layer homologous contact among alpha cells within the mantle of the islet and beta cells within the core of the islet

Pancreatic and Beta Cell Development

The ultimate architecture of the complete adult pancreas is the outcome of several necessary embryologic events (reviewed in[19]). During embryonic days 8.5 and 9, the emerging embryo moves from a lordotic position to a fetal position[20], which causes the endoderm layer to fold on itself and form a primitive gut tube that is divided into the foregut, midgut and hind-gut. Upon the establishment of the gut tube, the development of the dorsal pancreas is hereafter controlled by the notochord[19], which is the source of permissive signals that enable the differentiation of the foregut endoderm into a pancreas. The removal of the notochord is scientifically evidenced to eliminate the expression of pancreatic genes thus inhibiting pancreatic development and preventing the formation of all pancreatic cells, including beta cells[21]).

Of the three divisions of the gut tube, the foregut is the most essential[22] as the first morphological process in pancreatic formation, and beta cell development, is a condensation of the mesenchyme covering the dorsal aspect of the endodermal gut tube in the foregut. Succeeding this condensation, at 26 days post-conception, the endoderm evaginates into the mesenchyme and dorsal and ventral buds arise from the foregut. The buds are marked by transcription factors, such as pancreatic and duodenal homeobox factor 1 (PDX1) [22], SRY (sex-determining region Y)-box 9 (SOX9) and GATA binding protein 4 (GATA4), which are all necessary for pancreatic growth[23]. The epithelium, which constructs the mesenchyme surrounding the pancreas, coelomic epithelium, also begins to compartmentalise the pancreas away from non-gut structures and a substantial increase in the proliferation of mesenchymal cells, between the coelomic epithelium and pancreatic epithelium, is seen[19].

At approximately 37 to 42 days after gestation, the proximal portion of the dorsal bud form small accessory ducts called ducts of Santorini, while the remainder of the dorsal bud and ventral bud fuse to form the duct of Wirsung, which runs across the entire pancreas. Hereafter, the cellular architecture of the pancreas undergoes significant change and a major amplification in the amount of endocrine cells, particularly β-cells, is observed. Pancreatic acinar cells also undergo cell differentiation and gene expression for acinar enzymes increase in an exponential manner. The rough endoplasmic reticulum and zymogen granules also begin forming, consequently causing the pancreas to become opaque to the naked-eye due to high zymogen granule concentrations.

Although pancreatic alpha cells are differentiated and observed before beta cells, the earliest endocrine cells of the pancreas are collectively found in an admixture of endocrine, exocrine and epithelial cells, which all maintain close contact with the lumen. Eventual morphological transitions, however, allow endocrine cells to become distinct from epithelial cells and lose connection with the lumen[19]. At this stage in development, a down regulation of PDX1, which marks pluripotent precursor cells, is detected in endocrine progenitor cells as they become non-epithelial. Throughout pancreatic maturation, PDX1 remains principally expressed in the beta cells of the pancreas population[24], which is considered to be necessary for proper endocrine differentiation[20]. As the developmental process nears conclusion, endocrine cells aggregate in pancreatic ducts, as shown in Figure 4., and form islets of Langerhans[19].

Figure 4. Endocrine cells captured, at mid-gestation, showing periductal accumulations of cells. (A) Whole-mount insulin-staining of mouse pancreas displaying insulin cells. (B) Histologic sections with insulin in yellow, ducts in green and amylase in blue displaying the distribution of endocrine cells. (C) A TGF-β receptor II mutant mouse with amplification of periductal cord-like distribution of cells shown for emphasis. Image is reprinted with permission from [19].

On a hormonal level, at around 52 days after the conception of the human pancreas, Neurogenin-3 (NGN3), a regulator of pancreatic islet differentiation and regeneration is first detected in the pancreas[25]. Although the expression of the transcription factor PDX1 precedes them[24], insulin, glucagon and somatostatin are the first pancreatic hormones expressed. Pancreatic polypeptide is not detected until about 10 weeks post-conception. At around 12 weeks into the gestation period, at the point where pancreatic islet formation reaches its peak, all four hormones are expressed and thus the total number of hormone expressing cells, present within the islets, is increased[26].

Function

The overall function of the pancreas is to maintain glucose levels within the blood and beta cells play a specialised role within this process. The insulin gene, which provides instructions for the manufacture of insulin, is solely expressed in the endocrine portion of the pancreas within the beta cells of pancreatic islets. Insulin, a polypeptide hormone, is a key regulator of metabolism as it promotes the storage of excess glucose, amino acids and fatty acids by acting on the liver, muscle and adipose tissue. Insulin release into the bloodstream predominantly occurs as a consequence of increased glucose levels detected in the blood. Glucose phosphorylation, by glucokinase, is currently understood to act as the glucose sensor as it adjusts the rate of cellular metabolic activity to the extracellular concentration of glucose. Glucose metabolism generates intracellular signals in beta cells, which subsequently initiates insulin secretion, insulin mRNA translation and insulin gene transcription[27].

Video 2. Video Elucidating the Function of Insulin in the Human Body:  

Youtube Link

Insulin Gene Expression

In the late 1980s, the 5’ flanking region of the insulin gene was identified in transgenic mice. This proved to be an extraordinary breakthrough in science as it allowed the general location of binding sites, for transcription factors, to be discovered. The transcription factor binding sites, which direct beta-cell-specific expression, were eventually located to be between −520 and +1 base pairs relative to the transcription initiation site. In later studies, congruous expression data was collected for the human insulin gene. Both results thus collectively indicate that there are sequences conserved between mammalian insulin genes, which lie within 350bp of the transcription start site and control the specific cell-type expressions. The enhancer region in mammalian insulin genes is located between nucleotides -340 and -91. While the transcription factors that bind onto this region principally determine the glucose-regulated expression properties of the gene, the activity of the enhancer can be additionally up-regulated and/or down-regulated by cellular activity. For example, through autocrine signalling, the insulin secreted from beta cells may increase insulin transcription in the same beta cells, by positively influencing enhancer-mediated activation[27].


Insulin Biosynthesis

In the 1950s, insulin, as show in Figure. 5, became the first protein to have its structure clearly revealed. The discovery exposed insulin as a two-chain hormone and consequently triggered widespread speculation in the scientific community on the underlying mechanisms contributing to such a structure. Succeeding the discovery of single-chain precursor proteins, which occurred in 1967, insulin synthesis was finally understood to occur through several reactions with multiple single-chained precursor proteins, including preproinsulin and proinsulin.

File:Proinsulin to Insulin.JPG
Figure 5.Diagrammatic representation of proinsulin conversion to insulin. The image reveals the two-chain structure of insulin. Image is reprinted with permission from [28].

During insulin biosynthesis, the initial product formed instantaneously after insulin mRNA translation is preproinsulin, which contains a hydrophobic N-terminal 24 residue signal peptide. The signal peptide engages with the signal recognition particle (SRP), a ribonucleoprotein particle that is located within the cytosol, which enables the separation of the preproinsulin polypeptide chain from the cytosolic compartment into the secretory pathway. From here, the preprohormone is translocated across the membrane of the rough endoplasmic reticulum (RER) and into its lumen, via a peptide-conducting channel. A specialized signal peptidase, situated on the surface of the RER membrane, cleaves and rapidly degrades the signal sequence. Inside the RER, several chaperone proteins catalyse the folding of proinsulin and facilitate its manufacture of three disulfide bonds, which largely contribute to the development of its native structure.

Within a time period of ~10-20 minutes, proinsulin is rapidly transported from the RER to the Golgi apparatus. Here, proinsulin is packaged into immature secretory vesicles and cleaved to form equimolar amounts of insulin and connecting polypeptide (C-peptide) [29]. The predominant route for proinsulin processing is via cleavage at the junctions resulting in a 32,33 proinsulin peptide split, followed by the removal of 2 amino acids resulting in Des-31,32 proinsulin which finally forms mature C-peptide and insulin by the action of pro-protein convertase-2 (PC2) and carboxypeptide-E (CPE), see Figure. 5. The alternative pathway, which occurs less commonly, involves the removal of 2 amino acids are first[28]. The formation of insulin from its precursor, proinsulin, is initiated approximately 20 minutes after the synthesis of preproinsulin and typically lasts for 1-2 hours, independent of additional protein synthesis.

While proinsulin and insulin have a direct biological effect, C-peptide has no effect on homologous or heterologous tissue and no ability to influence the concentration or action of beta cell hormones (reviewed in[30]). Although small volumes of proinsulin and its immediate cleavage forms, C-peptide and insulin, are collectively stored in the secretion granules of beta cells, insulin is the predominant hormone released after signalling. Notably, proinsulin and insulin share similarities with respect to many of their properties, including solubility, isoelectric point, self-associative properties and relative reactivity with insulin antiserum[27]. The insulin moiety found within proinsulin is also highly similar to the one present in insulin itself, thus making their overall conformation highly similar[31].


Cell Biology of Insulin Biosynthesis

Congruous to other neurosecretory cells, the Golgi apparatus plays a substantial role in the formation of secretory granules in beta cells. However, its dynamic nature and the underlying mechanisms, which facilitate the transport and sorting of secretory products within it, is currently only partially understood. With further research, new models for Golgi progression are continuously proposed. Currently, a scientifically favoured model presents a form of the Golgi apparatus wherein individual cisternae, containing their secretory contents, migrate from cis to trans while small, coated vesicles transport various Golgi resident proteins and enzymes in an opposite manner from trans to cis. Relative to this model, while secretory products mature, they are kept in the same compartment and only exit from it as they dissipate into the trans Golgi network into immature secretory granules. Recent immunocyto-chemical studies have established that newly synthesized clathrin-clad granules in the trans Golgi cisternal network (TGN) are rich in proinsulin, which confirms the proposal that proinsulin conversion to insulin occurs principally during the maturation of the secretory granules. The proteolytic processing of proinsulin may be prevented by energy poisons, which block their transfer into secretory vesicles. Nevertheless, once newly manufactured proinsulin has reached the trans Golgi, energy is no longer required to convert it to insulin. While proinsulin conversion may begin in the trans compartment of the Golgi apparatus, it is now confirmed that it occurs predominantly within newly manufactured secretory vesicles as they leave the Golgi region and mature biochemically in the cytosol[29].

Quantitative Aspects of Insulin Secretion

In the late 1960s, the dynamics of insulin secretion, in response to glucose stimulation was studied and results demonstrated that glucose infused into the pancreas for extended amount of time, led to two different phases of insulin release. The first phase was characterised by rapid insulin release for 2 minutes, while the latter phase involved the continuous release of insulin, which slowly increased in rate until the termination of the glucose stimulus[32].

This was the first indication that insulin release from beta cells follows a biphasic pattern[33]. Insulin release in the initial phase is due to ATP-dependent potassium channels, which allow increased calcium influx and the discharge of ready and releasable insulin-containing granules. The second phase involves preparing granules for release and is thought to include the translocation of granules and checks to ensure that they are competent for exocytosis. Insulin secretion in the second phase therefore occurs over a greater length of time. In fact, in mouse islets, of the 13 000 granules present in beta cells, only ~100 are ready for release in phase one and thus the others must be finalized in phase two[34]. Quantitative comparisons can be made between both phases of insulin release by reports, which state that first and second phase insulin secretion in mouse islets occur at a rate of 0.14%/min and 0.05%/min, respectively[33].

Signalling

The Stimulus-Secretion Coupling Mechanism

Stimulus-secretion coupling refers to glucose-dependent insulin secretion from beta cells. Congruous to muscle cells, beta cells are also dependent on electrical activity and calcium entry in order to discharge insulin into the body. As a result, they have specific ion channels located in their plasma membrane, which enable the flow of calcium and potassium ions into and out of the cell. As these ions are electrically charged, their movement across the membrane causes action potentials, which are sharp changes in voltage[35].

In pancreatic beta cells, an increase in blood glucose levels block ATP-dependent potassium channels thus leading to the depolarisation of the membrane. Initially identified in ventricular myocytes, ATP-sensitive potassium channels are potassium channels that are inhibited by high intracellular concentrations of ATP (reviewed in[36]. As the activation of these channels disallow the production of action potentials, their inhibition, by glucose, stimulates action potentials by triggering voltage-dependent calcium channels in the membrane to open and thus allow increased calcium influx into the cell (reviewed in[37]). Within the cell, the calcium ions act on exocytotic machinery to stimulate the merging of vesicles, containing insulin, with the plasma membrane, thereby preparing them for secretion into the blood stream [33].

Conversely, as the electrical activity induced in beta cells is mainly due to calcium ion influx [38], decreased extracellular levels of calcium ions prevent the firing of action potentials and thus, by extension, inhibit insulin secretion [35].

Figure 6. An illustration of the endocrine pancreatic cell population with focus on the beta cell and its intracellular signalling mechanisms. Image is reprinted with permission from [35].

Glucose Metabolism and Potassium Channels

As glucose breakdown is imperative for insulin secretion, the inhibition of mitochondrial metabolism prevents insulin from being secreted by beta cells. Adenosine triphosphate (ATP) is the major product of glucose metabolism and therefore is a key factor that links the mitochondrial metabolism of glucose and ATP-sensitive potassium channels. ATP-dependent potassium channels contain four pore-forming subunits alongside four accessory sulfonylurea receptor subunits (SUR1). These SUR1 subunits are essential components of beta cells, as they are the focus site for anti-diabetic sulphonylurea drugs, which aim to increase insulin secretion by replicating the effect of glucose in order to block ATP-sensitive potassium channels[35].

While increased glucose levels generate a high cytoplasmic concentration of ATP and depolarize beta cells by blocking ATP-sensitive potassium channels[39], under low concentrations of glucose, these channels are open and enable the outward flux of potassium, causing a negative cellular membrane potential of ~ -70 mV. At this point, action potentials cease to occur and insulin exocytosis is inhibited. The membrane potential is only increased to more positive values once glucose-induced increases in ATP drive the closure of ATP-sensitive potassium channels. Hereafter, L-type voltage-dependent calcium channels, which are predominately expressed in beta cells, allow the release of insulin into the blood in order to maintain glucose homeostasis[35].

Un-Coupling Glucose Metabolism and ATP Production in Beta Cells

As mentioned above, the voltage of the cell membrane is dependent upon changes in the intracellular concentration of ATP. As a result of this, perturbations of metabolic pathways that produce ATP can, by extension, impact insulin secretion by beta cells. In all cells, ATP is generated in the mitochondria[35], which produces approximately 95% of the cell’s energy and is therefore colloquially termed “(the) powerhouse of the cell”[40].

Within the mitochondria, the electron transport chain (ETC), as depicted in Figure 7., is the central machinery responsible for ATP production (reviewed in[41]) and is heavily reliant upon a proton gradient across the mitochondrial membrane[35]. The four enzyme complexes of the ETC transfer electrons from donors, such as NADH, to the ultimate electron accepter, oxygen. Throughout this transfer of electron, the ETC concurrently pumps protons, or hydrogen ions (H+), into the inter-membrane space, which subsequently generates a gradient across the inner mitochondrial membrane. ATPase, an enzyme, then harnesses this gradient to drive ATP synthesis[42]. This process is additionally explained in Video 3.

Figure 7. Illustration of the components of the Mitochondrial Electron Transport Chain. Image is reprinted with permission from [43]

Specifically within beta cells, the uncoupling protein-2 (UCP2) can largely impair the generation of ATP via the mitochondrial ETC as it enables a proton leakage across the mitochondrial membrane[35] and therefore inhibits the necessary formation of a proton gradient. The over-expression of UCP2 can therefore bypass the production of ATP, which is reinforced by studies that report a 50% reduction in ATP content in the cells of UCP-2-induced pancreatic islets[44]). On the other hand, a loss of UCP2 expression is hence responsible for increased intracellular ATP concentrations and glucose-stimulated insulin secretion by beta cells, which serves to decrease levels of glycemia[45]). It has also been discovered that the expression of Sirt1, in beta cells, downregulates UCP2 expression, further enhancing insulin secretion [35].

Video 3. Explanation of the Mitochondrial Electron Transport Chain:  

Youtube Link

Role in Pathology

As established above, insulin is vital in the maintenance of glucose levels in blood. Through the signalling of liver, muscle and fat cells, insulin enables glucose uptake and allows for its use as an energy source. When the body has a sufficient amount of energy, insulin signals the liver to take up excess glucose and store it as glycogen. Thus, in the absence of insulin or responsiveness to insulin, glucose remains in the blood stream resulting in a rise of blood-glucose levels, leading to diabetes. This concept is reiterated visually in Video 4.

Video 4. Explanation of the relationship between insulin, glucose and diabetes:  

Youtube Link

Disease

The role of beta cells in disease in explained in Table 3.

Table 3. Comparison of Type 1 and Type 2 Diabetes Mellitus
Type 1 Diabetes Mellitus (T1DM) Type 2 Diabetes Mellitus (T2DM)
Epidemiology*

Type 1 diabetes is one of the most common chronic childhood diseases:

  • Two peaks in its occurrence present between the age of 5-7 and near puberty[46].
  • Accounts for approximately 5-10% of the diabetic population worldwide[47].

Type 1 diabetes varies dramatically on a global scale with >350-fold variation in incidence among reporting countries; overall:

  • It is the least common in China, India and Venezuela
  • It is the most common in Finland as well as Sweden, Norway, Portugal, Great Britain, Canada and New Zealand[48].
  • The number of type 2 diabetes patients is currently increasing, with 80% living in low and middle income countries.
  • It is estimated that 439 million people will have type 2 diabetes by the year 2030[49].
  • Type 1 diabtes incidence varies substantially from one geographic region to the another as a result of environmental and lifestyle risk factors[50].
Cause

Type 1 diabetes results from an insulin deficiency that is caused by the loss of pancreatic beta cells. This can be consequential of:

  • Autoimmune destruction of beta cells, which generally occurs over an extended period of time
  • Genetic susceptibility, which is believed to be a prerequisite for type 1 diabetes[47] However in a study by Barnett, Leslie & Pyke (1981). However type 1 diabetes does not fit any simple inheritance pattern and is considered a complex multifactorial disease[51].

Early familial and twin studies support the importance of both genetic and environmental risk factors[52]:

  • An analysis of 200 pairs of identical twins, within different age groups, revealed that approximately half the pairs were discordant; suggesting that type 1 diabetes is not entirely genetically based.
  • An environmental, or alternative non-genetic, cause was suggested as twins that were living separately, between the ages of 20-39, were shown to have a greater number of discordance[52].
  • Pancreatic beta-cell dysfunction and failure results in the prevalence of type 2 diabetes:


In the normal healthy body, beta-cells are able to function at a greater capacity when glucose increases, thus producing more insulin to maintain glucose homeostasis. Beta cells are able to adapt to the change by introducing in a compensatory response in insulin production. Beta-cell dysfunction is seen in Type 2 diabetes as this compensatory response results in the gradual failure of beta cells, primarily due to insulin resistance within the individual[53].

Primarily lifestyle factors cause this insulin resistance to occur. Such factors may include:

  • Physical inactivity
  • Sedentary lifestyle
  • Cigarette smoking and generous consumption of alcohol
  • Obesity contributing to 55% of cases[54].


Recent increases in the occurrence of type 2 diabetes may also be attributed to environmental factors (reveiwed in [55]).

Symptoms
  • Polyuria*
  • Increased thirst
  • Unexplained weight loss
  • Blurred vision,
  • Fasting plasma glucose* of >126mg/dL (7.0 mmol/L) ,
  • Two hour post-load plasma glucose of >200 mg/dL (11.1 mmol/L) during standard oral glucose tolerance test (OGTT)* [56]
  • Polyuria,
  • Polydipsia*,
  • Polyphagia*,
  • Raised fasting plasma glucose >126mg/dL (7.0 mmol/L),
  • Two hour post-load plasma glucose of >200mg/dL (11.1 mmol/L) during standard oral glucose tolerance test (OGTT)[55]
Pathogeneis*

The pathogenesis of autoimmune-induced type 1 diabetes has been extensively studied through the use of animal models, such as non-obese diabetic mice and diabetes-prone BioBreeding rats. From the studies, exact mechanisms of initiation and progression remain unclear, however through the it is generally believed that beta-cell auto-antigens, macrophages, dendritic cells, B lymphocytes and T lymphocytes are involved in the beta-cell specific autoimmune process. As seen in Figure 8., the beta-cell auto-antigens are processed by the macrophages, dendritic cells or B cells in the pancreatic islets and then presented to the auto-reactive CD4+ T cells in the peripheral lymphoid system. These cells are consequently activated, thus leading to the secretion of cytokines, which may activate beta-cell specific cytotoxic CD8+ T cells. Activated T cells also recruit at the islets, producing cytokines which further activate macrophages and other T cells; all contributing to the destruction of pancreatic beta-cells[57].

File:Beta Cell Destruction.JPG
Figure 8: Beta-cell destruction by autoimmune processes. Image is reprinted with permission from [57].

The evolution of beta-cell dysfunction is marked by 5 stages as identified by Weir & Bonner-Weir (2004) [58]:

  • Stage 1: Referred to as compensation; when the insulin secretion must compensate for degrees of insulin resistance to ensure the maintenance of glucose homeostasis.
  • Stage 2: Where fasting levels range between 5-7.3 mmol/L, representing 'beta-cell adaptation'. Patients progressing towards type 2 diabetes may remain here for many years, however as beta-cell mass becomes insufficient, glucose levels may rise to stage 4 rapidly.
  • Stage 3: Early decompensation: glucose levels rise beyond 7.3 mmol/L
  • Stage 4: Stable decompensation: glucose levels range between 16-20mmol/L
  • Stage 5: Severe decompensation: extreme beta cell failure; ketosis with blood glucose levels above 22 mmol/L
Figure 9: Flowchart depicting the progression of beta-cell dysfunction. This is a student-created illustration by user z5076777.

Pancreatogenic (Type 3c) Diabetes

Unlike T1DM and T2DM, Type 3c Diabetes Mellitus (T3cDM) is a form of secondary mellitus that is caused by underlying pancreatic diseases such as acute or chronic pancreatitis, cystic fibrosis, pancreatic cancer or other form of pancreatic trauma leading to loss of pancreatic tissue; the most common cause being chronic pancreatitis (CP). CP accounts for 75-80% of T3cDM cases, while pancreatic carncinoma accounts for 8%[59]. T3cDM was initially believed to have a lower prevalence (approximately 0.5-1.2%) among diabetes cases in North America, however recent studies suggest higher occurrences than originally anticipated. In fact, a recent study shows a 5-10% prevalence among all diabetic subjects in Western populations[60]. A review by Anderson et al. (2013) suggests that previous underestimations may be attributed to the fact that it has become easier to detect exocrine pancreatic pathology, and quantify exocrine dysfunction, with new advancements in imaging technology and noninvasive screening methods[61].

Moreover, the endocrinopathy is far more complex in T3cDM, than T1DM and T2DM, due to additional comorbidities[62]. As a result of the cross over in risk factors for T2DM and T3cDM, such as obesity and congruous symptoms associated with all three forms of diabetes; e.g. difficulties with glucose homeostasis, a method of discrimination between the diseases is required. The proposed criteria for this involves noting

  • Presence of exocrine pancreatic insufficiency (monoclonal fecal elastase-1 test)
  • Pathological pancreatic imaging (endoscopic ultrasound, MRI, CT)
  • Absence of type 1 diabetes mellitus associated autoimmune markers
  • Impaired beta cell function
  • No excessive insulin resistance
  • Impaired secretion of incretins
  • Low serum levels of lipid soluable vitamuns


However, despite the implementation of the proposed criteria, overlapping still occurs as patients suffering from T1DM and T2DM, for an extended period of time, are also victims of pancreatic failure and are at risk of acute and chronic pancreatitis. Additionally, patients with pancreatitis may develop T1DM or T2DM independently. Thus, the best discriminator between all three forms of diabetes is believed to be the pancreatic polypeptide's (PP) response to nutrients [63].

Interestingly, studies have revealed that isolated hepatic insulin resistance coexists with clinical studies of T3cDM [64]. This is documented to be consequential of CP, pancreatic cancer and/or cystic fibrosis, which results in unsuppressed hepatic glucose production. PP deficiency was also found to coincide with T3cDM and thus, is identified as a likely mediator of the hepatic defect. Animal studies indeed confirm that PP deficiency results in diminished hepatic insulin receptor availability and thus PP administration reverses hepatic insulin resistance in patients with CP, thereby improving glucose tolerance[65].

Figure 10: Diagram showing the effect of adrenomedulin on insulin secretion. Image is reprinted with permission from [66].

How cancer induces T3cDM:

The most likely explanation for the consequential occurence of diabetes in pancreactic ductal adenocarcinoma (PDAC) patients, is a paraneoplastic phenomenon caused by tumor-secreted products. One such product that results in beta-cell dysfunction is adrenomedullin; a pluripotent hormone with homology to amylin, which is over-expressed in PDAC. Adrenomedullin receptors are found on beta cells and therefore external administration of adrenomedulin causes the inhibition of insulin secretion, as evidenced in animal studies[67] One such study performed by identified adreninedulin (AM) to impair insulin secretion from beta cell and cintributing to the insulin inhibitory effect of pancreatic cancer cells in vitro and in vivo* (as seen in Figure 10.)[66]. These finding support that adrenomedulin is mediator of beta cell dysfunction in PDAC.

How chronic pancreatitis induces T3cDM

Development of diabetes in chronic pancreatitis patients mainly occurs due to the destruction of islet cells by pancreatic inflammation. Additionally maldigestion caused by pancreatitis leads to diminished insulin release[68]. GLP-1 is an incretin hormone secreted by the L-cells of the distal intestine, and has the effect of stimulating insulin gene expression and proinsulin biosynthesis. GLP-1 also has proliferative and anti-apoptotic effects on the beta-cell[69]. Thus, maldigestion leads to impaired incretin secretion and therefore diminished insulin release of the remaining beta-cells[68]. In contrast to the autoimmune-mediated destruction of beta-cells in T1DM, gulcagon-secreting alpha cells and PP cells are also subject to destruction in CP leading to a complex metabolic situation.

Treatments

Insulin Therapy

Insulin injections are used in place of the insulin that would normally be produced by the body. Individualised treatment plans are suggested for patients however, generally T1DM patients take 3-4 injections per day to provide optimal glucose control, while T2DM take 2 injections per day if not in conjunction with other medication[70][71]. Insulin shots are most effective when administered when food enters the blood, such as 30 minutes before eating. Furthermore, particular sites for injections, such as the abdomen, provide better results while insulin administered at the arms and thighs take a longer period of time to enter into the blood stream[72].

However, insulin vials and syringes provide an inconvenience to patients. Adverse psychological and social effects may occur to others, and to the patient, when using syringes. Incorrect insulin use and dosage could also result in risks. Insulin pens have thus been developed to counteract these issues by providing rapid, long-acting insulin[73]. Nevertheless, insulin pens have a greater cost per unit of insulin compared to the insulin supplied in vials[72].

Insulin pumps are another method of attaining insulin and counteracting insulin deficit, however they require frequent use as they come in the form of continuous subcutaneous insulin infusions (CSII). This method is therefore mainly utilised by patients with T1DM. Insulin pumps send insulin, through tubing, into an infusion set that delivers insulin to the body. A plastic tube is connected to the insulin reservoir and insulin flows into the subcutaneous tissue via the infusion set. The pumps are very costly and also require commitment to self-management, with frequent blood glucose checks throughout the day. Many adolescents may feel uncomfortable with the concept of being attached to a foreign object. It is also worth noting that insulin pumps do have the potential to over or under medicate patients if they are broken or used incorrectly, and thus potential complications of their use also include ketoacidoses and hypoglycemia[74]. Thus potential complications of use include ketoacidoses and hypoglycemia. [74]

Pancreatic Transplantation

As there is no definite cure for diabetes, much of the current research on beta cells focuses on developing new and better treatments for diabetic patients. One of the most promising treatments, that is presently being researched and monitored with experimentation, is pancreatic transplantation[75]. Insulin pumps also have the potential to over or undermedicate if they are to malfunction or are used improperly.

1. Pancreatic Islet Transplantation [76]

This method is specifically aimed to treat patients with type 1 diabetes mellitus. During treatment, the pancreatic islet is isolated within the donated pancreas and the exocrine functioning part of the pancreas is removed. The isolated islet is then transported to the liver of the patient by venous blood.

Figure 11: Diagrammatic representation of islet transplantation. Image is reprinted with permission from [76].

In a study performed by Shapiro et al. the Edmonton protocol was established and is now used by islet transplant centres around the world, greatly increasing islet transplant effectivity [76]. The protocol involves the islet transplantation in conjunction with immunosuppressive drugs in order to counteract rejection. The procedure of transplantation involves the isolation of islets with cold purified collagenase, which is then digested and purified in a xenoprotein-free medium, and transplanted immediately through a catheter; a small plastic tube using ultrasound for guidance, through the upper abdomen and into the liver (see Figure 11.). This procedure requires only a small dosage of local anaesthetic. Alternatively, some surgeons may create a small incision in patients, with use of general anesthesia. Once implanted, the beta cells in the islet begin to synthesise and release insulin. Ultimately the transplant successfully results in insulin independence with excellent metabolic control[14].

Currently, many limitations exist with the procedure. These include islet rejection and insufficient supply of islets for transplantation. Although current immunosuppressive regimens exist, they are expensive and may increase the risk of particular malignancies and opportunistic infections. Also as a contradiction, some drugs also impair normal islet function and insulin action, combined with other unwanted side effects, including anemia, weight loss, hypertension, diarrhea and fatigue[14]. Another important concern is renal failure associated with immunosuppressive agents as renal function is a crucial factor in determining the long-term outcomes of patients[77]. With regards to the limitation of islet donors; statistics highlight that at least 1 million americans have T1DM however, only a few thousand pancreas donors are available each year. To resolve this issues researchers continue to look for alternative methods such as growing islets, or at least cells capable of physiologically regulated insulin secretion in vitro.

2. Transplantation using Embryonic Pig Pancreatic Tissue

Instead of using human tissue or organ for transplantation, this method uses the pancreatic tissue of an embryonic pig. Although previous clinical studies failed to provide successful results in treating diabetes, this study has sought to examine the potential and functionality of pig embryonic pancreatic tissues, harvested at different stages of embryonic pig development, in diabetic treatment. In an experimental study, various embryonic pancreatic tissues were implanted in SCID mice and the 42nd day of gestation (E42) showed a substantial growth of pig islets for a prolonged period of time, thereby restoring normoglycemia in the diabetic mice as seen in Figure 12. The study also revealed that reduced tissue rejection was seen at this stage of embryonic tissue implantation, as opposed to E56 or at later stages. Ultimately, the fully immunocompetent diabetic mice, with E42 implanted pancreatic tissue, that were treated with the immunosuppression protocol, attained normal glucose levels[78]. These results thus highlighted the therapeutic potential of E42 embryonic pig pancreatic tissues transplantation in diabetic treatment.

Figure 12: Comparison of the implantation of pig embryonic pancreatic tissue, from varying developmental stages, on diabetic mice. Image is reprinted with permission from [78].

Stem Cell Research

Another promising anti-diabetic therapeutic option is within stem cell research. Mitutsova et al. (2017) investigated the possible use of muscle-derived stem cells (MDSC), from adult mice, to differentiate into functional beta cells in vitro; consequentially compensating for beta-cell deficiency. Within their study they successfully found in vitro cultured MDSC to spontaneously differentiate into insulin-expressing, islet-like cell clusters, under the control of an insulin promoter. These differentiated clusters of beta-like cells co-expressing insulin with transcription factors were shown to secrete significant levels of insulin in response to glucose challenges. Additionally, in vivo undifferentiated MDSC injected into streptozotocin* treated mice, engrafted within 48 hours specifically, to damaged pancreatic islets and were also shown to differentiate and express insulin within 10-12 days after injection. Also to add to the successful results, injection of MDSC into hyperglycemic diabetic mice was shown to reduce blood glucose levels for 2-4 weeks. Ultimately the study successfully showed MDSC as capable of differentiating into mature pancreatic beta like cells, both in vivo and in vitro highlighting a promising avenue in stem-cell based treatment of beta-cell deficiencies[79].

Current Research

Generation of Functional Beta-like Cells

In a recent study by Lima et. al. (2016), the generation of mature and functional beta-like cells from the human exocrine pancreas were assessed as a viable avenue for the treatment of type 1 diabetes. The pivotal finding of the study was that the knockdown of transcription factor, ARX, expression, combined with the over-expression of transcription factor, Pax4, considerably enhances the production of functional insulin secreting beta-like cells while suppressing of alpha cells. The beta-like cells produced were shown to efficiently exhibit glucose-responsive insulin secretion. They also showed immediate and prolonged effects in normalising blood glucose levels upon transplantation into diabetic mice.

The study estimated approximately 3 billion of these cells would have an immediate therapeutic effect following implantation in T1DM patients and potentially one pancreas could provide enough tissue for numerous transplants. Thus, the ability to reprogram exocrine pancreas tissue could circumvent the necessity for multiple pancreas donors to treat a single patient. The study, although not achieving exact human islet response levels, did succeed in attaining results of 15-30% insulin levels of that of the normal human islet. This response could potentially have large therapeutic benefits for a patient with T1DM, as reinstating even a fraction of the normal beta-cell mass would be beneficial.

The study thereby produced functional beta-like cells that efficiently processed proinsulin to insulin, contained insulin storage granules, secreted insulin in response to glucose and rescued diabetes in a streptozotocin mouse model. Essentially, this inexpensive and relatively simple protocol, for cell preparation, could provide an avenue to bypass the obstacle of pancreas donors as one donor could provide numerous islet grafts[80].

Glibenclamide as Potential Prevention of Diabetes

A study by Lamprianou et al. (2016) utilised previous findings on the importance of Cx35 as an enhancement factor for promoting beta cell insulin secretion and resistance to pro-inflammatory cytokines, and extended this research further by analysing the effect of glibenclamide on beta cells. Glibenclamide is shown to promote the assembly and function of Cx36 channels. This study utilised untreated NOD mice to model type 1 diabetes and found the glibenclamide to:

Figure 13: A series of images identifying the the therapeutic effect of Glibenclamide on NOD mice. Image is reprinted with permission from [81]
  • Protect Cx36 loss in vitro usually induced by Th1 cytokines
  • Prevent the development of hyperglycemia through the prevention of beta cell loss (which was shown to rapidly develop in the aging untreated NOD mice)
  • Modify the proportion of CD4+ and CD8+ T cells in pancreatic draining lymph nodes


Figure 13. highlights the study's highly successful results, comparing the before and after amounts of islet and beta cell mass. The images of the islets in Figure 13a. highlight the substantial increase in islet number and size after dose 1 and 2 of glibenclamide compared to the control. Figures 13b. and 13c. also highlight the numerical density changes in islet and beta cells respectively, emphasising a spike of approximately 66% islet density and 50% beta cell density after dose 2. The study, therefore ultimately establishes glibenclamide treatment as another plausible avenue for diabetic therapeutics[81].

RA index to Determine Beta-Cell Functionality

This study aims to identify parameters which influence the function of beta-cells in order to potentially find markers of disease progression or targets for intervention. Although, body mass index (BMI) and increased energy intake are commonly considered risk factors associated with beta-cell dysfunction, evidence of direct numerical correlation remain undefined. Thus, Curran et al. (2016) recognised the necessity for identification markers to allow for beta-cell function assessment.

Beta cells were calculated as a ratio of the incremental insulin to glucose response over 30 minutes of the OGTT. Insulin sensitivity and beta-cell homeostatic assessment of insulin resistance was calculated as well as C-peptide amount. After all else was accounted for, an RA index was formulated as a ratio of resistin to adiponectin at fasting levels. Ultimately the findings showed that the RA index was strongly associated with pancreatic beta-cell function; in vitro studies found direct correlation of RA index to insulin secretion. Previous studies have also found the RA index to coincide with T2DM however this study was the first to mark its connection to beta-cell functionality. The study concluded that there was a necessity for further future investigation into potential mechanisms for modulating the RA index which consequentially may lead to new mechanisms for improving beta-cell function[53].

Review Quiz

Try to attempt these questions from memory!

1

In which species does the pancreatic islet contain a core of beta cells surrounded by a mantle of non-beta cells?

Most humans and primates
Most mammals
Neither species

2

What is the name of the focal point where adjacent beta cells connect to each other along their plasma membrane?

Islets of Langerhans
Desmosomes
Rough endoplasmic reticulum

3

Which of the following statements is correct?

The proteolytic processing of proinsulin may be prevented by energy poisons, which block their transfer into secretory vesicles
Proinsulin and insulin are highly dissimilar and demonstrate large differences in solubility and isoelectric point
Type 2 diabetes is one of the most common chronic childhood diseases

4

How does an individual become at risk of Type 3c diabetes?

Through genetic predisposition leading to autoimmune attack of beta cells
As a secondary effect from some alternative disease effecting pancreatic tissue and sub-sequentially beta cells
Through a sedentary life style

5

How can beta-like cells become useful in the future of therapetics?

Cost effective treatment option
Less donors required
Simple protocol
All of the above

6

The notochord is:

The source of permissive signals that enable the differentiation of the foregut endoderm
The term for the first morphological process in pancreatic formation
Another name for the endoplasmic reticulum.

7

Polydipsia is a defining symptom of which beta-cell related disease?

Type 1 Diabetes
Type 2 Diabetes
All the above

8

The correct definition of polyphagia is:

Excessive eating or appetite symptomatic of disease
The production of abnormally large volumes of dilute urine ( >2.5L per day)
Abnormally increased thirst, symptomatic of disease


Glossary

Term Definition
Adiponectin A protein involved in regulating glucose levels as well as fatty acid breakdown.
Adipose Bodily tissue which stores brown or white fat.
Alloxan A toxic glucose analogue which selectively destroys insulin-producing cells in the pancreas when administered in rodents and many other animal species.
Anemia A deficiency of red blood cells.
Autocrine A cell produced substance that has an effect on the cell by which it was secreted.
Chrome sublimate A staining method to identify beta-cell granules (appear as a violet colour).
Clathrin-clad granule Clathrin is a protein that plays a major role in the formation of coated vesicles.
Cytoplasm The material within a living cell excluding the cell nucleus.
Edmonton Procedure Researchers use specialised enzymes to remove islets from the pancreas of a deceased donor and transplant to a patient via catheter through to small incision through to the liver as treatment for type 1 diabetes.
Endocrine Glands that secrete hormones directly into the blood.
Endoderm The innermost layer of cells or tissue of an embryo in early development.
Endoplasmic reticulum Usually has ribosomes attached and is involved in protein and lipid synthesis.
Epidemiology The study of distribution and determinant of diseases.
Ergastoplasms Ribosome-studded endoplasmic reticulum.
Etiological Relating to cause or origin.
Exocrine Glands that secret products through ducts.
Fetal position Back is curved, head is bowed, limbs are bent and drawn up to torso.
Fibroblasts Cells in connective tissue which produces collagen and other fibres.
Glucagon A hormone formed in the pancreas which promotes the breakdown of glycogen to glucose in the liver.
Glucokinase Recognises how high blood glucose levels are in the body.
Glycemia Presence of glucose in the blood.
Golgi complex Also known as golgi apparatus/body is a complex of vesicles and folded membranes within the cytoplasm of most eukaryotic cells, involved in secretion and intracellular transport.
Heterologous Anything other than homologous.
Homologous Having the same relation, relative position, or structure.
In vitro Performed or taking place in a test tube, culture dish, or elsewhere outside the living organism.
In vivo Performed within a living organism.
Islets of Langerhans A cluster of endocrine pancreatic cells, which secrete the hormones insulin and glucagon.
Lordotic position increased inward lumbar spine curvature.
Mesenchyme Mucoid connective tissue consisting of loosely packed, unspecialised cells set in a gelatinous ground substance, from which connective tissue, bone, cartilage, and the circulatory and lymphatic systems develop.
Mitochondria An organelle which carries out the biochemical process of respiration and energy production.
Neurosecretory Storage, synthesis and release of hormones from neurons.
NOD mice Non-obese diabetic mice are used as an animal model for type 1 diabetes.
Normoglycemia a normal concentration of sugar in the blood
Notochord A cartilaginous skeletal rod supporting the body in all embryonic animals.
Nucleus A dense organelle typically a single rounded double membrane structure containing genetic material.
Oral Glucose Tolerance Test (OGTT) Test determining the body's capacity to maintain glucose levels; results noted after overnight fasting and 4 times after administration (usually through sweet liquid) of 75g of glucose (100g for pregnant woman).
Pancreas A large gland within organisms which has an exocrine portion that secretes digestive enzymes and an endocrine portion that secretes the hormones insuln and glucagon.
Pancreatectomy Surgical removal of the pancreas.
Pathogenesis The manner of development of a disease.
Phosphorylation introduction of phosphate group into an organic compound.
Plasma glucose The concentration of glucose in blood measured in milligram per deciliter or milimole per litre. (normal fasting is >100 mg/dL (5.55 mmol/L).
Pluipotent Capable of giving rise to several cell types.
Polydipsia Abnormally increased thirst symptomatic of disease.
Polyphagia Excessive eating or appetite symptomatic of disease.
Polyuria The production of abnormally large volumes of dilute urine ( >2.5L per day).
Progenitor A cell that has a tendency to differentiate into a specific type of cell; like a stem cell.
Proliferation Rapid increase in the number of something.
Proteolytic The break down of proteins into smaller polypeptides or amino acids.
Resistin A cytokine secreted by adipocytes into the circulation causing resistance of peripheral tissues to insulin.
SCID mice Mice severely deficient in functional B and T lymphocytes.
Secretory granules Unique organelle in which neuropeptides and/or hormones are packaged and stored for secretion
Somatostatin Hormone secreted in the pancreas and pituitary gland which inhibits gastric secretion and somatotrophin release.
Streptozotocin A naturally occurring chemical that is particularly toxic to the insulin-producing beta cells of the pancreas in mammals.
Sulphonylurea A class of hypoglycaemic agents taken by people with type 2 diabetes to increase the secretion of insulin by the pancreas.
Unmyelinated Myelin is a fatty white substance that surrounds the axon of some nerve cells, forming an electrically insulating layer. When unmyelinated, the nerve does not have this surrounding layer.
Uremic Uremia is the condition of having urea in the blood; symptomatic of chronic kidney disease.
Zymogen Inactive forms of digestive enzymes.

References

  1. 1.0 1.1 <pubmed>26395141</pubmed>
  2. Brissova, M. & Powers, A. C. (2008). Architecture of Pancreatic Islets. Pancreatic Beta Cell in Health and Disease (pp. 3-4).
  3. Bell, G., Seino, S., & SpringerLink. (2008). Pancreatic Beta Cell in Health and Disease.
  4. 4.0 4.1 <pubmed>14687913</pubmed>
  5. 5.0 5.1 <pubmed>5333806</pubmed>
  6. <pubmed>22460761</pubmed>
  7. <pubmed>6993583</pubmed>
  8. 8.0 8.1 8.2 <pubmed><4192603></pubmed>
  9. 9.0 9.1 9.2 9.3 <pubmed>19765178</pubmed>
  10. 10.0 10.1 <pubmed>26216133</pubmed>
  11. <pubmed>5338113</pubmed>
  12. <pubmed>67403</pubmed>
  13. <pubmed>2108071</pubmed>
  14. 14.0 14.1 14.2 <pubmed>10911004</pubmed>
  15. <pubmed>25303535 </pubmed>
  16. Gittes, G. (2009). Developmental Biology of the Pancreas: a Comprehensive Review. Dev. Biol.: 326(1);4-35
  17. 17.0 17.1 17.2 17.3 17.4 17.5 <pubmed>26030186</pubmed>
  18. <pubmed>16547676</pubmed>
  19. 19.0 19.1 19.2 19.3 19.4 19.5 <pubmed>19013144</pubmed>
  20. 20.0 20.1 <pubmed>3420142</pubmed>
  21. <pubmed>9334273</pubmed>
  22. 22.0 22.1 <pubmed>17185316</pubmed>
  23. <pubmed>26395141</pubmed>
  24. 24.0 24.1 <pubmed> PMC232449</pubmed>
  25. <pubmed>23630303</pubmed>
  26. <pubmed>15072563</pubmed>
  27. 27.0 27.1 27.2 Artner, I. & Stein, R. (2008). Transcriptional Regulation of Insulin Gene. Pancreatic Beta Cell in Health and Disease (pp. 13-16).
  28. 28.0 28.1 <pubmed>26216140</pubmed>
  29. 29.0 29.1 Steiner, D. (2008). The Biosynthesis of Insulin. Pancreatic Beta Cell in Health and Disease (pp. 31-37).
  30. <pubmed>403392</pubmed>
  31. <pubmed>2252901</pubmed>
  32. <pubmed>4877098</pubmed>
  33. 33.0 33.1 33.2 <pubmed>12879249</pubmed>
  34. <pubmed>11815463</pubmed>
  35. 35.0 35.1 35.2 35.3 35.4 35.5 35.6 35.7 35.8 <pubmed>1363709</pubmed>
  36. <pubmed>3662377</pubmed>
  37. <pubmed>1779997</pubmed>
  38. <pubmed>1309425</pubmed>
  39. <pubmed>2417189</pubmed>
  40. <pubmed>22901785</pubmed>
  41. <pubmed>24372303</pubmed>
  42. <pubmed>4522279</pubmed>
  43. <pubmed> 20346106 </pubmed>
  44. <pubmed>11375330</pubmed>
  45. <pubmed>11440717</pubmed>
  46. <pubmed>18502302</pubmed>
  47. 47.0 47.1 <pubmed>9914216</pubmed>
  48. <pubmed>20723815</pubmed>
  49. <pubmed>20622160</pubmed>
  50. <pubmed>11742409</pubmed>
  51. <pubmed>22315720</pubmed>
  52. 52.0 52.1 <pubmed>7193616</pubmed>
  53. 53.0 53.1 <pubmed>27536890</pubmed>
  54. <pubmed>18055651</pubmed>
  55. 55.0 55.1 <pubmed>23071876</pubmed>
  56. <pubmed>9203460</pubmed>
  57. 57.0 57.1 <pubmed>16280652</pubmed>
  58. <pubmed>15561905</pubmed>
  59. <pubmed>22121010</pubmed>
  60. <pubmed>23375619</pubmed>
  61. <pubmed> 24152948</pubmed>
  62. <pubmed>16954337</pubmed>
  63. <pubmed>23890130</pubmed>
  64. <pubmed>21757968</pubmed>
  65. <pubmed>22226275</pubmed>
  66. 66.0 66.1 <pubmed>22960655</pubmed>
  67. <pubmed>23528347</pubmed>
  68. 68.0 68.1 <pubmed>6997121</pubmed>
  69. <pubmed>25401335</pubmed>
  70. <pubmed>25040034</pubmed>
  71. <pubmed>20589066 </pubmed>
  72. 72.0 72.1 <pubmed>20513314</pubmed>
  73. <pubmed>17594200</pubmed>
  74. 74.0 74.1 <pubmed>16774616 </pubmed>
  75. <pubmed>19196588</pubmed>
  76. 76.0 76.1 76.2 <pubmed>15630467</pubmed>
  77. <pubmed>12954741</pubmed>
  78. 78.0 78.1 <pubmed>16768546</pubmed>
  79. <pubmed>28420418</pubmed>
  80. <pubmed>27243814</pubmed>
  81. 81.0 81.1 <pubmed>28006000</pubmed>