Good morning, everyone. Please welcome our president of the Endocrine Society, Dr. Carol Weisham. Oh, I have to take a deep breath. It is so great to see all of you. I can't tell you how long I've waited for this moment. It's so nice to see all of the friendly faces out in the audience. Obviously, our life has changed. The world has changed. Endocrinology has changed. We have lost that opportunity to do the networking that we're used to doing in the past. And I consider networking as one of the most valuable parts of why we get together for this meeting. And I'm really delighted, again, to see all the familiar faces. I just want to take you back to last year. Gary passed me the gavel virtually. And I'm set up in my living room with a screen behind me, my computer, all the lights, all the cameras. My husband just took this picture without me even knowing what I was doing. One of the major problems caused by the pandemic was our inability to travel, which, of course, in turn affected our networking, our ability to attend meetings. I was really proud of the society. They moved quickly. They addressed the issue, worked diligently with the AMSC and staff, and developed two completely virtual meetings. The first was Indo 2020 Online, and the second was Indo 2021. And I can't tell you how hard it is to plan a meeting when you can't be in the same room with people. This year we're having our inaugural hybrid meeting, Indo 2022, and I'm so excited we're starting the meeting today. I would like to take this opportunity to thank the Annual Meeting Steering Committee, the chairs that helped to plan 2020, 2021, and, of course, my chairs for this meeting, Indo 2022. They've done an outstanding job, and you'll meet them and hear from them later. In addition to Indo, we conduct other important meetings that are very valuable to our clinician and training members, obviously Clinical Endocrine Update and Endocrine Board Review. Again, as a response to the pandemic, we were able to transition both of these to online meetings, and they were incredibly successful, highest paid attendance ever for both of those meetings. This year we're very excited to launch our first CEU hybrid experience. For the first time since 2019, we're going to meet in Miami, Florida to have an in-person meeting, but the entire program will also be available online. So I invite you to come down to Miami, Florida, September 8th to 10th, and help us discover the latest developments in endocrinology diagnosis and treatments. We learned that Endocrine Board Review was very successful as an online program and is our intention to continue with the online format moving forward. This is the leading online program for our trainees, those preparing for certification or recertification in endocrinology. Special interest groups, they're one of the ways we help to address the need for those who've been unable to travel and going forward who may have budgetary and time constraints. So this allows people in a more virtual arena to continue that critical element for networking and for their success. So if you haven't already joined one of the SIGs, start a new one. These will allow you to expand your professional networks, identify potential collaborators, and explore innovations in research and care. And I'd like to highlight two of the newest SIGs. Those are the Endocrine Disrupting Chemicals and Endocrine Cancers. We've launched several new and enhanced programs to demonstrate our greater commitment to diversity, equity, and inclusion. EndoCares is an outreach program that seeks to serve individuals and families from underserved or underrepresented communities who are affected or might be affected by endocrine conditions. In 2022, we'll be hosting four such EndoCare programs. They will be in Baltimore, Phoenix, and Seattle. And our flagship event is happening today in Atlanta, Georgia. We have partnered with Emory University, Grady Health, and the Clarkston Community Center to bring Atlanta complementary health services and hormone health education. The Future Leaders Advancing Research in Endocrinology, or FLARE, program has been an extremely successful program that's been going on for several years. But this provides basic science and clinical science trainees and junior faculty from underrepresented minority communities who've already demonstrated the achievement in research. We are giving them structured leadership development, in-depth and hands-on training and topics ranging from grantsmanship to lab management. This year, we have started a new program that's primarily designed for our clinician members who come from underrepresented communities. And this, again, is going to allow them to have comprehensive leadership training and mentorship to help them succeed in their careers. We've also developed more bite-sized digital learning opportunities to better address the needs of our members. These additional learning opportunities are shown here. They include endocrine case cards. These are handheld cards with concise case-based guidance, which will make it easier than ever to build confidence in identifying, treating, and management of endocrine disorders. Each topic has its own set of cards, several bindings, so that these decks can be customized to suit the specific needs. Comprehensive Care for Patients with Diabetes is a certificate program designed primarily for primary care. It's a series of 12 online modules to help make treatment recommendations based upon current management trends, as well as new ways to improve your patient's health. Our new Center for Learning is our online repository for on-demand education, and the mobile app just went live, so please check it out. You can access a variety of resources from podcasts to webinars to our premier case-based products, including Endocrine Self-Assessment Program, Pediatric ASAP, and Endocrine Board Review. Our advocacy efforts have continued without a hiccup through the last two years. We've been very strong. We've adapted to the new realities. We are one of the first organizations to conduct Hill visits and do them virtually. And so that has allowed more members to be able to participate in these programs, which has further strengthened our voice in the Congress. Several of our wins this past year include averting the physician payment cuts, prioritizing insulin affordability, increased funding for NIH, and expanding coverage of telehealth, just to name a few. And as you know, our advocacy is not limited to the U.S. We have a strong presence working with our European members in the area of endocrine-disrupting chemicals, and we will continue to influence legislation and regulations of EDCs in the European Union. We're very excited about a new journal that we're launching later this year. It's called JCEM Case Reports. It's publishing reports on clinical cases and clinical problem-solving from across the field of endocrinology, and we are delighted that Dr. Bill Young has agreed to be the editor-in-chief of this journal. In addition, for those of you who are basic scientists, we have waived all page charges to Endocrine Society members who publish in endocrinology. So while these past few years have brought forth significant challenges for all of us, our field of endocrinology will continue to be challenged moving forward. Who will be our next generation of endocrinologists and hormone scientists? How will we help them establish themselves and help propel the field forward? Life was already busy before the pandemic, but now with limited resources and so many demands on our times, how do we fight burnout and ensure that we're available and energized to pursue our passions? In the last few years, we've been discouraged by the erosion of public trust in medical and scientific expertise. And what is our role for helping to rebuild this trust and dispel the many misperceptions we see filling our news media? These are just a few questions that we are eager to answer, and of course, I'm sure you have many more. But it's only together will we be successful at overcoming these challenges, and I look forward to working alongside all of you to pursue the Endocrine Society's mission to unite, lead, and grow the endocrine community to accelerate scientific breakthroughs and improve health worldwide. I invite you to join us on this amazing journey as we address all of these issues by going to a website, click on the QR code up there, and explore our many volunteer opportunities. We are stronger together. And finally, I would like to call out the need for all of us to be more active in identifying and supporting young people to become our next generation of endocrine scientists and clinicians. Be a member. Reach out to even people outside of your own lab and your own clinical practice and find people who are passionate about endocrinology. We need to allow them and give them the tools so they can continue to follow that passion. I have a lot of thanks. I have a special thanks to the past members of the Executive Council. They were instrumental in ensuring the success of our society through the worst of the pandemic, and I have greatly benefited from their leadership skills. Each and every one of these very talented individuals on our Board of Directors have actively contributed to discussions surrounding the issues put before them. This was a very engaged board. I also want to thank our senior leadership team, starting with our new CEO, Kate Fryer. I highly recommend you reach out to her. She is a dynamo. She is a wonderful leader. And then the senior leadership team. They and their staff have worked so hard, not only carrying on the business as usual, but were responsible for the development and execution of all of what I reviewed earlier and more. And finally, I owe a special debt of gratitude to Elizabeth Kahn. Any of you in the audience who have been president of the Endocrine Society for the last 22 years can attest to the fact that she is key to our success. Thank you. I've had the pleasure to have these individuals as counsel and friends over the last year, and I can truthfully say that our society is in very good hands under their leadership. I am looking forward to working with you over the next year. And of course, you cannot finish such an address without addressing the thanks to your family. And I'd really like to start with my grandmother, who graduated from college at 18 in 1925, and who instilled that importance of education onto my mother, who, I have to say, pushed me a little hard. But what I like to say is her most important advice was learn how to type. I said, why? I'm going to have a secretary. I don't need to type. No, you need to know how to type. And why not be a doctor instead of a math teacher? And so I'm here because my mother encouraged me to be here. I'd like to thank my kids, my daughter Katie, her husband Luis, and sweet Olivia, my son Nick, wife Weya, and two kids, Lauren and Benji. And then the two newest members of our family, Theo and Henry, just joined my daughter's family three months ago. Finally, I'd like to thank my husband, who's sitting in the audience. Thank you for coming today. Without his support and patience, I would not have been able to devote as much time to my passion for endocrinology. I have had a wonderful career, I'm not done yet, by the way, which involved not only practice, but research and seminal studies that we all now have learned how to take better care of patients with diabetes and educating medical students and residents. And without his encouragement, I would not be on this stage today. So thank you. Dr. Stephen Hammes and our annual meetings during committee members are pictured here. They've developed a wide-ranging program showcasing the latest advances in our field. We are proud to offer a stellar program to those of you in the room with me in Atlanta, as well as our peers worldwide who are joining us virtually. I am sincerely grateful for the annual meetings during committee's dedication. And now, will you please welcome Stephen Hammes to the stage. He'll share with us what's in store for you. Thank you, Carol. It's my honor, first, to introduce my co-chairs. They have really worked tirelessly to create a truly engaging program. So many thanks to my co-chairs. We have Scott Dame, Lauren Fishbein, and Bulent Yildiz. Thank you for your dedication, all of you. Each co-chair's unique perspective helped ensure our program reflects the diversity of our field. And we're also thankful for the contributions of the team leads in the entire annual meeting steering committee who made this program possible. So let's give a big round of applause for all of the AMSC. And I also want to express my gratitude to Dr. Carol Weissman for her leadership and support over the past year. She's really been tremendous. So thank you, Carol. So in a few moments, Carol's going to introduce our presidential plenary speakers. The first is Moshe Phillip, MD, of the Schneider Children's Medical Center in Tel Aviv University. And the second is Mattia Seabrook, PhD, of the University of California, San Francisco. Today's important discussion of type 1 diabetes therapies is really just the beginning. Our innovative plenaries will feature top scientists and innovators exploring health equity, cancer, cardiovascular health, women, transgender, and intersex athletes, also infertility. Our popular basic science pathways are now part of an immersive meeting experience. Our basic science pavilion offers dedicated session rooms, and a social lounge where you can discuss symposium research with your peers. Whether you're following one of the four basic science pathways or catching a particular session, the basic science pavilion is your destination for basic research. In the expo hall, you'll find a new high-powered way to explore the posters. Our 11 digital poster pods will give you instant access to every single abstract. And the digital poster pods offer options for targeted searching and randomized discovery as well. You can view the content on a cluster of monitors throughout the expo. The digital poster pods will also host the daily rapid-fire poster presentations where you can hear directly from award-winning and top-scoring abstract authors. So right after this plenary, two adrenal experts will debate the best approaches for treating functional adrenal nodules. Stay in this room following the plenary to catch a ringside seat for the first of four debates that we'll be having during ENDO 2022. So, trainees and early career members, we're really excited that we're going to have a full schedule of professional development workshops to help you develop your important skills that are necessary for success. The workshops will cover key topics such as grant writing, teaching skills, and publishing strategies. You'll also want to visit our new communications and career center at ENDO Expo. It's part CNN-style situation desk, it's part semi-private and communal career building space. We're calling it the CCC, and it's your hub for professional growth and event news. And to help you make the most of this extensive meeting, the ENDO 2022 app is your tool to find sessions of interest. You can view abstracts and activities, you can customize your itinerary, participate in polling and submitting questions to the faculty, all right there in the app. You can also access a complimentary Wi-Fi on your device by clicking on the ENDO 2022 network. And session information is also available in the ENDO program guide that you received in your meeting bag. We'd also like to take a moment to express our gratitude to our sponsors, who support us through a variety of educational grants throughout the year. So please visit the ENDO Expo where you can meet face-to-face with industry partners, showcasing their latest products and services. The ENDO Expo is also the place to have a professional headshot taken to visit our job fair or play games with your colleagues at the Endocrine Society booth. And finally, I do want to say a word about the importance of respecting the science in our speakers. We are committed to featuring the latest groundbreaking, not yet published data at ENDO. And we can only do this by assuring that the speakers will have 100% compliance with our recording policy. There is no photography and no video recording during sessions, unless the presenter specifically states that they welcome photography. In addition, it can be really distracting to attendees when phones, tablets and cameras are obstructing their view. So please respect the science, as well as our fellow attendees, by not disrupting their sessions. So on behalf of the entire society, my co-chairs and the Annual Meeting Steering Committee. I wish you all a wonderful experience over the next four days at Endo 2022. Whether you're in Atlanta or joining us online, we're thrilled to have you here and we're really excited about the program. Thank you very much. Thank you, Steve. So today we recognize the first of our many esteemed 2022 Laureate Award recipients. Established in 1944, the Endocrine Society's Laureate Awards have recognized the highest achievements in the field of endocrinology, including groundbreaking research and innovations. These distinguished recipients join a prestigious list of past award recipients, all of whom have advanced scientific breakthroughs, medical practice, and human health around the world. The Fred Conrad Koch Lifetime Achievement Award, named for the 19th President of the Society, is the highest tribute to recognize the exceptional contributions to endocrinology over the awardee's career. This year we are honoring past president Dr. Henry Cronenberg. Dr. Cronenberg has served as the chief of the endocrine unit at Mass General Hospital for over 32 years and is a professor of medicine at Harvard Medical School in Boston, Massachusetts. His research interests studies the action of parathyroid hormone and parathyroid hormone related protein with a particular emphasis on bone development, bone biology, calcium homostasis, and the role of osteoblast lineage cells in hematopoiesis. His biggest accomplishment is bringing molecular biology to the field of bone and mineral with the cloning of the parathyroid hormone. Dr. Cronenberg is a past president of the Endocrine Society, serving from 2016 to 2017, and over the years he has served on endocrine society committees, most notably as vice president of basic science and as the endocrine society's representative to FASA board of directors. Thank you nominator Sandeep Khosla as well as Dolores Schoback and John Potts for supporting this nomination and congratulations to Dr. Henry Cronenberg on this significant honor and lifetime achievement. Thank you. Well, thank you very much Carol for that kind introduction and I've got lots of people to thank and not much time, so let me get started with that. Mainly I want to thank the Endocrine Society, which is the group of people who introduced me to all of you and to the scientific community of endocrinology in this country and around the world. It's absolutely key to my own personal development and I've been grateful since I joined society as a fellow many years ago. I of course want to thank the people that you just heard about, Dolores Schoback and Sandeep Khosla and John Potts who nominated me for this award because obviously there are lots of people who are deserving and I'm grateful to them for having made that possible. I also, you saw a picture of me and John Potts, my mentor from the time I started out in endocrinology. He is continuing to teach me all kinds of things all the time and I also want to thank you. You also saw a picture that flashed by of the faculty of the endocrine unit at the Mass General Hospital, which I've had the privilege of working with now for several decades. What you didn't see is all the fellows and students who've worked with me and made the research that I've been involved with possible. I finally of course need to thank my family, starting with my wife Gretchen, who from our first day at medical school together in 1966 has been my partner in everything I've been doing, including work in research. We were joined a few years later by my daughters Amanda and Leah, who are here today, as well as their husbands, David and Chris, and their children, Max and Ben and Hugh. So they're the ones who keep me thinking about things through the eyes of young people and that's quite wonderful and that's of course what research does too. So I want to thank everybody in the Endocrine Society for this award. I'm deeply humbled to have received it. Thank you very much. It is now my pleasure to introduce Professor Moshe Phillip. He's from Snyder's Children's Medical Center of Israel in Tel Aviv University. He will present this morning's first plenary for type 1 diabetes, is it technology versus biology. Professor Moshe Phillip graduated from Ben-Gurion University in Beersheba, Israel. He specialized in pediatrics at Soroka Medical Center in Beersheba and in pediatric endocrinology at the University of Maryland School of Medicine. Since 1997, he's been director of the Institute for Endocrinology and Diabetes, National Center of Childhood Diabetes at Snyder Children's Medical Center in Pitotibka. He also serves as vice dean for research and development, as well as a chair of the Irene and Nicholas Marsh Fund for Endocrinology and Diabetes at the Sackler Faculty of Medicine, Tel Aviv University. He is active in both clinical and basic research in various endocrine issues, focusing on growth, nutrition, obesity, and childhood diabetes. But he's particularly well known for his development of technologies for the treatment of diabetes. He's an active member of many national and international organizations. He's the co-chair of the Advanced Technologies and Treatments of Diabetes, or ATTD, and of the International Conference on Nutrition and Growth. He's received multiple awards, including the Linder Prize of the Israel Endocrine Society, the SP Research Award, the ISPAD Achievement Award, as well as the ESPE Andrea Prater Award. Today, he'll be exploring technological versus biological approaches to treating type 1 diabetes. Please join me in warmly welcoming Professor Mosh Phillip. Thank you, Dr. Carl Wieschm for the nice introduction. And I would like to thank the organizing committee for the opportunity to be with you today and share some of our experience and vision. So my share in this presentation of biology versus technology is the technology part. These are my disclosures. And a few days ago, a journalist, American journalist, approached me and she wanted to know who is going to win the race. Is it the technology or biology? And I told her what I'm going to tell you, that we have, and I'm sure you are sharing with me, the same dream that one day when we woke up in the morning, we will find out that the cure for diabetes was found. And the people, probably from the biology team, will be invited to get the Nobel Prize. In the meantime, until this happens, we have a substitute to the dream, a minor dream, and this is to use the most advanced technologies for the care of diabetes. And the goals are to improve the care of people with diabetes, but also to reduce the burden of the shoulders of people with diabetes and the health care providers. We can't talk about advanced technologies without mentioning what happened in the field of insulin, since insulin was discovered probably around 100 years ago, was introduced into clinical use in 1922, which is pretty much exactly 100 years ago. And the rapid changes that have occurred over the years in short-acting insulins, long-acting insulin, even inhaled insulin, and many are working now, as we talk, on more advanced insulin, like the more ultra-rapid insulin, more ultra-long basal insulin. Of course, we all know about experiments with smart insulin that will be released according to the blood glucose level. And many attempts in the technology field are focused on trying to avoid the needles, like inhaled insulin, nasal insulin, transdermal, and several studies are focusing on oral, of course. And, for example, this is one of those inventions that uses microneedles on one hand with the smart insulin together in order to overcome the need to use needles for injecting insulin. And oral studies are quite few. Some of them are using new technologies, like the one I decided to share with you the picture of. It looks like a small particle that is designed to get to the right position where it can inject insulin into the gastric cells. So this is where some of the technology of insulin is going to develop, and we are going to enjoy it. Of course, we cannot talk about insulin without mentioning the new pens, the new generation of pens, from the fact that we had a simple pen to a pen that can record how much and when did we inject insulin to the kind that can transmit or connect connected pens that can transmit the data to the cell phone and from the cell phone to the cloud, and those that we are working on using decision support system with the connected pen, and I'll elaborate on it later. But I think that the most important invention in the last 17 years was the introduction of CGM, continuous glucose measurements, to the care of type 1 diabetic patients, and it happened the FDA cleared the first version of it only in 2006, and I think that CGM is the Achimedian point of diabetics technology and is the basis for many technologies that are developed right now and for those that will come in the future. So we all know how opening eyes was the discovery of continuous glucose insulin that suddenly we could see not just four, five, six measurements a day, but the entire picture of the day, and this alone changed the way we are treating our patients with diabetes, and just taking you all back to 2005, where I participated actually in designing and running one of eight groups, running a study, the first study that I think it was the first study in the world with prospective randomized controlled study to look at what can be done with the CGM. So we had people with diabetes type 1, some of them on some of them on pumps, some of them on SMPG, and we divided them into three groups, a control group of course, those that used the real-time CGM continuously, and those that used it for a while, for a week, every other, every two weeks. And what we saw is that despite the fact that we had no clue what to tell the patients, what they should do with the results, because we didn't know, we didn't see ever results of CGM before, real-time CGM before, so we didn't know what to tell the patients, but despite the fact that they didn't know what to tell the patients, they reduced the hemoglobin AOC by 1.1 percent, and I think that this, they didn't get to the target, but I think that this was an eye-opening to understand the power of the knowledge. So immediately after we started to run consensus meetings to discuss how we can use, together with pumps, also a CGM, and this was the beginning of sensor-augmented pump therapy, and then in 2017 we had a consensus to to go beyond hemoglobin AOC levels and to use the CGM metrics in order to to improve the care of our people with diabetes, and it was published in 2017, and then in 2018 the CGM again was in the focus of our attempt to define what is the target, how many minutes should we be in the desired range, what is the desired range, we already agreed, but how many hours a day, what's the percentage of time that we would like people to be in certain levels of glucose levels, and indeed we defined it for type 1 and type 2, for children and adults, for pregnant women, and for elderly people. In 2020, just two weeks before the pandemic reached Europe, we were sitting in Madrid and we were discussing again in a consensus meeting how can we use the new technologies in order to develop a virtual clinic, and of course CGM was one of the most important building blocks of it, and we recommended that a digital clinic would be based on information that will come from either a connected pen if the patient is on MDI, or with a passive data transmission from the CGM that will be used in the decision support system to help us navigate, in addition to many other building blocks, navigate our patients remotely when it's needed, and two weeks later the entire world switched to remote therapy. Right now, a month ago, we were again trying to think how we can use CGM not only to improve the care but also to improve the outcome of clinical studies, that the end point will be not just hemoglobin A1c or hypoglycemia but also the metrics of CGM, and this was done about a month ago, was not finished yet, and I hope that we will agree it was a combination with regulators, industry, and of course clinicians, but the CGM did not reduce the burden, and burden was one of our goals, how we can use technology to improve the burden, and I don't have to convince you that type 1 diabetes is a huge burden, actually insulin-treated patients, it's a huge burden on the person with diabetes, and so many decisions a day, so many times a day here to decide should I eat, should I walk, should I inject, and if there are special events of course it complicates it, and also for the physicians, as you know, we used to have four, five, six measurements a day, and suddenly we have 288 measurements a day, out of the last 14 days we get sometimes 20 to 30 pages, and we have to sit on it and make decisions like, are you familiar with this kind of picture? So it's not just my patients, and you have to make decisions about how to change the basal, how to change the CR, the CF, the insulin activity time, and so on, so it takes time, it increases the burden, so if we used to practice medicine in the past, relatively faster, because we didn't have the electronic medical records, we didn't have downloads, and it became complicated, it became time-consuming, and indeed many physicians felt the burden burn out and find it difficult to practice. So we thought about how, the world thought about how can we use new technologies in order to, in order to ease the burden, and I would like to focus on two technologies that are artificially intelligent-based. One is the closed loop on the left side, and the other one is a decision support system, and I'll elaborate on each of them. So we all know that the closed loop is based on a sensor that measures the glucose levels and then delivers it to the computer. The computer makes the decision of how much insulin to inject. And in 2011, for the first time ever, we took 54 children outside of the CLC to a resort area to run one night, and it was a breakthrough at that time, one night outside the hospital to run with an artificially intelligent-based, or what it's called, automated insulin delivery, artificial pancreas, you name it, and it was successful. And they improved the automated insulin delivery, improved the blood glucose level, and was safe. It was followed in 2016 by a manuscript by Bergenstahl on the 670G pump of 124 participants. It was without a control arm, but he showed that it is safe. Not only safe, the blood glucose levels during the night were pretty much reasonably controlled, while during the day, and especially in the adolescent age group, they found it difficult to manage them. And a lot of it has to do with eating and bolusing and corrections and so on. So when our technology that I've described earlier, that has the ability to identify meal event, which was not associated with a pre-bolus, it was incorporated into the 670 to create the 780G, and with many other changes that have been introduced, we, with the support of FDA grant, sorry, of NIH grant, we had compared the 670G, the first artificial pancreas that was approved, with the advanced hyper-closed loop, and we showed that even during the day, you can improve the timing range and reduce the level above 180, if you have a system that can identify boluses that did not get a bolus before and can give correction boluses. Many other groups, like the group of Control IQ, joined the race and brought their technology to people with diabetes with the clearance from the FDA. And when we looked at prospective randomized clinical trials that were published, I think what's common to all of them is that the automated insulin deliveries reduced hemoglobin A1c level and induced the timing range, the timing desired range in all studies. And recently, real-world data started to appear, and this is real-world data of 4,122 users of the 780G pump that is used outside of the U.S., because it was not clear, I want to make sure you know it, it's written down there in a small sentence, it was not clear yet here, but you can see that regardless of which part of the globe you are using it, you can get to a very nice timing range and very little hypoglycemic evidence. Another real-world data that came out very recently, actually in April, on 12,000 patients and showed pretty much the same results. So again, we were sitting in 2001, in 2021, during the pandemic, we had a consensus meeting, a virtual consensus meeting, discussing how can we get the best out of the technology of artificial pancreas, who should be involved, who should not be involved, what kind of education a person with diabetes who is going to use automated insulin delivery has to get. So the breakthrough of automated insulin delivery was already done, and now we are getting slowly, step by step, to improve the system. It's still a hybrid closed loop, meaning the patient has to give boluses, and the patient still has some burden using it. So the future is going to be introducing more sensors, sensors that can, first of all, the future should be a full automated insulin delivery, covering also for me, how can it be done, introducing more sensors, sensors that will be connected to the fact that I started to eat, sensors that will be able to assess the carbs, sensors that will be able to assess the location and the physical activity, and some other metabolites, and all of it will be integrated with artificial intelligence to help us navigate the right therapy with artificial intelligence, navigate the automated insulin delivery. But this new era, a new ecosystem, is going to serve us also when we will switch to a group that is not going to use it. They are either using pumps or they are going to, or using MDI, but they are not interested for many, many reasons, or not able, or it's not available for them. Those kind of things will help them to use a clinical decision support system. And why do we need a clinical decision support system? We have guidelines, we have standards of care, we have many, many guidelines. Do we really need a clinical decision support system? And I think that the answer is in this picture, this figure from 21 centers of excellence in the U.S. when they compared the results of hemoglobin A1C in the years 2010-2012 to the results of hemoglobin A1C of 2016 and 2018. And what they have discovered is that despite the fact that we have more pumps, more sensors, the hemoglobin A1C levels in those centers of excellence is going up, not down. And that was a full surprise. We called it the technology paradox, and you wonder why is it? And it reminds me of a story that I would like to share with you when I was a physician in the emergency room. And I was there one night and there was a bus accident outside. Two buses clashed into each other and many wounded people poured into the emergency room. So we didn't have enough manpower. We asked one of the brilliant students, a six-year medical student. We have a six-year program. We asked him if he can take one of the pictures of the wounded people to the CT scan and told him, look, it's a dangerous place. We know, we have experience. Please take his vital all the time. So he took him to the CT scan. And when he came back, one glance at the patient and we knew we have to resuscitate him. So we asked the student, how come we asked you to measure? And he said, I did. It was the blood pressure started with a systolic of 122 and ended up going down and down all the time, but he did nothing about it. And does it surprise you? What happens with our patients who are using CGM? How many times are they making decisions of how to change their boluses or basals? How many of your patients are doing it? I don't know. I know that mine depend on the age usually, and the adolescent many times just ignore it. So you can either go in the old way with the guidelines or try to use sophisticated ways like the Waze. I don't know how many. It was called Waze before Google bought it. And they, by the way, their office was two blocks from ours. So a clinical decision support system provides clinicians, staff, patients, or other individuals with the knowledge and person-specific information intelligently filtered to enhance health and healthcare. Clinical decision support system uses a variety of tools to enhance decision-making in the clinical workflow. And there are quite a few studies around different clinical support systems. Many of them are looking—not many. There are not many anyhow. They are looking at different aspects, different types of patients, and I want to focus on the one that we were working on and studying. This clinical decision support system is for the physician to help him make a decision and to share it with his patients. So what is it composed of? There is an uploader where you can download everything passively or not passively. You can upload the information of pumps, sensors, connected pens, or diary. It goes to the cloud. In the cloud, it's integrated. And within a split of a second, a physician gets specific advice of how to change the basal, how to change if it's in pump, also the CR, CF, and insulin time, and if they are on MDI, the basal and the boluses. And once the physician approved it, it goes directly to the cellular phone of the person with diabetes to be introduced into his life. So the platform is on the cellular phone, and it is designed to help people with diabetes who are using insulin, and they can use it whether they are on sensor or SMBG. So the first step that we have done was to try to see whether it's worthwhile, whether we can get a reasonable advice from this artificial intelligence-based decision support system. So what we have done, we took different downloads, different scenarios of 15 patients with type 1 diabetes. We sent it to 26 physicians from different places in the world, and we asked them to make a decision on the basal, the CR, and the CF. And what we found is that physicians among themselves not always agree. And only in 45%, roughly, they agreed on the basal or the CR and the CF. And then we asked the advisor and measured how many times the advisor matched the decisions that the physicians have made, and we found, surprisingly, the advisor was pretty similar in this percentage, and this is here in blue. The red is physicians between themselves, and the blue is the percentage of agreement with the advisor. So pretty much similar. So we did it for type 1 with pumps and sensors. We have done it for type 2 on MDI therapy. We have done the same, and all of it is published in the literature with type 1 and MDI therapy. So we actually concluded that our advisor behaves pretty much like another team member. He agrees and disagrees in the same percentage. It's as if you knocked on the door of your neighbor or of your colleague and asked him, what would you do in such a situation? And we moved forward to test it in a prospective study. We took four centers of excellence in the U.S., one center for Germany with Professor Thomas Dannet, another in Slovenia with Professor Tadej Bertolino, and we divided randomly patients into two groups, a group that got advice from the advisor and a group that got advice from a real physician, and we compared the two. And we had 108 participants in this study, age 10 to 21, meaning the tough ones. And what we have seen is that whether the advice came from a physician or whether the advice came from the advisor, we got pretty much to the same result. There was no inferiority, no difference in time and range or in time below 54 or in hemoglobin A1C level. And when we asked physicians who used it during the study, what was the main benefit that you got from this advisor when we use it, they said for the first time we had time, enough time to talk to the person about other stuff besides just dealing with how to change the basal, the bolus, the CRF and the CF. So we have many expectations from clinical decision support system, which is artificial intelligence-based. We wanted to improve the clinical performance and the care of people with diabetes. We hope that it will reduce the variability in the quality of diabetic care across providers and practice settings because we discovered that even in our group, two or three different physicians give different advice. We facilitate timely and more frequently insulin drug adjustment because once physician will start trusting the system, they can allow people to use it in between visits. It will reduce therapeutic inertia because I don't know how does it work in your centers, but in my center most people with diabetes will wait to the meeting with the physician before they dare to change, for example, the basal in their pump or the basal in their MDI therapy. It can serve the people with diabetes between visits, as I've mentioned, once we trust it. It can be integrated in the EMR. It can support initiation of new technologies by helping reduce the burden of the shoulder of the person with diabetes of making a decision, so many decisions a day and so on and so forth. I think that the main benefit of those tools is that you are not alone. It's not the person with diabetes and not the healthcare provider are not alone anymore because when you sit alone in a clinic somewhere and you want to discuss what to do with one of your colleagues, it is helpful to have a kind of a clinical decision support system to consult with and, of course, for people with diabetes. And I love this figure that was presented by David Merrill, who was the ADA president in 2015. It shows in blue the time that the patient is alone and in white the time the patient spent with the provider over a year. So the patients are most of the time alone. And this is why I think that the vision of a clinical decision support system and artificial pancreas and artificially intelligent-based technologies that we are going to enjoy. I think it will be in our clinical practice in a few years, both for the clinicians and the other healthcare providers and for the patients, a kind of a genie in the pocket, a physician in their pocket that will help them to make a decision every moment during the day. We'll integrate all those different sensors into one decision mechanism. And with that, thank you for the opportunity to share with you our vision. And I would like to thank the team, my team in my hospital, and especially the people and the children with diabetes, their parents, for the support and participating in our studies. Thank you. Thank you, Dr. Philip. It is now my pleasure to introduce Dr. Hebrook Mathias, Dr. Mathias Hebrook, who will present our second lecture entitled Modifying Stem Cell-Derived Beta Cell Function. Unfortunately, he was unable to join us today, but he did record his presentation. He is a Herbert Johnson Distinguished Professor in Diabetes Research at the Diabetes Center at the University of California, San Francisco. He earned his diploma in cell biology from the Albert Ludwig University, performed his Ph.D. thesis at the Max Planck Institute, and conducted his postdoctoral research at HHMI at Harvard University. His laboratory has made seminal contributions to our understanding how embryonic signals control the fetal development of the pancreas and the insulin-producing beta cells. His recent work has implemented information gained from these studies to generate functional beta cells from human stem cell populations for cell therapy purposes. He is a recipient of several honors, including the JDRF Scholar and the Gerald and Kayla Grodzki Award honoring outstanding scientific research to diabetes. Now let's hear from Dr. Matthias Hiebrock. Hello, everyone. It's a pleasure for me to be here today and unfortunately, again, give a lecture via Zoom rather than being in person. I apologize for that. That's something that was out of my control, but I would like to thank the organizers, particularly to invite me here to give this lecture, and I'm really looking forward to share our data with you. So I was asked to talk about modifying stem cell drive beta cell function, and I would like to just jump into this. This slide I have to show because my university asked me to do this. These are my disclosures that I would like to share with you. I would like to start out by just setting the stage. Many of you know this, but diabetes is a growing global disease, and I think this is very well illustrated here on the slide from the IDF, in which we know that over the next 20 or so, 25 years within the world, we're going to have a 46% increase in the patients with diabetes. And specifically in certain areas of the world, in the North Americas, we have a 24%, but it's anticipated that in other parts, like in Africa, for example, it's going to be more than 130% increase. So this is something that is afflicting many of us, and it certainly is something that we need to try to address and help these patients. I would like to therefore start out in telling you how we think that this is something we can do about it. And if you strip everything away, and this is true for type 1 and type 2 diabetes, then it's essentially the cell here that is sitting within the islet of Langerhans. It's the insulin-producing cell, we call it the beta cell, that releases insulin, the hormone, into the bloodstream, and then insulin is taken up by peripheral tissues, in this particular case, a muscle fiber, and then leads to the uptake of glucose from the system. So it's insulin that is the gene or the hormone that keeps our glucose levels in a very tight and normal range. And under type 1 conditions, the beta cells are being destroyed through an autoimmune disease, and the type 2 conditions, they're being exhausted over time. They just cannot keep up with the demand that the body needs to produce the levels of insulin. So it's the beta cell that we think is the culprit. And therefore, as I will tell you in a second, we set out to generate the cell, and for most of my talk, the cells that are shown being green are the beta cells, so the ones that we're really interested in. We set out to generate this beta cell, as I will tell you, by using a specific differentiation protocol from human stem cell populations. But actually, we not only generated beta cell, but within the islets of Langerhans, there are other cell types that are required to regulate the levels of glucose, most notably next to the beta cell, the alpha cell that produces the antagonistic hormone called glucagon. The delta cells are really important as well because they seem to regulate both the activity of the alpha and the beta cell. So we set out to generate beta cells, but it turns out that we were actually generating immature clusters of islet cells. This is how we treat patients today. And this is with, of course, what I would consider a miracle drug. It's now 100 years old, that since we've been able to use insulin to treat patients, particularly in the beginning, patients with type 1 diabetes, and it has saved untold lives. But as of today, what we're still doing is we have to inject ourselves with insulin, and we therefore have to calculate either ourselves or through devices now what the need is for insulin. So this, of course, is cumbersome and in some cases even dangerous because if you inject too much of insulin, and then we're facing hypoglycemic events, I'm sorry, lower levels of sugar. Now, what we are interested in is using a cell that was first described more than 100 years ago by Valentin Heckler, and this is the cell shown over here. And the cell, as he described it, had a peculiar activity in that it was able to divide. And then some of its progeny were turning into cells that we would call differentiated cells. But the other parts of it, the other cells, were essentially maintained in a state that he described as a stem cell, a cell that can, in a way, renew itself. And that cell was then identified approximately 100 years later by James Thompson, and this was shown over here in this cover article in Times, where we were able, or he was able, to generate these human embryonic stem cells derived from the inner cell mass of the blastocyst. And therefore, these cells have the capacity to generate all of the cells that they have in our body. Another 10 or so years later, Shinya Yamanaka went on to demonstrate that he can actually take somatic cells. And by just using four of these factors here, turn them into what he called induced pluripotent stem cells. So then the question, of course, is why don't we just take these cells, either embryonic cells or iPSCs, and turn them into our cell of interest, which is the insulin-producing beta cell? And while, of course, the ability of the cell exists, I would like to point out that the beauty of this and the promise of the cell that we can generate all of the cell types in our body is also the problem. It can generate all of our cells in our body. So what we and others therefore had to learn, and we did this by studying the development of embryos, mostly in the mouse, what kind of signals were being used to take an embryonic stem cells first into definitive endoderm, then towards the pancreatic foregut area, then into pancreatic progenitors, and then into beta cells. And essentially by establishing this blueprint, by defining the signals that are required for this, we were able to replicate the process on the cell culture conditions. This is just to show you how we in my lab have been doing this. We're starting out at day zero with a human pluripotent stem cell. This can either be an embryonic stem cell or an iPSC line. And then we follow the signals, we use the signals that the embryo has provided us with to turn this into gut tube, posterior foregut, pancreatic endoderm, immature beta-like cells. So, and I just want to point that out, after just around three or so weeks, we are generating already beta cells, but those cells are not fully functional. They cannot really respond to glucose-stimulating insulin secretion. So we used a trick by then identifying cells that were positive for what we call insulin GFP, meaning that there is a GFP produced under control of the insulin promoter. So therefore we were able to identify these green cells here, isolate them, sort them by fax, and then put them back together, go for another week or so, and then end up with something we call enriched beta cell clusters, or for short, EVCs. And we published this, and if I don't want to dwell on that for too long, but I just want to tell you that these cells are within the endocrine lineage. So this is these typical clusters that we find. They have approximately actually the size of a human eyelid. They're positive for C-peptide, a breakdown product of the maturation for insulin. They also express critical transcription factors like PDX1, NKX6.1, NKX2.2. All of these markers are required for the formation and the function of the beta cells. They do not express, or if at all, at very low levels, SOX9, which is a progenitor marker, or CK19, a duct marker, or amylase, a marker for acinar cells. So the conclusion from that is that we are generating endocrine cells, but not duct or acinar cells. We could call them exocrine cells that also exist within the pancreas. Our analysis then showed, by electron microscopy analysis here, for example, that the cells that we're generating, focusing on just one of those beta cells in the EBC cluster, and we're seeing here that they have these beautiful granules and insulin vesicles, and they have the typical shape, this halo surrounding this dense core of insulin that is typically found in a normal beta cell. We also did a transcriptome analysis, and the take-home message is just shown over here, where approximately 86 or so percent identity exists between the cells that we generate in our EBCs when they are compared to cadaveric islet beta cells. So therefore, 86 percent, in some cases up to 90 percent, identity exists between the cells that we can generate from stem cells and those that we have in our body. So it's still not 100 percent. We're close, but not quite there yet. The point I want to make here, the latest point on this one slide, is that upon transplantation of these cells, under the kidney capsule in this particular case, we found that, as I mentioned to you earlier, we're not just only generating these green cells, these insulin-producing cells. We're also generating cells that are red and blue. Red is for glucagon, and blue is for somatostatin. So while we set out to just generate beta cells, we are also generating at least some of the other cell types that are normally found within the human islets, the alpha cells and the delta cells. I just have this slide up to illustrate to you that this is a technology that is not quite common yet. Not everyone is able to do this, but there are quite a few labs that are being able to use very, very similar differentiation protocols to end up at the same place. This includes Jeff Millman, for example, or Timo Toskonsky, Heiko Likert, as well as Doug Melton. And again, there are some others that essentially are also very good at generating these cells. So it's, again, it's not quite fully established, but it becomes a technology, and it has been replicated many, many times that now is able to generate these cells that we can study. So what I would like to do today is I will tell you what I think we can do with these cells and what my lab has been working on. So I wanna just briefly start out by talking about human biology. What I'm trying to say, is I'm gonna show you an example of that, that despite the rodent and the human beta cells are being very, very similar, they're not identical, meaning that there are certain aspects of human beta cell biology that only can be studied in human cells and not in rodent cells. And I'm gonna give you an example of that. I'm also gonna briefly talk about cell therapy. One of the biggest problems for cell therapy right now is not that we're not being able to generate these cells, I just provided the evidence that many people are able to do this now, but once you would generate these cells, then you have to protect them from immune destruction. And then finally, I'm gonna tell you a little bit about designer cells. And what I mean by that is essentially cells that we can use to enhance, in the example I'm gonna give you, the metabolism of these cells to make them more robust. And this is something that we believe also would be very beneficial for cell therapy. So let's jump into this and let's start, and I'm gonna give you two examples. Both of them, I'm gonna just focus on very quickly, both of them are published. So the first one is what I just mentioned to you that we've learned a tremendous amount from just studying the beta cells or the islets, I should say, in rodents. And they are very similar to the cells and the islets that we have in our own body, but they're not identical. So an example of that is this list of conscription factors in the rodent, there's a factor that has quite a bit of notoriety, it's called MAF-A. And MAF-A is one of those factors that come up when the beta cells mature. Now, in the human context, we do have MAF-A present as well, but there's another member of the same family, it's called MAF-B, very closely related to MAF-A. But MAF-B is only expressed in the human beta cells and not in the mature beta cells of the rodent. So therefore, if you would like to understand and test what the function of this particular factor is, you have to actually do this analysis in humans. And so we set out to do that, and we generated lines that were negative for MAF-B, and we're just showing a couple of the data here. And the first observation we made is that by doing so, the level of GFP, which is a readout for insulin production was dramatically curved. So just losing this one transcription factor leads to a very significant reduction in insulin expression. And actually, if you look at this, and we've done this by single-cell analysis, you can see these are the controls up here, and these are the MAF-B mutants down here. You can see that the level of insulin is dramatically reduced. And it's not just only the level of insulin or the insulin-positive cells, it's also the alpha cells, the glucagon-positive cells normally found down here. So this is dramatically reduced in our cells as well. In contrast, if you look at the other hormone, sorry, produced somatostatin by delta cells, you can see that there seems to be a robust increase in the level of somatostatin-producing cells. And if you looked at this a little bit further, this is a Western blot analysis that shows that there's a very low level of somatostatin under normal conditions in the control of the heterozygous. But as soon as you eliminate this gene MAF-B, you see that there's a robust increase in the level of this hormone. And this can also be shown by looking at specific markers for the data cells. HX is one of the transcription factors, somatostatin is the hormone. And you can see immediately that upon elimination of MAF-B, you have a robust increase in these delta cells that are present normally, but at a much lower level in the cells that have MAF-B. So the conclusion from that, again, is that they're now revealing something that would be harder to study in the rodents, specific activities of the human beta cells, and they have to do with a switch of the identity or the differentiation identity of the hormone-producing cells within the islet. I wanna give you a second example of how we're using our technologies, and this has to do now with cell therapy. The proof of principle has actually been done through cadaveric islet transplantation. The promise of the cells that we are generating is that if we generate fully differentiated beta cells or islet cells, we should be able to cure diabetes. And again, cadaveric islet transplantation is the closest analogy to that. So if a patient with diabetes is being given these islets, then the idea would be that this person is cured of diabetes. And there's lots and lots of data to indicate that this is actually the case. This is a patient that actually we had at UCSF. This patient, despite trying very, very hard, was unable, even with an insulin pump, to regulate the glucose levels in the normal range. Upon islet transplantation, you can see that almost immediately the glucose levels were falling down and were in this really tight range that is essentially similar to what we would have in a patient who is not suffering from diabetes. So the idea here is that, yes, if we can generate the equivalent of these structures of the islets here, we should be able to help patients with diabetes. Now, if we do this, then, of course, the major concern is that there's an immune rejection of the stem cells, because the cells that we would be giving are generated from a line that is not identical, genetically identical, to the genetics of the person who would be receiving this transplant. And there's a number of ways where you can try to mitigate this effect. One would be by immune suppression. This is what's being done in the clinic right now. Another way would be by encapsulation, essentially protecting the cells from the immune system. And what I would like to describe to you is by doing this via genetic engineering. And so this is the issue here. If you have a cell, in this case, a cell that was generated from human progenitor cells, a beta cell, this cell produces molecules that we call HLA molecules. And these HLA molecules are now being recognized by T cells. Unfortunately, there is a mismatch in most cases because the T cell, again, has a different composition and recognizes different HLA molecules than the ones that are being expressed on the beta cell degenerated from the stem cells. So this cell would essentially would go ahead and destroy the beta cell. Now you can say, okay, why don't we just take out all of these HLA molecules, and then the T cell would not recognize it at all. It would be completely clogged. This is true. One could do this. But the problem is that these molecules, these HLA, A, B, and C in particular, also provide a signal peptide for a different set of HLA molecules, E, F, and G. Those are being recognized by NK cells. And NK cells actually have to recognize it. And only upon recognition are they not destroying the beta cells. So what I mean by that is, and what we tried to do is, if you knock out all of the molecules, the ABC molecules, those are the ones that are mostly recognized by these allergenic T cells here, then yes, the T cells would not recognize it anymore. But because they also would not have the HLAE molecule that requires the signal peptide to get to the membrane, the NK cells would not recognize the cell either, and then would go on to destroy it. So what you would have is you would have a reduction in T cell mediator rejection, but you would have an activation in NK cell mediator rejection. So what we decided to do is, we decided to eliminate most of the HLA molecule, but leave one intact. And this is called A2, this particular allele. The reason why we left this one intact is because it's actually expressed in 50% of the human population, the Caucasian population, but also across Asia. And so the idea now would be is that HLA-A2 would be recognized by the allogeneic T cells, and T cells therefore would not destroy it because it would recognize it as its own. And at the same time, we would have activation and expression of HLA-E, and HLA-E then would be recognized by NK cells, so NK cells also would not destroy the cell. So we would have a reduction in T cell-mediated rejection and a reduction in NK cell activation. And I'm just going to give you one example. Again, this is published and you can look it up. It was published last year, but this is the take-home message of the experiment we did. If you take these A2 cells, A2 retained, and you compare them upon transplantation for, in this particular case, four weeks, you can see that the signal is mostly stable over four weeks. And that is in contrast to when you just transplant Y-type embryonic stem cells, where you would expect to see an elimination of the cells, and this is exactly what you observe over time. These cells are being eliminated, and this is just the quantification of this. So I'm not saying that this is the end of it. There's many, many people who are working on this. There are other modifications you can do, but it just shows you as a proof of principle that by modulating the MHC molecules, you should be able to at least partially cloak these cells against immune-mediated rejection. I would like to now move on to the third part of my talk and tell you a story that is not published yet, and I call this designer cells. And what I mean by designer cells is essentially focusing on cells and making them more robust. So the overarching goal is to accelerate the evolution of superior beta or islet cells. Just to show this in a cartoon, it has taken us plus minus 400 million years to get out of the water and essentially start walking. The hope would be that at some point, actually, we don't have to walk anymore. We potentially could fly. Now, if you use this analogy and put this in the context of the beta cells, it has taken us 400 or so million years to get to the point that we have all beta cells today. But there's really no reason to assume that evolution will not go on. So if you would add another several hundred million years, we should get to a beta cell that is more robust, just more functional than the ones we have today in our body. Now, the hope would be that we don't have to do this for many hundred years, million years. We try to optimize the process and do this in a reasonable timeframe, let's say around 10 years. So how would we do something like this? Well, we decided to focus on metabolism in the mitochondria. This is just how a immature beta cell works. It takes on glucose, and glucose essentially goes through glycolysis. This is being transferred into the mitochondria, which is then through the TCA cycle, used to produce energy. And this energy is really important for a number of different things, including the production of insulin, but also is involved in the secretion of insulin because ATP blocks the potassium channels. And the blocking of the potassium channels leads to a membrane depolarization, calcium influx, and then insulin secretion. So this is a critical part, possibly the essential part of the beta cell, in which it just produces energy for all of these different processes that go on within the human beta cell. And so the idea would be to modulate this. What I mean by that is, if you take a mitochondria, you can equate it more or less to a battery or a power plant. And what we would love to do is, we would like to increase energy so that the beta cell can withstand stresses, can produce more insulin, for example, can secrete insulin than ever needed. But at the same time, we have to be careful that we don't increase the risk for oxidative stress, because if you overpower, if you overcharge the battery, this is what would happen. And the beta cell, again, is not very well equipped to deal with this kind of stress. So we're looking forward to increase the energy without overcharging. And we focused on a molecule that we think has the properties to do exactly that. And the molecule we've chosen is called Bola3. So what is Bola3 doing? Bola3 has at least two different functions. It actually is required to donate iron-sulfur clusters to an enzyme called a lipoic acid synthase. And this enzyme here, upon receiving the iron-sulfur clusters, is generating lipoic acid. Lipoic acid is then given to two essential enzymes of the TCS cycle, pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase. And those require lipoic acid as cofactors. And again, only then will they get these cofactors if this enzyme is able to produce lipoid acid. So therefore, in its indirect fraction, Bola3 is required to maintain the activity of these enzymes in the TCA cycle. It has a more direct effect, too, in that it directly can give the iron-sulfur clusters to members of the electron transport chain shown over here, particularly 1, 2, and 3. So Bola3, therefore, is a critical mediator and activator of mitochondrial function. But we don't think it can overcharge it because it does not lead to an increase in the enzymes or the electron transport chains. The proteins itself just provides cofactors. Now critically, loss of Bola3 also have been known to occur in humans. There's very few of those, and they have a mitochondrial dysfunction syndrome. So we started out by looking in the mouse because the mouse allows us to do elimination of genes over time and look at the consequences in vivo. The first thing we did is we looked at Bola3. It's expressed at particularly high levels in the beta cells, as you can see here, with co-staining with insulin. And what we decided to do is we used a Bola3 flux optimized. And through crossing it with this PDX1 Cre-ER, at the time of our choosing, we usually do this around two or so months, we can give tamoxifen, and then we go for several months to see what is the outcome of elimination of Bola3. PDX1 Cre-ER is mostly expressed in the beta cells, in the mature beta cells. And so by doing that, and we're following this up from two, four, six to eight months, you can see how the curves, and this is a glucose tolerance test, you can see how the curves slowly separating. And by eight months, you see that the mice that have lost Bola3 in the beta cells are not able to cope with high levels of glucose as efficiently as the controls that are made that essentially have Bola3 in the beta cells. And this can be quantified, and it's just shown here that there's a significant increase in the area under the curve. And the fasting glucose is approaching significance here as well, meaning that yes, those mice are moving towards a frank diabetic phenotype. Now, we are interested, as I mentioned to you, in the human cells. So we asked the question, it's expressed in the mouse, how does it look in the human? And similar to what we've seen in the rodent, there's high level of expression of Bola3, again, in the insulin producing cells of a human islet. So Bola3 is expressed at high levels in the beta cells of a human islet. Is it expressed in our stem cell-derived cells? The answer is yes. Although, as you can see here, in day 20, there's low levels of Bola3. And if you go to these enriched clusters that are more functional, you see that there's an enrichment in C-peptide, but also an enrichment in the red staining, which is Bola3. So one maturation, we see, as we would have expected it, an increase in Bola3 in our stem cell-derived beta cells. Beauty of the human stem cell system is that you can use iCRISPR, or in general, gene editing technologies to more or less do whatever you would like to do. So in our case, what we decided to do is to put three guide RNAs against Bola3 into, and they're shown here, in the open locus, the ABS locus in the human stem cells. And upon doxycycline, you can now drive the expression of the guide RNA. Cas9 is being produced as well. And therefore, you can eliminate Bola3. I apologize for the quality of this western blot. Bola3 is expressed at lower levels in our cells. But you can see here, this is in the controlled, and this is upon elimination, that there's a reduction in Bola3, so the system works. We're looking at the lipolated versions of PDH and other ketone dehydrogenase here. And what you can see is that upon giving doxycycline, there's a reduction in the lipolated versions of these cofactors, these coenzymes. So what that means is, yes, we're reducing Bola3, and therefore, these enzymes in the TCA cycle have a reduction in the lipolated, the activated forms. What is the consequence of this? I showed you pictures before when we take out MAFB, and if you remember this, insulin was almost completely gone. Here, in the context of Bola3 elimination, we still have expression of insulin, so we can generate these beta cells. Having said this, though, the beta cells seem to be compromised, so we have a reduction in Bola3. It's not a complete elimination. They're only doing this for five days. But we can see in the most robust cases that the expression of molecules like PDX1, which is one of the transcription factors required for the function of the beta cells, is reduced. And this is not only true for PDX1. We also see this for NKX6.1, where the levels of insulin seem to be unperturbed. So there is a reduction of what we would call the hierarchy of transcription factors in those cells upon elimination of this metabolic factor. Now, this is probably the most important experiment. We're doing this glucose-stimulated insulin secretion. It's a dynamic one, and if you just focus on the blue, which is the control, without doxycycline, you can see that upon giving a stimulation of, in our case, 20 millimolar glucose, you have a robust increase in glucose-stimulated insulin secretion. And this is reduced, particularly in this lower end of the curve here, which is reminiscent of what we see in the rodents, where you see that those cells that have reduced levels of Bola3 cannot cope with this bolus of glucose, as well as their controls. So like we've seen in rodents, a reduction of Bola3 impairs with the functional capacity of the stem cell-derived beta cells. Now, there was something interesting about Bola3, and I should tell you this in a second. We've looked at the metabolic proteins and subunits in the mitochondria, and what we find is, if you compare the immature beta cells in black to the mature beta cells, EBCs in green, to the islet beta cells, cadaveric islet beta cells that you would have in your body, you can see that many of these mitochondrial factors, the green and the purple, is the same, which means that the cells that we are generating have the full expression level or complement of these metabolic proteins and subunits. But that's not true for Bola3. So here we see that we have an increase from the immature to the mature, as I showed you already, but that that level is still significantly lower than what you would find in a cadaveric islet. So what that means is that Bola3 is one of those few proteins where the level is lower than what you have endogenously in our body, and therefore this is an opportunity to overexpress it. And this is exactly what we did. Again, we're taking advantage of the CRISPR, the gene editing technology that we have in our lab, and what we can do is we can now have placed a different construct into the ABS locus that upon doxycycline treatment allows for the production of Bola3. This works quite well. As you can see here, we have a 40 or so fold increase in Bola3 transcript levels. Not only do we have an increase in the transcript, we also see now a clear increase in the protein levels and the EBCs here upon stimulation with doxycycline. We also see an increase in, again, these lipolated versions within the TCA cycle, so the outcome is as we expected. It's a stabilization of these factors, and we see that we can still generate these mature clusters that doxycycline treatment doesn't have an effect on this, or overexpression of Bola3 doesn't have an effect on the formation of these insulin-producing clusters. And again, probably the most important experiment is the insulin secretion or the dynamic, and what you can see here now is that we have the light blue, which is the control, is performing not very well, but what you can see here is that upon activation of Bola3, which is the dark blue level, you see a very robust increase above what you normally would find in these stem cell drive beta cells, and that increase, we've done this some numerous times now, is really robust. That leads to a significant increase in glucose stimulated insulin secretion upon overexpression of Bola3, and again, that is not dependent on the insulin content. It's not that we're just generating cells that have more insulin. We think that we have changed the metabolism in those cells, and we're looking at this right now, that would allow them to be a little bit more robust, to have a little bit of extra capacity to secrete insulin when needed. And at the end of my talk, I just want to briefly summarize this. We think that Bola3 is a critical mediator of mitochondrial function in beta cells, and I hope I have convinced you of that, that elimination of Bola3 can compromise beta cell function, but on the flip side, which is probably the more important thing, is that increasing Bola3 function might provide this energy boost to increase beta cell activities, including insulin secretion, therefore make the beta cells just more robust and hopefully more healthy also upon transplantation into patients. I have given you some flavors of what I think one can do with these cells. I think we can study human biology to learn something that we really can only study in humans rather than rodents, and that would of course then translate into us making modifications to make these cells more robust. I've given you an example of how we can use CRISPR gene editing to immune cloak our cells, essentially to provide a little bit of protection against the immune system upon cell transplantation, and then I have given you an example of how I think we can use designer cells, and it's just the beginning of what we're doing, to enhance or to modify the metabolism in a manner to make these cells more robust. I want to close with a slide showing that I'm not sure if you're going to fly even in another 400 million years. That might be a little bit too much, but I do think that we can accelerate evolution to help our cells by providing immune protection as well as providing or identifying and then using new rheostats to improve their function and stability. The last slide I want to show is one that is almost personal. There was an article published in the New York Times in October 9th, 1903. The personal part is that this was actually a day after my grandmother was born, and in this article the person writing it was saying that the ridiculous fiasco which attended the attempt at aerial navigation in the Langley flying machine was not unexpected. Essentially, this person goes on to say that it's almost impossible to fly because this is going against nature and possibly it's going to take us a million or so years for us to be able to get into the air as a human. This feels a little bit like how the stem cell field has been over the last 20 years. It's a huge promise, but will it ever be realized? As you I think have noticed throughout my talk, I believe that it absolutely will be realized. In this particular case, this person was writing this literally two months before the Wright brothers took off, appeared to be a little bit short-sighted as well. I do think that in analogy to the stem cell fields, this not only has a huge promise, I think we're going to realize that promise. I need to thank the people in the lab. This is how the lab used to look under Zoom. Unfortunately, we do not have, now that we are getting back together in person, I don't have an updated version of this. Rodent was a postdoc who is now a scientist at Genentech who did the beautiful work on the MAF-B. Audrey has been in the lab. She's an assistant professor in the Diabetes Center now. She was working with us on the immune cloaking. Natalia here was a grad student. She moved on as well, who has done most of the work on VOLA3, although she's now getting a significant help from Zybiton as well. With that, I'd like just to thank the rest of the lab, as well as our funding organizations, as well as my colleagues who have been critical in helping us getting these things off the ground. Thank you very much for your attention. Thank you, Dr. Hebrook. It's been an honor to hear from both of our presenters this morning. Thank you for joining our first plenary of ENDO 2022. For those of you who are attending in person or virtually, we hope you have an amazing four days. Our next session is a debate about functional adrenal nodules, which is supposed to start at 9.45. We'll, of course, wait for whoever of you plans to attend other sessions to exit the hall. For those of you who plan to stay, obviously, stay put. You're in for a treat, I'm sure. Enjoy the rest of the meeting, and I will look forward to seeing you this afternoon at 2 o'clock for the second plenary session. Thank you.

Dr. Carol Weisham

Endocrine Society

virtual meetings

hybrid meeting Indo 2022

clinical decision support systems

insulin advancements

continuous glucose monitoring

closed-loop insulin delivery systems

artificial intelligence in diabetes care

ENDO Expo

collaboration

support for healthcare providers

stem cell-derived beta cell function

potential applications