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Han Y, Liu X, Jia Q, Xu J, Shi J, Li X, Xie G, Zhao X, He K. Longitudinal multi-omics analysis uncovers the altered landscape of gut microbiota and plasma metabolome in response to high altitude. MICROBIOME 2024; 12:70. [PMID: 38581016 PMCID: PMC10996103 DOI: 10.1186/s40168-024-01781-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/22/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Gut microbiota is significantly influenced by altitude. However, the dynamics of gut microbiota in relation to altitude remains undisclosed. METHODS In this study, we investigated the microbiome profile of 610 healthy young men from three different places in China, grouped by altitude, duration of residence, and ethnicity. We conducted widely targeted metabolomic profiling and clinical testing to explore metabolic characteristics. RESULTS Our findings revealed that as the Han individuals migrated from low altitude to high latitude, the gut microbiota gradually converged towards that of the Tibetan populations but reversed upon returning to lower altitude. Across different cohorts, we identified 51 species specifically enriched during acclimatization and 57 species enriched during deacclimatization to high altitude. Notably, Prevotella copri was found to be the most enriched taxon in both Tibetan and Han populations after ascending to high altitude. Furthermore, significant variations in host plasma metabolome and clinical indices at high altitude could be largely explained by changes in gut microbiota composition. Similar to Tibetans, 41 plasma metabolites, such as lactic acid, sphingosine-1-phosphate, taurine, and inositol, were significantly elevated in Han populations after ascending to high altitude. Germ-free animal experiments demonstrated that certain species, such as Escherichia coli and Klebsiella pneumoniae, which exhibited altitude-dependent variations in human populations, might play crucial roles in host purine metabolism. CONCLUSIONS This study provides insights into the dynamics of gut microbiota and host plasma metabolome with respect to altitude changes, indicating that their dynamics may have implications for host health at high altitude and contribute to host adaptation. Video Abstract.
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Affiliation(s)
- Yang Han
- Medical Big Data Research Center, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China
- Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China
- National Engineering Research Center for Medical Big Data Application Technology, Chinese PLA General Hospital, Beijing, China
| | | | - Qian Jia
- Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China
- National Engineering Research Center for Medical Big Data Application Technology, Chinese PLA General Hospital, Beijing, China
| | - Jiayu Xu
- Medical Big Data Research Center, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China
- National Engineering Research Center for Medical Big Data Application Technology, Chinese PLA General Hospital, Beijing, China
| | - Jinlong Shi
- Medical Big Data Research Center, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China
- National Engineering Research Center for Medical Big Data Application Technology, Chinese PLA General Hospital, Beijing, China
| | - Xiang Li
- Ping An Healthcare Technology, Beijing, China
| | - Guotong Xie
- Ping An Healthcare Technology, Ping An Health Cloud Company Limited, Beijing, China
| | - Xiaojing Zhao
- Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China.
- National Engineering Research Center for Medical Big Data Application Technology, Chinese PLA General Hospital, Beijing, China.
| | - Kunlun He
- Medical Big Data Research Center, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China.
- Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Medical Innovation Research Division, Chinese PLA General Hospital, Beijing, China.
- National Engineering Research Center for Medical Big Data Application Technology, Chinese PLA General Hospital, Beijing, China.
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Zegarra-Rodríguez CA, Plasencia-Dueñas NR, Failoc-Rojas VE. Disparities in the prevalence of screened depression at different altitudes in Peru: A retrospective analysis of the ENDES 2019. PLoS One 2022; 17:e0278947. [PMID: 36542597 PMCID: PMC9770421 DOI: 10.1371/journal.pone.0278947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Depression is a public health concern, nearing 1.5 million cases and accounting for 9.7% of years lost due to disability. Several factors, including altitude, contribute to its development. Altitude has become a topic for recent research, but its association with depressive symptoms has not been fully clarified. Therefore, this study aimed to determine the association between altitude and depressive symptoms in the Peruvian population. METHODS A retrospective, cross-sectional study of the 2019 Demographic and Family Health Survey (ENDES in Spanish) was conducted. The dependent variable, depressive symptoms, was measured using the Patient Health Questionnaire (PHQ-9) and the independent variable, altitude, was categorized into: <1500 meters above sea level (masl), 1500-2499 masl and ≥2500 masl. To evaluate the association between altitude and depressive symptoms, we used Poisson regression model, constructing crude and multiple models. RESULTS Of those living at 1500 to 2499 masl and ≥2500 masl, 7.23% and 7.12% had depressive symptoms, respectively. After adjusting for confounding variables, high altitude was found to be associated with depressive symptoms (prevalence ratio adjusted (aPR): 1.38, 95% confidence interval: 1.04-1.84; aPR 1.41, 95% CI: 1.20-1.66). CONCLUSIONS A statistically significant association was found between high altitude and depressive symptoms. This may be attributable to hypobaric hypoxia that occurs at high altitudes and its effects on brain function. This study's findings should be considered to identify the population at risk and expand the coverage of preventive and therapeutic measures in high-altitude areas of Peru with poor access to health services.
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Affiliation(s)
- Cynthia Alejandra Zegarra-Rodríguez
- School of Medicine, Universidad Nacional Pedro Ruiz Gallo, Lambayeque, Peru
- Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional Pedro Ruiz Gallo (SOCIEM-UNPRG), Lambayeque, Peru
| | - Nahún Raphael Plasencia-Dueñas
- School of Medicine, Universidad Nacional Pedro Ruiz Gallo, Lambayeque, Peru
- Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional Pedro Ruiz Gallo (SOCIEM-UNPRG), Lambayeque, Peru
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Burtscher J, Niedermeier M, Hüfner K, van den Burg E, Kopp M, Stoop R, Burtscher M, Gatterer H, Millet GP. The interplay of hypoxic and mental stress: Implications for anxiety and depressive disorders. Neurosci Biobehav Rev 2022; 138:104718. [PMID: 35661753 DOI: 10.1016/j.neubiorev.2022.104718] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 12/14/2022]
Abstract
Adequate oxygen supply is essential for the human brain to meet its high energy demands. Therefore, elaborate molecular and systemic mechanism are in place to enable adaptation to low oxygen availability. Anxiety and depressive disorders are characterized by alterations in brain oxygen metabolism and of its components, such as mitochondria or hypoxia inducible factor (HIF)-pathways. Conversely, sensitivity and tolerance to hypoxia may depend on parameters of mental stress and the severity of anxiety and depressive disorders. Here we discuss relevant mechanisms of adaptations to hypoxia, as well as their involvement in mental stress and the etiopathogenesis of anxiety and depressive disorders. We suggest that mechanisms of adaptations to hypoxia (including metabolic responses, inflammation, and the activation of chemosensitive brain regions) modulate and are modulated by stress-related pathways and associated psychiatric diseases. While severe chronic hypoxia or dysfunctional hypoxia adaptations can contribute to the pathogenesis of anxiety and depressive disorders, harnessing controlled responses to hypoxia to increase cellular and psychological resilience emerges as a novel treatment strategy for these diseases.
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Affiliation(s)
- Johannes Burtscher
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland.
| | - Martin Niedermeier
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Katharina Hüfner
- Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, University Clinic for Psychiatry II, Innsbruck Medical University, Innsbruck, Austria
| | - Erwin van den Burg
- Department of Psychiatry, Center of Psychiatric Neuroscience (CNP), University Hospital of Lausanne (CHUV), Prilly, Lausanne, Switzerland
| | - Martin Kopp
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Ron Stoop
- Department of Psychiatry, Center of Psychiatric Neuroscience (CNP), University Hospital of Lausanne (CHUV), Prilly, Lausanne, Switzerland
| | - Martin Burtscher
- Department of Sport Science, University of Innsbruck, Innsbruck, Austria
| | - Hannes Gatterer
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Grégoire P Millet
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland; Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
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Zou L, Li X, Chen Q, Lv F, Min S. Focal points of preanesthesia evaluations for electroconvulsive therapy in patients with depression: a retrospective analysis of clinical characteristics in nonremission. BMC Anesthesiol 2022; 22:163. [PMID: 35619081 PMCID: PMC9134596 DOI: 10.1186/s12871-022-01686-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 05/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background This study explored the patient clinical characteristics that may affect electroconvulsive therapy (ECT) efficacy to enable improved focus during evaluations and preparation for ECT. Methods Patients were enrolled for ECT at the Department of Psychiatry and Anesthesiology of the First Affiliated Hospital of Chongqing Medical University from December 2017 to January 2019. The primary outcome in our study was defined as the development of nonremission. A multivariate logistic analysis was performed to identify the risk factors for nonremission. Results In total, 874 depressed patients were included in the study. After the ECT treatment, 255 cases (29.2%) exhibited nonremission. A multivariate logistic regression analysis of the variables was performed, and the results showed that atherosclerosis (OR 8.072, 95% CI 2.442 to 16.675; P = 0.001), COPD (OR 2.919, 95% CI 1.240 to 6.871; P = 0.014), diabetes (OR 2.202, 95% CI 1.115 to 4.348; P = 0.023) and smoking (OR 1.519, 95% CI 1.015 to 2.273; P = 0.042) were independent risk factors for nonremission. Conclusion In the retrospective analysis, we found that atherosclerosis, diabetes, COPD and smoking may be high-risk factors for nonremission. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01686-6.
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Affiliation(s)
- Lei Zou
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiao Li
- Departments of Psychiatry, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qibin Chen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Feng Lv
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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High altitude is associated with pTau deposition, neuroinflammation, and myelin loss. Sci Rep 2022; 12:6839. [PMID: 35477957 PMCID: PMC9046305 DOI: 10.1038/s41598-022-10881-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 04/14/2022] [Indexed: 11/30/2022] Open
Abstract
Mammals are able to adapt to high altitude (HA) if appropriate acclimation occurs. However, specific occupations (professional climbers, pilots, astronauts and other) can be exposed to HA without acclimation and be at a higher risk of brain consequences. In particular, US Air Force U2-pilots have been shown to develop white matter hyperintensities (WMH) on MRI. Whether WMH are due to hypoxia or hypobaria effects is not understood. We compared swine brains exposed to 5000 feet (1524 m) above sea level (SL) with 21% fraction inspired O2 (FiO2) (Control group [C]; n = 5) vs. 30,000 feet (9144 m) above SL with 100% FiO2 group (hypobaric group [HYPOBAR]; n = 6). We performed neuropathologic assessments, molecular analyses, immunohistochemistry (IHC), Western Blotting (WB), and stereology analyses to detect differences between HYPOBAR vs. Controls. Increased neuronal insoluble hyperphosphorylated-Tau (pTau) accumulation was observed across different brain regions, at histological level, in the HYPOBAR vs. Controls. Stereology-based cell counting demonstrated a significant difference (p < 0.01) in pTau positive neurons between HYPOBAR and C in the Hippocampus. Higher levels of soluble pTau in the Hippocampus of HYPOBAR vs. Controls were also detected by WB analyses. Additionally, WB demonstrated an increase of IBA-1 in the Cerebellum and a decrease of myelin basic protein (MBP) in the Hippocampus and Cerebellum of HYPOBAR vs. Controls. These findings illustrate, for the first time, changes occurring in large mammalian brains after exposure to nonhypoxic-hypobaria and open new pathophysiological views on the interaction among hypobaria, pTau accumulation, neuroinflammation, and myelination in large mammals exposed to HA.
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Sex-based changes in rat brain serotonin and behavior in a model of altitude-related vulnerability to treatment-resistant depression. Psychopharmacology (Berl) 2021; 238:2867-2881. [PMID: 34159421 DOI: 10.1007/s00213-021-05902-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/08/2021] [Indexed: 01/03/2023]
Abstract
RATIONALE Rates of depression and suicide increase with altitude. In our animal model, rats housed at moderate altitude vs. at sea level exhibit increased depressive symptoms in the forced swim test (FST) and lack of response to selective serotonin reuptake inhibitors (SSRIs). Depression and SSRI resistance are linked to disrupted serotonergic function, and hypobaric hypoxia may reduce the oxygen-dependent synthesis of serotonin. We therefore tested brain serotonin in rats housed at altitude. METHODS Sprague-Dawley rats were housed at altitude (4,500 ft, 10,000 ft) vs. sea level for 7-36 days. Brain serotonin was measured by ELISA, or behavior evaluated in the FST, sucrose preference (SPT), or open-field tests (OFT). RESULTS After 2 weeks at 4,500 ft or 10,000ft vs. sea level, serotonin levels decreased significantly at altitude in the female prefrontal cortex, striatum, hippocampus, and brainstem, but increased with altitude in the male hippocampus and brainstem. Female brain serotonin decreased from 7 to 36 days at 4,500 ft, but males did not vary. At 2 weeks and 24 days, females at altitude exhibit lower brain serotonin and increased depressive symptoms in the FST and SPT, with motor behavior unaltered. In males, serotonin, passive coping in the FST and OFT immobility increased with altitude at 2 weeks, but not at 24 days. Male SPT behavior did not change with altitude. CONCLUSIONS Females may be more vulnerable to depressive symptoms at altitude, while males may be resilient. Chronic hypoxic stress at altitudes as low as 4,500 ft may cause a brain serotonin imbalance to worsen vulnerability to depression and SSRI resistance, and potentially worsen suicide risk.
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Prescot A, Huber R, Kanekar S, Kondo D, Prisciandaro J, Ongur D, Renshaw PF. Effect of moderate altitude on human cerebral metabolite levels: A preliminary, multi-site, proton magnetic resonance spectroscopy investigation. Psychiatry Res Neuroimaging 2021; 314:111314. [PMID: 34098247 DOI: 10.1016/j.pscychresns.2021.111314] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 05/14/2021] [Accepted: 05/27/2021] [Indexed: 12/19/2022]
Abstract
Epidemiological studies show that altitude-of-residence is an independent risk factor for worsening rates of mood disorders, substance abuse, and suicide. Proton (1H) magnetic resonance spectroscopy (MRS) studies in rodent models of moderate-to-high altitude exposure have documented significant alterations in total creatine, glutamate, and myo-inositol, neurometabolites involved in bioenergetic homeostasis and neuronal/glial cell function. This preliminary study utilized 3 Tesla 1H MRS to study anterior cingulate cortex (ACC) and parietal-occipital cortex (POC) neurochemistry in healthy subjects residing in Utah (n = 19), Massachusetts (n = 10), and South Carolina (n = 10), to test the hypothesis that individuals residing at moderate altitude (Utah; 1,372 m) would show neurometabolite alterations vs. subjects living at sea level. Expressed as ratios to total N-acetyl aspartate (NAA), Utah participants showed lower ACC (p = 0.03) and POC (p < 0.01) total creatine, a trend towards lower ACC glutamate (p = 0.06), and lower POC myo-inositol (p = 0.02). Study limitations include small sample sizes and uncorrected multiple comparisons. To our knowledge, this is the first MRS investigation to identify potential neurochemical differences in individuals residing at moderate altitudes vs. sea level, warranting future 1H MRS studies in larger cohorts and across a range of altitudes-of-residence.
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Affiliation(s)
- Andrew Prescot
- Department of Radiology and Imaging Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States.
| | - Rebekah Huber
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Shami Kanekar
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, United States; Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC), George E. Whalen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Douglas Kondo
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, United States; Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC), George E. Whalen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - James Prisciandaro
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States; Center for Biomedical Imaging, Medical University of South Carolina, Charleston, SC, United States
| | - Dost Ongur
- Psychotic Disorders Division, McLean Hospital, Belmont, MA, United States; Department of Psychiatry, Harvard Medical School, Cambridge, MA, United States
| | - Perry F Renshaw
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, United States; Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC), George E. Whalen Department of Veterans Affairs Medical Center, Salt Lake City, UT, United States
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Kanekar S, Ettaro R, Hoffman MD, Ombach HJ, Brown J, Lynch C, Sheth CS, Renshaw PF. Sex-Based Impact of Creatine Supplementation on Depressive Symptoms, Brain Serotonin and SSRI Efficacy in an Animal Model of Treatment-Resistant Depression. Int J Mol Sci 2021; 22:ijms22158195. [PMID: 34360959 PMCID: PMC8348220 DOI: 10.3390/ijms22158195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Rates of major depressive disorder (MDD) increase with living at altitude. In our model, rats housed at moderate altitude (in hypobaric hypoxia) exhibit increased depression-like behavior, altered brain serotonin and a lack of antidepressant response to most selective serotonin reuptake inhibitors (SSRIs). A forebrain deficit in the bioenergetic marker creatine is noted in people living at altitude or with MDD. Methods: Rats housed at 4500 ft were given dietary creatine monohydrate (CRMH, 4% w/w, 5 weeks) vs. un-supplemented diet, and impact on depression-like behavior, brain bioenergetics, serotonin and SSRI efficacy assessed. Results: CRMH significantly improved brain creatine in a sex-based manner. At altitude, CRMH increased serotonin levels in the female prefrontal cortex and striatum but reduced male striatal and hippocampal serotonin. Dietary CRMH was antidepressant in the forced swim test and anti-anhedonic in the sucrose preference test in only females at altitude, with motor behavior unchanged. CRMH improved fluoxetine efficacy (20 mg/kg) in only males at altitude: CRMH + SSRI significantly improved male striatal creatine and serotonin vs. CRMH alone. Conclusions: Dietary CRMH exhibits sex-based efficacy in resolving altitude-related deficits in brain biomarkers, depression-like behavior and SSRI efficacy, and may be effective clinically for SSRI-resistant depression at altitude. This is the first study to link CRMH treatment to improving brain serotonin.
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Affiliation(s)
- Shami Kanekar
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
- VISN19 MIRECC, 500 Foothill Drive, Salt Lake City, UT 84148, USA
- Veterans Affairs Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
- Correspondence: ; Tel.: +1-801-587-1477 or +1-801-585-5375
| | - Robert Ettaro
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
| | - Michael D. Hoffman
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
| | - Hendrik J. Ombach
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
| | - Jadeda Brown
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
| | - Cayla Lynch
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
| | - Chandni S. Sheth
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
| | - Perry F. Renshaw
- Diagnostic Neuroimaging, Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA; (R.E.); (M.D.H.); (H.J.O.); (J.B.); (C.L.); (C.S.S.); (P.F.R.)
- VISN19 MIRECC, 500 Foothill Drive, Salt Lake City, UT 84148, USA
- Veterans Affairs Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148, USA
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Hermesdorf M, Szentkirályi A, Teismann H, Teismann I, Young P, Berger K. Sleep characteristics, cognitive performance, and gray matter volume: findings from the BiDirect Study. Sleep 2021; 44:5919359. [PMID: 33029624 DOI: 10.1093/sleep/zsaa209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/24/2020] [Indexed: 11/15/2022] Open
Abstract
STUDY OBJECTIVES Sleep is essential for restorative metabolic changes and its physiological correlates can be examined using overnight polysomnography. However, the association between physiological sleep characteristics and brain structure is not well understood. We aimed to investigate gray matter volume and cognitive performance related to physiological sleep characteristics. METHODS Polysomnographic recordings from 190 community-dwelling participants were analyzed with a principal component analysis in order to identify and aggregate shared variance into principal components. The relationship between aggregated sleep components and gray matter volume was then analyzed using voxel-based morphometry. In addition, we explored how cognitive flexibility, selective attention, and semantic fluency were related to aggregated sleep components and gray matter volume. RESULTS Three principal components were identified from the polysomnographic recordings. The first component, primarily described by apnea events and cortical arousal, was significantly associated with lower gray matter volume in the left frontal pole. This apnea-related component was furthermore associated with lower cognitive flexibility and lower selective attention. CONCLUSIONS Sleep disrupted by cortical arousal and breathing disturbances is paralleled by lower gray matter volume in the frontal pole, a proposed hub for the integration of cognitive processes. The observed effects provide new insights on the interplay between disrupted sleep, particularly breathing disturbances and arousal, and the brain.
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Affiliation(s)
- Marco Hermesdorf
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - András Szentkirályi
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Henning Teismann
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Inga Teismann
- Department for Stroke and Respiratory Medicine, Alexianer Misericordia GmbH, Münster, Germany
| | - Peter Young
- Department of Neurology, Medical Park Bad Feilnbach, Bad Feilnbach, Germany
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
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Kopyta I, Sarecka-Hujar B, Raczkiewicz D, Gruszczyńska K, Machnikowska-Sokołowska M. Assessment of Post-Stroke Consequences in Pediatric Ischemic Stroke in the Context of Neuroimaging Results-Experience from a Single Medical Center. CHILDREN-BASEL 2021; 8:children8040292. [PMID: 33917968 PMCID: PMC8068320 DOI: 10.3390/children8040292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/25/2021] [Accepted: 04/06/2021] [Indexed: 11/16/2022]
Abstract
Arterial ischemic stroke (AIS) in children is a rare condition; its frequency is estimated at 0.58 to 7.9 new onsets in 100,000 children per year. The knowledge on risk factors, clinical outcomes and consequences of pediatric AIS is increasing. However, there are still many unknowns in the field. The aim of the study was to analyze the clinical presentation of pediatric AIS and its consequences according to the neuroimaging results and location of ischemia. The research was retrospective and observational. The analyzed group consisted of 75 AIS children (32 girls, 43 boys), whereby the age of the patients ranged from 9 months to 18 years at stroke onset. All the patients were diagnosed and treated in one tertiary center. The most frequent stroke subtype was total anterior circulation infarct (TACI) with most common ischemic focus location in temporal lobe and vascular pathology in middle cerebral artery (MCA). The location of ischemic focus in the brain correlated with post-stroke outcomes: intellectual delay and epilepsy, hemiparesis corresponded to the location of vascular pathology. A correlation found between ischemic lesion location and vascular pathology with post-stroke consequences in pediatric AIS may be important information and helpful in choosing proper early therapy. The expected results should lead to lesser severity of late post-stroke outcomes.
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Affiliation(s)
- Ilona Kopyta
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland;
| | - Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, 41-200 Sosnowiec, Poland;
| | - Dorota Raczkiewicz
- Department of Medical Statistics, School of Public Health, Center of Postgraduate Medical Education, 01-826 Warsaw, Poland
- Correspondence: ; Tel.: +48-605-313-261
| | - Katarzyna Gruszczyńska
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland; (K.G.); (M.M.-S.)
| | - Magdalena Machnikowska-Sokołowska
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, 40-752 Katowice, Poland; (K.G.); (M.M.-S.)
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Kang I, Kondo D, Kim J, Lyoo IK, Yurgelun-Todd D, Hwang J, Renshaw PF. Elevating the level of hypoxia inducible factor may be a new potential target for the treatment of depression. Med Hypotheses 2020; 146:110398. [PMID: 33246695 DOI: 10.1016/j.mehy.2020.110398] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/09/2020] [Indexed: 12/28/2022]
Abstract
Hypoxia inducible factor-1 (HIF-1) is a transcriptional factor that regulates gene expressions in response to decreased oxygen levels in the tissue, or hypoxia. HIF-1 exerts protective effects against hypoxia by mediating mitochondrial metabolism and consequently reducing oxidative stress. Recently, increased levels of oxidative stress and abnormal energy metabolism in the brain have been suggested to play essential roles in the pathogenesis of depression. Given that HIF-1 activates creatine metabolism and increases phosphocreatine levels in the intestinal epithelial cells, we assume that HIF-1 may induce similar processes in the brain. Elevated phosphocreatine levels in the brain, as measured by magnetic resonance spectroscopy, were associated with better treatment response to the antidepressants in individuals with depression. In addition, oral creatine supplements, which led to increased phosphocreatine levels in the brain, also enhanced the effects of antidepressants in individuals with depression. As such, we hypothesized that increasing the HIF-1, which potentially facilitates creatine metabolism in the brain, might be a new therapeutic target in depression. With this regard, we suggested that interventions to elevate the HIF-1 levels in the brain, including the intermittent hypoxia conditioning and hyperbaric oxygen therapy, might be considered as new additional treatments for depression.
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Affiliation(s)
- Ilhyang Kang
- Ewha Brain Institute, Ewha W. University, Seoul, South Korea
| | - Douglas Kondo
- Department of Psychiatry, University of Utah, Salt Lake City, USA; The Brian Institute, University of Utah School of Medicine, Salt Lake City, USA
| | - Jungyoon Kim
- Ewha Brain Institute, Ewha W. University, Seoul, South Korea; Department of Brain and Cognitive Sciences, Ewha W. University, Seoul, South Korea
| | - In Kyoon Lyoo
- Ewha Brain Institute, Ewha W. University, Seoul, South Korea; Department of Psychiatry, University of Utah, Salt Lake City, USA; The Brian Institute, University of Utah School of Medicine, Salt Lake City, USA
| | - Deborah Yurgelun-Todd
- Department of Psychiatry, University of Utah, Salt Lake City, USA; The Brian Institute, University of Utah School of Medicine, Salt Lake City, USA; Veterans Integrated Service Network 19 Mental Illness Research Education Clinical, Centers of Excellence, Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Jaeuk Hwang
- Department of Psychiatry, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea.
| | - Perry F Renshaw
- Department of Psychiatry, University of Utah, Salt Lake City, USA; The Brian Institute, University of Utah School of Medicine, Salt Lake City, USA; Veterans Integrated Service Network 19 Mental Illness Research Education Clinical, Centers of Excellence, Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah, USA.
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12
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Li B, Xu Y, Quan Y, Cai Q, Le Y, Ma T, Liu Z, Wu G, Wang F, Bao C, Li H. Inhibition of RhoA/ROCK Pathway in the Early Stage of Hypoxia Ameliorates Depression in Mice via Protecting Myelin Sheath. ACS Chem Neurosci 2020; 11:2705-2716. [PMID: 32667781 DOI: 10.1021/acschemneuro.0c00352] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Neuroplasticity and connectivity in the central nervous system (CNS) are easily damaged after hypoxia. Long-term exposure to an anoxic environment can lead to neuropsychiatric symptoms and increases the likelihood of depression. Demyelination is an important lesion of CNS injury that may occur in depression. Previous studies have found that the RhoA/ROCK pathway is upregulated in neuropsychiatric disorders such as multiple sclerosis, stroke, and neurodegenerative diseases. Therefore, the chief aim of this study is to explore the regulatory role of the RhoA/ROCK pathway in the development of depression after hypoxia by behavioral tests, Western blotting, immunostaining as well as electron microscopy. Results showed that HIF-1α, S100β, RhoA/ROCK, and immobility time in FST were increased, sucrose water preference ratio in SPT was decreased, and the aberrant activity of neurocyte and demyelination occurred after hypoxia. After the administration of Y-27632 and fluoxetine in hypoxia, these alterations were improved. Lingo1, a negative regulatory factor, was also overexpressed after hypoxia and its expression was decreased when the pathway blocked. However, fluoxetine had no effect on the expression of Lingo1. Then, we demonstrated that demyelination was associated with failures of oligodendrocyte precursor cell proliferation and differentiation and increased apoptosis of oligodendrocytes. Collectively, our data indicate that the RhoA/ROCK pathway plays a vital role in the initial depression during hypoxia. Blocking this pathway in the early stage of hypoxia can enhance the effectiveness of antidepressants, rescue myelin damage, and reduce the expression of the negative regulatory protein of myelination. The findings provide new insight into the prophylaxis and treatment of depression.
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Affiliation(s)
- Baichuan Li
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
| | - Yang Xu
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
| | - Yong Quan
- Department of Teaching Experiment Center, Army Medical University, Chongqing 400038, China
| | - Qiyan Cai
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
| | - Yifan Le
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
| | - Teng Ma
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
| | - Zhi Liu
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
| | - Guangyan Wu
- Department of Teaching Experiment Center, Army Medical University, Chongqing 400038, China
| | - Fei Wang
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
| | - Chuncha Bao
- Department of Teaching Experiment Center, Army Medical University, Chongqing 400038, China
| | - Hongli Li
- Department of Histology and Embryology, Chongqing Key Laboratory of Neurobiology, Army Medical University, Chongqing 400038, China
- Department of Teaching Experiment Center, Army Medical University, Chongqing 400038, China
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13
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Riljak V, Laštůvka Z, Mysliveček J, Borbélyová V, Otáhal J. Early postnatal hypoxia induces behavioral deficits but not morphological damage in the hippocampus in adolescent rats. Physiol Res 2019; 69:165-179. [PMID: 31852194 DOI: 10.33549/physiolres.934234] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Hypoxia is one of the major pathological factors affecting brain function. The aim of the present study was to describe the effect of neonatal hypobaric hypoxia on the behavior of rats and to analyze its effect on hippocampal neurodegeneration. Hypobaric hypoxia at a simulated altitude of 9000 m was induced for one hour in neonatal rat pups (PND7 and PND9) of both sexes. Subsequently, the rats underwent behavioral testing on PND25 and PND35 using a LABORAS apparatus to assess spontaneous behavior. Hypoxia did not cause any morphological damage in the hippocampus of rats. However, hypoxia on PND7 led to less horizontal locomotor activity both, in males (on PND25) and females (on PND35). Hypoxia on PND9 led to higher rearing in females on PND25. Hypoxic males exhibited higher grooming activity, while females lower grooming activity on PND35 following hypoxia induced on PND7. In females, hypoxia on PND9 resulted in higher grooming activity on PND25. Sex differences in the effect of hypoxia was observed on PND35, when hypoxic males compared to hypoxic females displayed more locomotor, rearing and grooming activity. Our data suggest that hypoxia on PND7 versus PND9 differentially affects locomotion and grooming later in adolescence and these effects are sex-dependent.
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Affiliation(s)
- V Riljak
- Institute of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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14
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Hwang J, DeLisi LE, Öngür D, Riley C, Zuo C, Shi X, Sung YH, Kondo D, Kim TS, Villafuerte R, Smedberg D, Yurgelun-Todd D, Renshaw PF. Cerebral bioenergetic differences measured by phosphorus-31 magnetic resonance spectroscopy between bipolar disorder and healthy subjects living in two different regions suggesting possible effects of altitude. Psychiatry Clin Neurosci 2019; 73:581-589. [PMID: 31125152 PMCID: PMC6771782 DOI: 10.1111/pcn.12893] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 05/17/2019] [Accepted: 05/22/2019] [Indexed: 12/26/2022]
Abstract
AIM Increased oxidative stress in cerebral mitochondria may follow exposure to the systemic hypobaric hypoxia associated with residing at higher altitudes. Because mitochondrial dysfunction is implicated in bipolar disorder (BD) pathophysiology, this may impact the cerebral bioenergetics in BD. In this study, we evaluated the cerebral bioenergetics of BD and healthy control (HC) subjects at two sites, located at sea level and at moderate altitude. METHODS Forty-three veterans with BD and 33 HC veterans were recruited in Boston (n = 22) and Salt Lake City (SLC; n = 54). Levels of phosphocreatine, β nucleoside triphosphate (βNTP), inorganic phosphate, and pH over total phosphate (TP) were measured using phosphorus-31 magnetic resonance spectroscopy in the following brain regions: anterior cingulate cortex and posterior occipital cortex, as well as bilateral prefrontal and occipitoparietal (OP) white matter (WM). RESULTS A significant main effect of site was found in βNTP/TP (Boston > SLC) and phosphocreatine/TP (Boston < SLC) in most cortical and WM regions, and inorganic phosphate/TP (Boston < SLC) in OP regions. A main effect analysis of BD diagnosis demonstrated a lower pH in posterior occipital cortex and right OP WM and a lower βNTP/TP in right prefrontal WM in BD subjects, compared to HC subjects. CONCLUSION The study showed that there were cerebral bioenergetic differences in both BD and HC veteran participants at two different sites, which may be partly explained by altitude difference. Future studies are needed to replicate these results in order to elucidate the dysfunctional mitochondrial changes that occur in response to hypobaric hypoxia.
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Affiliation(s)
- Jaeuk Hwang
- Department of Psychiatry, University of Utah, Salt Lake City, USA.,Department of Psychiatry, Soonchunhyang University Hospital, Seoul, South Korea
| | - Lynn E DeLisi
- US Department of Veterans Affairs Boston Healthcare System, Brockton, USA
| | - Dost Öngür
- Brain Imaging Center, McLean Hospital, Department of Psychiatry, Harvard Medical School, Belmont, USA
| | - Colin Riley
- Department of Psychiatry, University of Utah, Salt Lake City, USA
| | - Chun Zuo
- Brain Imaging Center, McLean Hospital, Department of Psychiatry, Harvard Medical School, Belmont, USA
| | - Xianfeng Shi
- Department of Psychiatry, University of Utah, Salt Lake City, USA
| | - Young-Hoon Sung
- Department of Psychiatry, University of Utah, Salt Lake City, USA
| | - Douglas Kondo
- Department of Psychiatry, University of Utah, Salt Lake City, USA.,Rocky Mountain Mental Illness Research, Education and Clinical Center, US Department of Veterans Affairs Healthcare System, Salt Lake City, USA
| | - Tae-Suk Kim
- Department of Psychiatry, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Rosemond Villafuerte
- Brain Imaging Center, McLean Hospital, Department of Psychiatry, Harvard Medical School, Belmont, USA
| | - Diane Smedberg
- US Department of Veterans Affairs Boston Healthcare System, Brockton, USA
| | - Deborah Yurgelun-Todd
- Department of Psychiatry, University of Utah, Salt Lake City, USA.,Rocky Mountain Mental Illness Research, Education and Clinical Center, US Department of Veterans Affairs Healthcare System, Salt Lake City, USA
| | - Perry F Renshaw
- Department of Psychiatry, University of Utah, Salt Lake City, USA.,Rocky Mountain Mental Illness Research, Education and Clinical Center, US Department of Veterans Affairs Healthcare System, Salt Lake City, USA
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15
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Creatine for the Treatment of Depression. Biomolecules 2019; 9:biom9090406. [PMID: 31450809 PMCID: PMC6769464 DOI: 10.3390/biom9090406] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/28/2022] Open
Abstract
Depressed mood, which can occur in the context of major depressive disorder, bipolar disorder, and other conditions, represents a serious threat to public health and wellness. Conventional treatments are not effective for a significant proportion of patients and interventions that are often beneficial for treatment-refractory depression are not widely available. There is, therefore, an immense need to identify novel antidepressant strategies, particularly strategies that target physiological pathways that are distinct from those addressed by conventional treatments. There is growing evidence from human neuroimaging, genetics, epidemiology, and animal studies that disruptions in brain energy production, storage, and utilization are implicated in the development and maintenance of depression. Creatine, a widely available nutritional supplement, has the potential to improve these disruptions in some patients, and early clinical trials indicate that it may have efficacy as an antidepressant agent.
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16
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Sabic H, Kious B, Boxer D, Fitzgerald C, Riley C, Scholl L, McGlade E, Yurgelun-Todd D, Renshaw PF, Kondo DG. Effect of Altitude on Veteran Suicide Rates. High Alt Med Biol 2019; 20:171-177. [PMID: 31045435 PMCID: PMC6602111 DOI: 10.1089/ham.2018.0130] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 03/15/2019] [Indexed: 11/12/2022] Open
Abstract
Aims: Suicide rates in the general population in the United States are correlated with altitude. To explore factors contributing to suicide among military veterans, we examined the relationship between veteran state-level suicide rates and altitude for 2014, including firearm-related and nonfirearm-related rates. Methods: Pearson's coefficients were calculated for altitude and each outcome. Mixed linear models were used to determine the association between suicide and altitude while adjusting for demographic confounds. Results: State mean altitude was significantly correlated with total veteran suicide rate (r = 0.678, p < 0.0001), veteran firearm-related suicide rate (r = 0.578, p < 0.0001), and veteran nonfirearm suicide rate (r = 0.609, p < 0.0001). In mixed models, altitude was significantly correlated with total veteran suicide rate (β = 0.331, p < 0.05), veteran firearm suicides (β = 0.282, p < 0.05), and veteran nonfirearm suicides (β = 0.393, p < 0.05). Conclusion: This study adds to evidence linking altitude and suicide rates, arguing for additional research into the relationship between altitude and suicide among veterans.
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Affiliation(s)
- Hana Sabic
- Brain Institute, University of Utah, Salt Lake City, Utah
| | - Brent Kious
- Department of Psychiatry, University of Utah, Salt Lake City, Utah
| | - Danielle Boxer
- Brain Institute, University of Utah, Salt Lake City, Utah
| | | | - Colin Riley
- Brain Institute, University of Utah, Salt Lake City, Utah
| | - Lindsay Scholl
- Brain Institute, University of Utah, Salt Lake City, Utah
| | - Erin McGlade
- Brain Institute, University of Utah, Salt Lake City, Utah
- Department of Psychiatry, University of Utah, Salt Lake City, Utah
- Veterans Integrated Service Network 19 Mental Illness Research Education Clinical, Centers of Excellence, Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Deborah Yurgelun-Todd
- Brain Institute, University of Utah, Salt Lake City, Utah
- Department of Psychiatry, University of Utah, Salt Lake City, Utah
- Veterans Integrated Service Network 19 Mental Illness Research Education Clinical, Centers of Excellence, Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Perry F. Renshaw
- Brain Institute, University of Utah, Salt Lake City, Utah
- Department of Psychiatry, University of Utah, Salt Lake City, Utah
- Veterans Integrated Service Network 19 Mental Illness Research Education Clinical, Centers of Excellence, Salt Lake City Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Douglas G. Kondo
- Brain Institute, University of Utah, Salt Lake City, Utah
- Department of Psychiatry, University of Utah, Salt Lake City, Utah
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17
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Abstract
After participating in this activity, learners should be better able to:• Assess epidemiologic evidence that increased altitude of residence is linked to increased risk of depression and suicide• Evaluate strategies to address hypoxia-related depression and suicidal ideation ABSTRACT: Suicide and major depressive disorder (MDD) are complex conditions that almost certainly arise from the influences of many interrelated factors. There are significant regional variations in the rates of MDD and suicide in the United States, suggesting that sociodemographic and environmental conditions contribute. Here, we review epidemiological evidence that increases in the altitude of residence are linked to the increased risk of depression and suicide. We consider the possibility that chronic hypobaric hypoxia (low blood oxygen related to low atmospheric pressure) contributes to suicide and depression, which is suggested by animal models, short-term studies in humans, and the effects of hypoxic medical conditions on suicide and depression. We argue that hypobaric hypoxia could promote suicide and depression by altering serotonin metabolism and brain bioenergetics; both of these pathways are implicated in depression, and both are affected by hypoxia. Finally, we briefly examine treatment strategies to address hypoxia-related depression and suicidal ideation that are suggested by these findings, including creatine monohydrate and the serotonin precursors tryptophan and 5-hydroxytryptophan.
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18
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Kious BM, Bakian A, Zhao J, Mickey B, Guille C, Renshaw P, Sen S. Altitude and risk of depression and anxiety: findings from the intern health study. Int Rev Psychiatry 2019; 31:637-645. [PMID: 31084447 PMCID: PMC8530170 DOI: 10.1080/09540261.2019.1586324] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Multiple studies suggest that the risks of depression and suicide increase with increasing altitude of residence, but no studies have assessed whether changing altitude changes these risks. To address this gap, this study used data from the Intern Health Study, which follows students from the end of medical school through the first year of residency, recording depression via the 9-item Patient Health Questionnaire (PHQ-9), anxiety via the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7), and multiple risk factors for these symptoms. Data from 3764 medical students representing 46 schools and 282 residencies were available. Odds ratios (OR) representing the effects of altitude on psychiatric symptoms were estimated using generalized linear models. After excluding participants with missing altitude data, 3731 medical students were analyzed. High altitude residence (> 900 m) was significantly associated with PHQ-9 total score (OR = 1.32, 95% CI = 1.001-1.75, p < 0.05), and PHQ-9 suicidal ideation (OR = 1.79, 95% CI = 1.08-0.02, p = 0.02). Moving from low to high altitude was significantly associated with PHQ-9 total score (OR = 1.47, 95% CI = 1.087-1.98, p = 0.01), GAD-7 total score (OR = 1.40, 95% CI = 1.0040-1.95, p < 0.05), and PHQ-9 suicidal ideation (OR = 1.10, 95% CI = 1.01-1.19, p = 0.02). The data suggest that moving from low to high altitude is associated with increasing symptoms of depression, anxiety, and suicidal ideation.
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Affiliation(s)
- Brent M. Kious
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - Amanda Bakian
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - Joan Zhao
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Brian Mickey
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - Constance Guille
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - Perry Renshaw
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - Srijan Sen
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Zaeh S, Miele CH, Putcha N, Gilman RH, Miranda JJ, Bernabe-Ortiz A, Wise RA, Checkley W. Chronic respiratory disease and high altitude are associated with depressive symptoms in four diverse settings. Int J Tuberc Lung Dis 2018; 20:1263-9. [PMID: 27510256 DOI: 10.5588/ijtld.15.0794] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
SETTING Depression is a prevalent comorbidity of chronic respiratory disease (CRD), and may indicate worse clinical outcomes. The relationship between depression and living with chronic hypoxia due to CRD or residence at altitude has received little attention in resource-poor settings. OBJECTIVE To investigate the association between CRD conditions and depressive symptoms in four settings in Peru. DESIGN We collected data on CRD and depressive symptoms in adults aged ⩾35 years. Depressive symptoms were measured according to the Center for Epidemiologic Studies Depression scale. Multivariable ordinal logistic regression was used to assess the adjusted odds of being in a higher category of depressive symptoms as a function of CRD. RESULTS We analyzed data from 2953 participants (mean age 55.3 years, 49% male). The prevalence of major depressive symptoms was 19%, with significant variation according to setting. Participants with at least one CRD (OR 1.34, 95%CI 1.06-1.69) and those living at altitude (OR 1.64, 95%CI 1.10-2.43) had an increased adjusted odds of being in a higher category of depressive symptoms. CONCLUSION We found a high prevalence of depressive symptoms, and a positive association between depressive symptoms with CRD and with living at altitude, both of which cause chronic hypoxia.
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Affiliation(s)
- S Zaeh
- Division of Pulmonary and Critical Care, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - C H Miele
- Division of Pulmonary and Critical Care, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - N Putcha
- Division of Pulmonary and Critical Care, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - R H Gilman
- Program in Global Disease Epidemiology and Control, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - J J Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - A Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - R A Wise
- Division of Pulmonary and Critical Care, School of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - W Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA; School of Medicine, Program in Global Disease Epidemiology and Control, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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20
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Sheth C, Ombach H, Olson P, Renshaw PF, Kanekar S. Increased Anxiety and Anhedonia in Female Rats Following Exposure to Altitude. High Alt Med Biol 2018; 19:81-90. [PMID: 29431475 DOI: 10.1089/ham.2017.0125] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Sheth, Chandni, Hendrik Ombach, Paul Olson, Perry F. Renshaw, and Shami Kanekar. Increased anxiety and anhedonia in female rats following exposure to altitude. High Alt Med Biol. 19:81-90, 2018.-Anxiety disorders are chronic, highly prevalent conditions, often comorbid with depression. Both anxiety and depression form major risk factors for suicide. Living at altitude is associated with higher rates of depression and suicide, leading us to address whether anxiety disorders may also be amplified at altitude. Using a novel translational animal model, we previously showed that depression-like behavior increases with altitude of housing in female, but not male rats. We now use this model to examine the effects of altitude on both anxiety-like behavior and anhedonia, a core symptom of depression. After housing for a week at sea level, 4500 or 10,000 ft, rats were evaluated for anxiety in the open-field test or the elevated plus maze, and anhedonia in the sucrose preference test. Another group was tested at baseline. Anxiety-like behavior increased in females housed at altitude. In females, lower sucrose preference was seen in those housed at 10,000 ft versus those at sea level. Males showed no change in anxiety or anhedonia across groups. These data suggest that living at moderate-high altitude may pose a risk factor for those vulnerable to anxiety disorders, with the potential to be particularly detrimental to females at altitude.
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Affiliation(s)
- Chandni Sheth
- 1 Diagnostic Neuroimaging, Department of Psychiatry, University of Utah School of Medicine , Salt Lake City, Utah
| | - Hendrik Ombach
- 1 Diagnostic Neuroimaging, Department of Psychiatry, University of Utah School of Medicine , Salt Lake City, Utah
| | - Paul Olson
- 1 Diagnostic Neuroimaging, Department of Psychiatry, University of Utah School of Medicine , Salt Lake City, Utah
| | - Perry F Renshaw
- 1 Diagnostic Neuroimaging, Department of Psychiatry, University of Utah School of Medicine , Salt Lake City, Utah.,2 VISN 19 Mental Illness Research, Education and Clinical Center (MIRREC) , Salt Lake City Veterans Health Administration, Salt Lake City, Utah
| | - Shami Kanekar
- 1 Diagnostic Neuroimaging, Department of Psychiatry, University of Utah School of Medicine , Salt Lake City, Utah.,2 VISN 19 Mental Illness Research, Education and Clinical Center (MIRREC) , Salt Lake City Veterans Health Administration, Salt Lake City, Utah
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21
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An Open-Label Pilot Study of Combined Augmentation With Creatine Monohydrate and 5-Hydroxytryptophan for Selective Serotonin Reuptake Inhibitor- or Serotonin-Norepinephrine Reuptake Inhibitor-Resistant Depression in Adult Women. J Clin Psychopharmacol 2017; 37:578-583. [PMID: 28787372 PMCID: PMC5578880 DOI: 10.1097/jcp.0000000000000754] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE Many women with major depressive disorder (MDD) respond inadequately to standard treatments. Augmentation of conventional antidepressants with creatine monohydrate and 5-hydroxytryptophan (5-HTP) could correct deficits in serotonin production and brain bioenergetics associated with depression in women, yielding synergistic benefit. We describe an open-label study of 5-HTP and creatine augmentation in women with MDD who had failed selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) monotherapy. METHODS Fifteen women who were adequately adherent to an SSRI or SNRI and currently experiencing MDD, with a 17-item Hamilton Depression Rating Scale (HAM-D) score of 16 or higher, were treated with 5 g of creatine monohydrate daily and 100 mg of 5-HTP twice daily for 8 weeks, with 4 weeks of posttreatment follow-up. The primary outcome was change in mean HAM-D scores. RESULTS Mean HAM-D scores declined from 18.9 (SD, 2.5) at pretreatment visits to 7.5 (SD, 4.4) (P < 0.00001), a decrease of 60%. Participants did not experience any serious treatment-related adverse events. CONCLUSIONS Combination treatment with creatine and 5-HTP may represent an effective augmentation strategy for women with SSRI- or SNRI-resistant depression. Given the limitations of this small, open-label trial, future study in randomized, placebo-controlled trials is warranted.
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22
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Gould TD, Georgiou P, Brenner LA, Brundin L, Can A, Courtet P, Donaldson ZR, Dwivedi Y, Guillaume S, Gottesman II, Kanekar S, Lowry CA, Renshaw PF, Rujescu D, Smith EG, Turecki G, Zanos P, Zarate CA, Zunszain PA, Postolache TT. Animal models to improve our understanding and treatment of suicidal behavior. Transl Psychiatry 2017; 7:e1092. [PMID: 28398339 PMCID: PMC5416692 DOI: 10.1038/tp.2017.50] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 01/16/2017] [Accepted: 02/01/2017] [Indexed: 02/08/2023] Open
Abstract
Worldwide, suicide is a leading cause of death. Although a sizable proportion of deaths by suicide may be preventable, it is well documented that despite major governmental and international investments in research, education and clinical practice suicide rates have not diminished and are even increasing among several at-risk populations. Although nonhuman animals do not engage in suicidal behavior amenable to translational studies, we argue that animal model systems are necessary to investigate candidate endophenotypes of suicidal behavior and the neurobiology underlying these endophenotypes. Animal models are similarly a critical resource to help delineate treatment targets and pharmacological means to improve our ability to manage the risk of suicide. In particular, certain pathophysiological pathways to suicidal behavior, including stress and hypothalamic-pituitary-adrenal axis dysfunction, neurotransmitter system abnormalities, endocrine and neuroimmune changes, aggression, impulsivity and decision-making deficits, as well as the role of critical interactions between genetic and epigenetic factors, development and environmental risk factors can be modeled in laboratory animals. We broadly describe human biological findings, as well as protective effects of medications such as lithium, clozapine, and ketamine associated with modifying risk of engaging in suicidal behavior that are readily translatable to animal models. Endophenotypes of suicidal behavior, studied in animal models, are further useful for moving observed associations with harmful environmental factors (for example, childhood adversity, mechanical trauma aeroallergens, pathogens, inflammation triggers) from association to causation, and developing preventative strategies. Further study in animals will contribute to a more informed, comprehensive, accelerated and ultimately impactful suicide research portfolio.
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Affiliation(s)
- T D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - P Georgiou
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - L A Brenner
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Military and Veteran Microbiome Consortium for Research and Education, U.S. Department of Veterans Affairs, Washington, DC, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - L Brundin
- Center for Neurodegenerative Science, Van Andel Research Institute, Grand Rapids, MI, USA
| | - A Can
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Psychology, Notre Dame of Maryland University, Baltimore, MD, USA
| | - P Courtet
- Department of Emergency Psychiatry and Post Acute Care, CHU Montpellier, Montpellier, France
- Université Montpellier, Inserm U1061, Montpellier, France
| | - Z R Donaldson
- Department of Molecular, Cellular, and Developmental Biology, University of Colorado Boulder, Boulder, CO, USA
- Department of Psychology, University of Colorado, Boulder, Boulder, CO, USA
- Department of Neuroscience, University of Colorado Boulder, Boulder, CO, USA
| | - Y Dwivedi
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - S Guillaume
- Department of Emergency Psychiatry and Post Acute Care, CHU Montpellier, Montpellier, France
- Université Montpellier, Inserm U1061, Montpellier, France
| | - I I Gottesman
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
| | - S Kanekar
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - C A Lowry
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Military and Veteran Microbiome Consortium for Research and Education, U.S. Department of Veterans Affairs, Washington, DC, USA
- Department of Integrative Physiology and Center for Neuroscience, University of Colorado Boulder, Boulder, CO, USA
- Department of Physical Medicine and Rehabilitation and Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - P F Renshaw
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - D Rujescu
- Department of Psychiatry, University of Halle-Wittenberg, Halle, Germany
| | - E G Smith
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - G Turecki
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - P Zanos
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - P A Zunszain
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - T T Postolache
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
- Rocky Mountain Mental Illness Research Education and Clinical Center, Denver, CO, USA
- Military and Veteran Microbiome Consortium for Research and Education, U.S. Department of Veterans Affairs, Washington, DC, USA
- VISN 5 Mental Illness Research Education and Clinical Center, Baltimore MD, USA
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Amelioration of apelin-13 in chronic normobaric hypoxia-induced anxiety-like behavior is associated with an inhibition of NF-κB in the hippocampus. Brain Res Bull 2017; 130:67-74. [DOI: 10.1016/j.brainresbull.2017.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 12/20/2016] [Accepted: 01/03/2017] [Indexed: 12/25/2022]
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Kanekar S, Bogdanova OV, Olson PR, Sung YH, D'Anci KE, Renshaw PF. Hypobaric hypoxia induces depression-like behavior in female Sprague-Dawley rats, but not in males. High Alt Med Biol 2016; 16:52-60. [PMID: 25803141 DOI: 10.1089/ham.2014.1070] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rates of depression and suicide are higher in people living at altitude, and in those with chronic hypoxic disorders like asthma, chronic obstructive pulmonary disorder (COPD), and smoking. Living at altitude exposes people to hypobaric hypoxia, which can lower rat brain serotonin levels, and impair brain bioenergetics in both humans and rats. We therefore examined the effect of hypobaric hypoxia on depression-like behavior in rats. After a week of housing at simulated altitudes of 20,000 ft, 10,000 ft, or sea level, or at local conditions of 4500 ft (Salt Lake City, UT), Sprague Dawley rats were tested for depression-like behavior in the forced swim test (FST). Time spent swimming, climbing, or immobile, and latency to immobility were measured. Female rats housed at altitude display more depression-like behavior in the FST, with significantly more immobility, less swimming, and lower latency to immobility than those at sea level. In contrast, males in all four altitude groups were similar in their FST behavior. Locomotor behavior in the open field test did not change with altitude, thus validating immobility in the FST as depression-like behavior. Hypobaric hypoxia exposure therefore induces depression-like behavior in female rats, but not in males.
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Affiliation(s)
- Shami Kanekar
- 1 The Brain Institute, University of Utah , Salt Lake City, Utah
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25
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Guo WY, Bian SZ, Zhang JH, Li QN, Yu J, Chen JF, Tang CF, Rao RS, Yu SY, Jin J, Huang L. Physiological and psychological factors associated with onset of high-altitude headache in Chinese men upon acute high-altitude exposure at 3700 m. Cephalalgia 2016; 37:336-347. [PMID: 27152016 DOI: 10.1177/0333102416646761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim We aimed to identify clinical characteristics and risk factors associated with onset of high-altitude headache (HAH) after acute exposure at 3700 m. Method In two hours, 163 individuals ascended by plane to 3700 m. Demographic information, physiological and psychological measurements, cognitive function, physical work capacity tests and profile of mood states within one week prior to the departure and within 24 hours after arrival were examined. Results HAH patients featured significantly higher vertebral artery diastolic velocity (Vd), heart rate (HR) and pulmonary artery diameter. HAH was also associated with a more negative mood state, including scores for tension anxiety, depression, hostility, fatigue and confusion, as well as lower vigor (all p values <0.05). Furthermore, negative emotions were positively related to HAH severity. HAH slightly decreased cognitive functioning. HR, Vd, lack of vigor, confusion and self-reported anxiety (all p values <0.05) were independent risk factors for HAH. We have identified three independent baseline predictors for HAH including internal diameter of the left ventricle (LVD), Athens Insomnia Scale (AIS) and confusion score. Conclusions Higher HR, Vd, confusion and self-reported anxiety and insufficient vigor were independent risk factors for HAH. Furthermore, higher baseline LVD, AIS and confusion score are independent predictors of HAH.
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Affiliation(s)
- Wen-Yun Guo
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
| | - Shi-Zhu Bian
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
| | - Ji-Hang Zhang
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
| | - Qian-ning Li
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, China
| | - Jie Yu
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
| | - Jian-Fei Chen
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
| | - Cai-Fa Tang
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, China
| | - Rong-Sheng Rao
- Department of Ultrasonography, Xinqiao Hospital, Third Military Medical University
| | - Shi-Yong Yu
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
| | - Jun Jin
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
| | - Lan Huang
- Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Third Military Medical University, China
- Department of Cardiology, Xinqiao Hospital, Third Military Medical University, China
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26
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Guanfacine promotes neuronal survival in medial prefrontal cortex under hypobaric hypoxia. Brain Res 2016; 1636:152-160. [DOI: 10.1016/j.brainres.2016.01.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 11/19/2022]
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