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Beaulieu D, Treit S, Pagano JJ, Beaulieu C, Thompson R. Cardiac Magnetic Resonance Imaging in Individuals With Prenatal Alcohol Exposure. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:150-161. [PMID: 37969351 PMCID: PMC10642128 DOI: 10.1016/j.cjcpc.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/16/2023] [Indexed: 11/17/2023]
Abstract
Background Prenatal alcohol exposure (PAE) has teratogenic effects on numerous body systems including the heart. However, research magnetic resonance imaging (MRI) studies in humans with PAE have thus far been limited to the brain. This study aims to use MRI to examine heart structure and function, brain volumes, and body composition in children and adolescents with PAE. Methods Heart, brain, and abdominal 3T MRI of 17 children, adolescents, and young adults with PAE and 53 unexposed controls was acquired to measure: (1) left ventricular ejection fraction, end-diastolic volume, end-systolic volume, stroke volume, cardiac output, longitudinal strain, circumferential strain, and heart mass; (2) total brain, cerebellum, white matter, grey matter, caudate, thalamus, putamen, and globus pallidus volumes; and (3) subcutaneous fat, visceral fat, muscle fat, and muscle (body composition). Results Cardiac MRI revealed no abnormalities in the PAE group on evaluation by a paediatric cardiologist and by statistical comparison with a control group. Cardiac parameters in both groups were in line with previous reports, including expected sex- and age-related differences. Cerebellum, caudate, and globus pallidus volumes were all smaller. Body mass index and subcutaneous fat percent were higher in females with PAE relative to control females, but lower in males with PAE relative to control males. Conclusions Children with PAE did not have abnormalities in MRI-derived measures of cardiac structure or function despite smaller brain volumes and sex-specific differences in body composition relative to healthy controls.
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Affiliation(s)
- Danielle Beaulieu
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Sarah Treit
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph J. Pagano
- Division of Pediatric Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christian Beaulieu
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
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2
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Boots A, Wiegersma AM, Vali Y, van den Hof M, Langendam MW, Limpens J, Backhouse EV, Shenkin SD, Wardlaw JM, Roseboom TJ, de Rooij SR. Shaping the risk for late-life neurodegenerative disease: A systematic review on prenatal risk factors for Alzheimer's disease-related volumetric brain biomarkers. Neurosci Biobehav Rev 2023; 146:105019. [PMID: 36608918 DOI: 10.1016/j.neubiorev.2022.105019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/08/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
Environmental exposures including toxins and nutrition may hamper the developing brain in utero, limiting the brain's reserve capacity and increasing the risk for Alzheimer's disease (AD). The purpose of this systematic review is to summarize all currently available evidence for the association between prenatal exposures and AD-related volumetric brain biomarkers. We systematically searched MEDLINE and Embase for studies in humans reporting on associations between prenatal exposure(s) and AD-related volumetric brain biomarkers, including whole brain volume (WBV), hippocampal volume (HV) and/or temporal lobe volume (TLV) measured with structural magnetic resonance imaging (PROSPERO; CRD42020169317). Risk of bias was assessed using the Newcastle Ottawa Scale. We identified 79 eligible studies (search date: August 30th, 2020; Ntotal=24,784; median age 10.7 years) reporting on WBV (N = 38), HV (N = 63) and/or TLV (N = 5) in exposure categories alcohol (N = 30), smoking (N = 7), illicit drugs (N = 14), mental health problems (N = 7), diet (N = 8), disease, treatment and physiology (N = 10), infections (N = 6) and environmental exposures (N = 3). Overall risk of bias was low. Prenatal exposure to alcohol, opioids, cocaine, nutrient shortage, placental dysfunction and maternal anemia was associated with smaller brain volumes. We conclude that the prenatal environment is important in shaping the risk for late-life neurodegenerative disease.
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Affiliation(s)
- A Boots
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Aging and later life, Amsterdam Public Health, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - A M Wiegersma
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Aging and later life, Amsterdam Public Health, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands
| | - Y Vali
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Methodology, Amsterdam Public Health, Amsterdam, the Netherlands
| | - M van den Hof
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands
| | - M W Langendam
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Methodology, Amsterdam Public Health, Amsterdam, the Netherlands
| | - J Limpens
- Amsterdam UMC location University of Amsterdam, Medical Library, Meibergdreef 9, the Netherlands
| | - E V Backhouse
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - S D Shenkin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Ageing and Health Research Group and Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - J M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute Centre at the University of Edinburgh, UK
| | - T J Roseboom
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Aging and later life, Amsterdam Public Health, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands; Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands
| | - S R de Rooij
- Amsterdam UMC location University of Amsterdam, Department of Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Aging and later life, Amsterdam Public Health, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands
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3
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Solar KG, Treit S, Beaulieu C. High-resolution diffusion tensor imaging identifies hippocampal volume loss without diffusion changes in individuals with prenatal alcohol exposure. Alcohol Clin Exp Res 2022; 46:1204-1219. [PMID: 35567310 DOI: 10.1111/acer.14857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) studies of prenatal alcohol exposure (PAE) commonly report reduced hippocampal volumes, which animal models suggest may result from microstructural changes that include cell loss and altered myelination. Diffusion tensor imaging (DTI) is sensitive to microstructural changes but has not yet been used to study the hippocampus in PAE. METHODS Thirty-six healthy controls (19 females; 8 to 24 years) and 19 participants with PAE (8 females; 8 to 23 years) underwent high-resolution (1 mm isotropic) DTI, anatomical T1-weighted imaging, and cognitive testing. Whole-hippocampus, head, body, and tail subregions were manually segmented to yield DTI metrics (mean, axial, and radial diffusivities-MD, AD, and RD; fractional anisotropy-FA), volumes, and qualitative assessments of hippocampal morphology and digitations. Automated segmentation of T1-weighted images was used to corroborate manual whole-hippocampus volumes. RESULTS Gross morphology and digitation counts were similar in both groups. Whole-hippocampus volumes were 18% smaller in the PAE than the control group on manually traced diffusion images, but automated T1-weighted image segmentations were not significantly different. Subregion segmentation on DTI revealed reduced volumes of the body and tail, but not the head. There were no significant differences in diffusion metrics between groups for any hippocampal region. Correlations between age and volume were not significant in either group, whereas negative correlations between age and whole-hippocampus MD/AD/RD, and head/body (but not tail) MD/AD/RD were significant in both groups. There were no significant effects of sex, group by age, or group by sex for any hippocampal metric. In controls, seven positive linear correlations were found between hippocampal volume and cognition; five of these were left lateralized and included episodic and working memory, and two were right lateralized and included working memory and processing speed. In PAE, left tail MD positively correlated with executive functioning, and right head MD negatively correlated with episodic memory. CONCLUSIONS Reductions of hippocampal volumes and altered relationships with memory suggest disrupted hippocampal development in PAE.
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Affiliation(s)
- Kevin Grant Solar
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sarah Treit
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christian Beaulieu
- Department of Biomedical Engineering, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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4
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Botdorf M, Canada KL, Riggins T. A meta-analysis of the relation between hippocampal volume and memory ability in typically developing children and adolescents. Hippocampus 2022; 32:386-400. [PMID: 35301771 PMCID: PMC9313816 DOI: 10.1002/hipo.23414] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/07/2022] [Indexed: 12/24/2022]
Abstract
Memory is supported by a network of brain regions, with the hippocampus serving a critical role in this cognitive process. Previous meta-analyses on the association between hippocampal structure and memory have largely focused on adults. Multiple studies have since suggested that hippocampal volume is related to memory performance in children and adolescents; however, the strength and direction of this relation varies across reports, and thus, remains unclear. To further understand this brain-behavior relation, we conducted a meta-analysis to investigate the association between hippocampal volume (assessed as total volume) and memory during typical development. Across 25 studies and 61 memory outcomes with 1357 participants, results showed a small, but significant, positive association between total hippocampal volume and memory performance. Estimates of the variability across studies in the relation between total volume and memory were not explained by differences in memory task type (delayed vs. immediate; relational vs. nonrelational), participant age range, or the method of normalization of hippocampal volumes. Overall, findings suggest that larger total hippocampal volume relates to better memory performance in children and adolescents and that this relation is similar across the memory types and age ranges assessed. To facilitate enhanced generalization across studies in the future, we discuss considerations for the field moving forward.
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Affiliation(s)
- Morgan Botdorf
- Department of PsychologyUniversity of MarylandCollege ParkMarylandUSA
- Present address:
Department of PsychologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Kelsey L. Canada
- Institute of GerontologyWayne State UniversityDetroitMichiganUSA
| | - Tracy Riggins
- Department of PsychologyUniversity of MarylandCollege ParkMarylandUSA
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5
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Gutherz OR, Deyssenroth M, Li Q, Hao K, Jacobson JL, Chen J, Jacobson SW, Carter RC. Potential roles of imprinted genes in the teratogenic effects of alcohol on the placenta, somatic growth, and the developing brain. Exp Neurol 2021; 347:113919. [PMID: 34752786 DOI: 10.1016/j.expneurol.2021.113919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 12/22/2022]
Abstract
Despite several decades of research and prevention efforts, fetal alcohol spectrum disorders (FASD) remain the most common preventable cause of neurodevelopmental disabilities worldwide. Animal and human studies have implicated fetal alcohol-induced alterations in epigenetic programming as a chief mechanism in FASD. Several studies have demonstrated fetal alcohol-related alterations in methylation and expression of imprinted genes in placental, brain, and embryonic tissue. Imprinted genes are epigenetically regulated in a parent-of-origin-specific manner, in which only the maternal or paternal allele is expressed, and the other allele is silenced. The chief functions of imprinted genes are in placental development, somatic growth, and neurobehavior-three domains characteristically affected in FASD. In this review, we summarize the growing body of literature characterizing prenatal alcohol-related alterations in imprinted gene methylation and/or expression and discuss potential mechanistic roles for these alterations in the teratogenic effects of prenatal alcohol exposure. Future research is needed to examine potential physiologic mechanisms by which alterations in imprinted genes disrupt development in FASD, which may, in turn, elucidate novel targets for intervention. Furthermore, mechanistic alterations in imprinted gene expression and/or methylation in FASD may inform screening assays that identify individuals with FASD neurobehavioral deficits who may benefit from early interventions.
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Affiliation(s)
- Olivia R Gutherz
- Institute of Human Nutrition, Columbia University Medical Center, United States of America
| | - Maya Deyssenroth
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, United States of America
| | - Qian Li
- Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, United States of America
| | - Ke Hao
- Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, United States of America
| | - Joseph L Jacobson
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, United States of America; Department of Human Biology, University of Cape Town Faculty of Health Sciences, South Africa
| | - Jia Chen
- Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, United States of America
| | - Sandra W Jacobson
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, United States of America; Department of Human Biology, University of Cape Town Faculty of Health Sciences, South Africa
| | - R Colin Carter
- Institute of Human Nutrition, Columbia University Medical Center, United States of America; Departments of Emergency Medicine and Pediatrics, Columbia University Medical Center, United States of America.
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Lee J, Naik V, Orzabal M, Lunde-Young R, Ramadoss J. Morphological alteration in rat hippocampal neuronal dendrites following chronic binge prenatal alcohol exposure. Brain Res 2021; 1768:147587. [PMID: 34297994 DOI: 10.1016/j.brainres.2021.147587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/15/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Prenatal alcohol exposure (PAE) may result in Fetal Alcohol Spectrum Disorders (FASD). The hippocampus has been recognized as a vulnerable target to alcohol-induced developmental damage. However, the effect of prenatal exposure to alcohol on dendritic morphological adaptations throughout the hippocampal fields in the developing brain still remains largely unknown in the context of FASD. We hypothesized that chronic binge alcohol exposure during pregnancy alters dendrite arborization throughout the developing rat hippocampus. Pregnant Sprague-Dawley rats were assigned to either a pair-fed control (PF-Cont) or a binge alcohol (Alcohol) treatment group. Alcohol dams were acclimatized via a once-daily orogastric gavage of 4.5 g/kg alcohol from gestational day (GD) 5-10 and progressed to 6 g/kg alcohol from GD 11-21. Pair-fed dams similarly received isocaloric maltose dextrin. After parturition, all dams received an ad libitum diet and nursed their offspring until postnatal day (PND) 10 when the pup brains were collected for morphological analysis. PAE increased dendritic arborization and complexities of CA1, CA2/3, and DG neurons in the PND 10 rat hippocampus. The number of primary dendrites, total dendritic length, and number of dendritic branches were significantly increased following PAE, and Sholl analysis revealed significantly more intersections of the dendritic processes in PND 10 offspring following PAE compared with those in the PF-Cont group. We conclude that chronic binge PAE significantly alters hippocampal dendritic morphology in the developing hippocampus. We conjecture that this morphological alteration in postnatal rat hippocampal dendrites following chronic binge prenatal alcohol exposure may play a critical role in FASD neurobiological phenotypes.
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Affiliation(s)
- Jehoon Lee
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - Vishal Naik
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - Marcus Orzabal
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - Raine Lunde-Young
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA
| | - Jayanth Ramadoss
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843, USA.
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7
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Lee J, Lunde-Young R, Naik V, Ramirez J, Orzabal M, Ramadoss J. Chronic Binge Alcohol Exposure During Pregnancy Alters mTOR System in Rat Fetal Hippocampus. Alcohol Clin Exp Res 2020; 44:1329-1336. [PMID: 32333810 DOI: 10.1111/acer.14348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 04/10/2020] [Accepted: 04/19/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Gestational alcohol exposure can contribute to fetal alcohol spectrum disorders (FASD), an array of cognitive, behavioral, and physical developmental impairments. Mammalian target of rapamycin (mTOR) plays a key role in regulating protein synthesis in response to neuronal activity, thereby modulating synaptic plasticity and long-term memory formation in the brain. Based on our previous quantitative mass spectrometry proteomic studies, we hypothesized that gestational chronic binge alcohol exposure alters mTOR signaling and downstream pathways in the fetal hippocampus. METHODS Pregnant Sprague-Dawley rats were assigned to either a pair-fed control (PF-Cont) or a binge alcohol (Alcohol) treatment group. Alcohol dams were acclimatized via a once-daily orogastric gavage of 4.5 g/kg alcohol (peak BAC, 216 mg/dl) from GD 5-10 and progressed to 6 g/kg alcohol (peak BAC, 289 mg/dl) from GD 11-21. Pair-fed dams similarly received isocaloric maltose dextrin. RESULTS In the Alcohol group, following this exposure paradigm, fetal body weight and crown-rump length were decreased. The phosphorylation level of mTOR (P-mTOR) in the fetal hippocampus was decreased in the Alcohol group compared with controls. Alcohol exposure resulted in dysregulation of fetal hippocampal mTORC1 signaling, as evidenced by an increase in total 4E-BP1 expression. Phosphorylation levels of 4E-BP1 and p70 S6K were also increased following alcohol exposure. P-mTOR and P-4E-BP1 were exclusively detected in the dentate gyrus and oriens layer of the fetal hippocampus, respectively. DEPTOR and RICTOR expression levels in the fetal hippocampus were increased; however, RAPTOR was not altered by chronic binge alcohol exposure. CONCLUSION We conclude that chronic binge alcohol exposure during pregnancy alters mTORC1 signaling pathway in the fetal hippocampus. We conjecture that this dysregulation of mTOR protein expression, its activity, and downstream proteins may play a critical role in FASD neurobiological phenotypes.
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Affiliation(s)
- Jehoon Lee
- From the, Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Raine Lunde-Young
- From the, Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Vishal Naik
- From the, Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Josue Ramirez
- From the, Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Marcus Orzabal
- From the, Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Jayanth Ramadoss
- From the, Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
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8
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Uban KA, Kan E, Wozniak JR, Mattson SN, Coles CD, Sowell ER. The Relationship Between Socioeconomic Status and Brain Volume in Children and Adolescents With Prenatal Alcohol Exposure. Front Hum Neurosci 2020; 14:85. [PMID: 32322193 PMCID: PMC7156853 DOI: 10.3389/fnhum.2020.00085] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 02/27/2020] [Indexed: 01/07/2023] Open
Abstract
The positive relationship between socioeconomic status (SES) and cognitive performance is mediated, in part, by differences in brain structure in typically developing youth. Associations between brain regions that relate to SES overlap with brain regions known to be sensitive to prenatal alcohol exposure (PAE). Animal models demonstrate that PAE attenuates neural and cognitive benefits of early life enrichment. However, whether or not environmental factors related to SES are associated with brain development in youth affected by PAE remains unknown in humans.
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Affiliation(s)
- Kristina A Uban
- Public Health, University of California, Irvine, Irvine, CA, United States.,Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, United States
| | - Eric Kan
- Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, United States
| | - Jeffrey R Wozniak
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, United States
| | - Sarah N Mattson
- Department of Psychology, San Diego State University, San Diego, CA, United States
| | - Claire D Coles
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, United States
| | - Elizabeth R Sowell
- Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, United States
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9
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Little G, Beaulieu C. Multivariate models of brain volume for identification of children and adolescents with fetal alcohol spectrum disorder. Hum Brain Mapp 2019; 41:1181-1194. [PMID: 31737980 PMCID: PMC7267984 DOI: 10.1002/hbm.24867] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/29/2019] [Accepted: 11/04/2019] [Indexed: 01/17/2023] Open
Abstract
Magnetic resonance imaging (MRI) studies of fetal alcohol spectrum disorder (FASD) have shown reductions of brain volume associated with prenatal exposure to alcohol. Previous studies consider regional brain volumes independently but ignore potential relationships across numerous structures. This study aims to (a) identify a multivariate model based on regional brain volume that discriminates children/adolescents with FASD versus healthy controls, and (b) determine if FASD classification performance can be increased by building classification models separately for each sex. Three‐dimensional T1‐weighted MRI from two independent childhood/adolescent datasets were used for training (79 FASD, aged 5.7–18.9 years, 35 males; 81 controls, aged 5.8–18.5 years, 32 males) and testing (67 FASD, aged 6.0–19.6 years, 38 males; 74 controls, aged 5.2–19.5 years, 42 males) a classification model. Using FreeSurfer, 87 regional brain volumes were extracted for each subject and were used as input into a support vector machine generating a classification model from the training data. The model performed moderately well on the test data with accuracy 77%, sensitivity 64%, and specificity 88%. Regions that contributed heavily to prediction in this model included temporal lobe and subcortical gray matter. Further investigation of two separate models for males and females showed slightly decreased accuracy compared to the model including all subjects (male accuracy 70%; female accuracy 67%), but had different regional contributions suggesting sex differences. This work demonstrates the potential of multivariate analysis of brain volumes for discriminating children/adolescents with FASD and provides indication of the most affected regions.
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Affiliation(s)
- Graham Little
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Christian Beaulieu
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
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10
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Agnihotri S, Subramaniapillai S, Keightley M, Rasmussen C, Cameron D, Ryan J, Rovet J. Everyday memory difficulties in children and adolescents with Fetal Alcohol Spectrum Disorder. Dev Neurorehabil 2019; 22:462-469. [PMID: 30289318 DOI: 10.1080/17518423.2018.1519608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Purpose: To investigate whether significant differences exist in everyday memory between youth with Fetal Alcohol Spectrum (FASD) compared with a nonexposed (NE) control group, while controlling for socioeconomic status and other comorbidities. Methods: Caregiver ratings using the Everyday Memory Questionnaire were obtained for 105 youth (9-17 years of age). Scores were compared between youth with a FASD diagnosis (N = 41; 56% male) and the NE group (N = 64; 53% male) using multivariate analysis of variance. Results: Significantly poorer scores were found across all domains of everyday memory in youth with FASD (p<0.01 for all comparisons). Findings maintained significance after controlling for group differences in socioeconomic status, presence of learning, and attention disorders, as well as exposure to other teratogens. Conclusions: This study provides important insights regarding the memory issues that underlie daily functional challenges faced by youth with FASD and the need for future intervention research.
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Affiliation(s)
- Sabrina Agnihotri
- Bloorview Research Institute, Holland-Bloorview Kids Rehabilitation Hospital , Toronto , Ontario , Canada.,Rehabilitation Sciences Institute, University of Toronto , Toronto , Ontario , Canada
| | | | - Michelle Keightley
- Bloorview Research Institute, Holland-Bloorview Kids Rehabilitation Hospital , Toronto , Ontario , Canada.,Rehabilitation Sciences Institute, University of Toronto , Toronto , Ontario , Canada
| | - Carmen Rasmussen
- Department of Pediatrics, University of Alberta , Edmonton , Alberta , Canada
| | - Debra Cameron
- Rehabilitation Sciences Institute, University of Toronto , Toronto , Ontario , Canada.,Department of Occupational Science and Occupational Therapy, University of Toronto , Toronto , Ontario , Canada
| | - Jennifer Ryan
- Rotman Research Institute, Baycrest Hospital , Toronto , Ontario , Canada
| | - Joanne Rovet
- The Hospital for Sick Children , Toronto , Ontario , Canada
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11
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Hughes E, Baca E, Mahmoud KF, Edwards A, Griffith KJ, Matthews E, Puskar KR, Mitchell AM. Nurses and Fetal Alcohol Spectrum Disorders Prevention. Issues Ment Health Nurs 2019; 40:621-625. [PMID: 31045467 DOI: 10.1080/01612840.2019.1565871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Women of reproductive age who are drinking alcohol and not using effective contraception are at-risk for an alcohol-exposed pregnancy, which could result in a child with a fetal alcohol spectrum disorder (FASD). Nurses are an important partner in addressing at-risk alcohol use. It is imperative for alcohol education to be incorporated into nursing curricula so that future nurses have the tools to identify at-risk alcohol use. Three universities have worked together to create Fetal Alcohol Spectrum Disorders: A Toolkit. This toolkit was designed for nurses to facilitate the recognition and prevention of FASD and address gaps that exists around alcohol use.
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Affiliation(s)
- Erica Hughes
- a UPMC Children's Hospital , Pittsburgh , Pennsylvania , USA
| | - Elizabeth Baca
- b UPMC Shadyside Hospital , Pittsburgh , Pennsylvania , USA
| | - Khadejah F Mahmoud
- c Health & Community Systems, University of Pittsburgh School of Nursing , Pittsburgh , Pennsylvania , USA
| | - Alexandra Edwards
- d Center for Behavioral Health Research and Services, University of Alaska, Anchorage , Anchorage , Alaska , USA
| | - Kira J Griffith
- c Health & Community Systems, University of Pittsburgh School of Nursing , Pittsburgh , Pennsylvania , USA
| | - Emily Matthews
- c Health & Community Systems, University of Pittsburgh School of Nursing , Pittsburgh , Pennsylvania , USA
| | - Kathryn R Puskar
- e Department of Undergraduate Education , University of Pittsburgh School of Nursing , Pittsburgh , Pennsylvania , USA
| | - Ann M Mitchell
- f Department of Nursing and Psychiatry , University of Pittsburgh School of Nursing , Pittsburgh , Pennsylvania , USA
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12
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Lunde‐Young R, Ramirez J, Naik V, Orzabal M, Lee J, Konganti K, Hillhouse A, Threadgill D, Ramadoss J. Hippocampal transcriptome reveals novel targets of FASD pathogenesis. Brain Behav 2019; 9:e01334. [PMID: 31140755 PMCID: PMC6625466 DOI: 10.1002/brb3.1334] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Prenatal alcohol exposure can contribute to fetal alcohol spectrum disorders (FASD), characterized by a myriad of developmental impairments affecting behavior and cognition. Studies show that many of these functional impairments are associated with the hippocampus, a structure exhibiting exquisite vulnerability to developmental alcohol exposure and critically implicated in learning and memory; however, mechanisms underlying alcohol-induced hippocampal deficits remain poorly understood. By utilizing a high-throughput RNA-sequencing (RNA-seq) approach to address the neurobiological and molecular basis of prenatal alcohol-induced hippocampal functional deficits, we hypothesized that chronic binge prenatal alcohol exposure alters gene expression and global molecular pathways in the fetal hippocampus. METHODS Timed-pregnant Sprague-Dawley rats were randomly assigned to a pair-fed control (PF) or binge alcohol (ALC) treatment group on gestational day (GD) 4. ALC dams acclimatized from GDs 5-10 with a daily treatment of 4.5 g/kg alcohol and subsequently received 6 g/kg on GDs 11-20. PF dams received a once daily maltose dextrin gavage on GDs 5-20, isocalorically matching ALC counterparts. On GD 21, bilateral hippocampi were dissected, flash frozen, and stored at -80° C. Total RNA was then isolated from homogenized tissues. Samples were normalized to ~4nM and pooled equally. Sequencing was performed by Illumina NextSeq 500 on a 75 cycle, single-end sequencing run. RESULTS RNA-seq identified 13,388 genes, of these, 76 genes showed a significant difference (p < 0.05, log2 fold change ≥2) in expression between the PF and ALC groups. Forty-nine genes showed sex-dependent dysregulation; IPA analysis showed among female offspring, dysregulated pathways included proline and citrulline biosynthesis, whereas in males, xenobiotic metabolism signaling and alaninine biosynthesis etc. were altered. CONCLUSION We conclude that chronic binge alcohol exposure during pregnancy dysregulates fetal hippocampal gene expression in a sex-specific manner. Identification of subtle, transcriptome-level dysregulation in hippocampal molecular pathways offers potential mechanistic insights underlying FASD pathogenesis.
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Affiliation(s)
- Raine Lunde‐Young
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - Josue Ramirez
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - Vishal Naik
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - Marcus Orzabal
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - Jehoon Lee
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - Kranti Konganti
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - Andrew Hillhouse
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - David Threadgill
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
| | - Jayanth Ramadoss
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical SciencesTexas A&M UniversityCollege StationTexas
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Hippocampus-dependent memory and allele-specific gene expression in adult offspring of alcohol-consuming dams after neonatal treatment with thyroxin or metformin. Mol Psychiatry 2018; 23:1643-1651. [PMID: 28727687 PMCID: PMC5775940 DOI: 10.1038/mp.2017.129] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 02/06/2023]
Abstract
Fetal alcohol spectrum disorder (FASD), the result of fetal alcohol exposure (FAE), affects 2-11% of children worldwide, with no effective treatments. Hippocampus-based learning and memory deficits are key symptoms of FASD. Our previous studies show hypothyroxinemia and hyperglycemia of the alcohol-consuming pregnant rat, which likely affects fetal neurodevelopment. We administered vehicle, thyroxine (T4) or metformin to neonatal rats post FAE and rats were tested in the hippocampus-dependent contextual fear-conditioning paradigm in adulthood. Both T4 and metformin alleviated contextual fear memory deficit induced by FAE, and reversed the hippocampal expression changes in the thyroid hormone-inactivating enzyme, deiodinase-III (Dio3) and insulin-like growth factor 2 (Igf2), genes that are known to modulate memory processes. Neonatal T4 restored maternal allelic expressions of the imprinted Dio3 and Igf2 in the adult male hippocampus, while metformin restored FAE-caused changes in Igf2 expression only. The decreased hippocampal expression of DNA methyltransferase 1 (Dnmt1) that maintains the imprinting of Dio3 and Igf2 during development was normalized by both treatments. Administering Dnmt1 inhibitor to control neonates resulted in FAE-like deficits in fear memory and hippocampal allele-specific expression of Igf2, which were reversed by metformin. We propose that neonatal administration of T4 and metformin post FAE affect memory via elevating Dnmt1 and consequently normalizing hippocampal Dio3 and Igf2 expressions in the adult offspring. The present results indicate that T4 and metformin, administered during the neonatal period that is equivalent to the third trimester of human pregnancy, are potential treatments for FASD and conceivably for other neurodevelopmental disorders with cognitive deficits.
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Nash K, Stevens S, Clairman H, Rovet J. Preliminary Findings that a Targeted Intervention Leads to Altered Brain Function in Children with Fetal Alcohol Spectrum Disorder. Brain Sci 2017; 8:brainsci8010007. [PMID: 29283403 PMCID: PMC5789338 DOI: 10.3390/brainsci8010007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 12/14/2017] [Accepted: 12/22/2017] [Indexed: 11/16/2022] Open
Abstract
Children with fetal alcohol spectrum disorder (FASD) exhibit behavioral dysregulation, executive dysfunction, and atypical function in associated brain regions. Previous research shows early intervention mitigates these outcomes but corresponding brain changes were not studied. Given the Alert® Program for Self-Regulation improves behavioral regulation and executive function in children with FASD, we asked if this therapy also improves their neural functioning in associated regions. Twenty-one children with FASD aged 8–12 years were randomized to the Alert®-treatment (TXT; n = 10) or waitlist-control (WL; n = 11) conditions. They were assessed with a Go-NoGo functional magnetic resonance imaging (fMRI) paradigm before and after training or the wait-out period. Groups initially performed equivalently and showed no fMRI differences. At post-test, TXT outperformed WL on NoGo trials while fMRI in uncorrected results with a small-volume correction showed less activation in prefrontal, temporal, and cingulate regions. Groups also demonstrated different patterns of change over time reflecting reduced signal at post-test in selective prefrontal and parietal regions in TXT and increased in WL. In light of previous evidence indicating TXT at post-test perform similar to non-exposed children on the Go-NoGo fMRI paradigm, our findings suggest Alert® does improve functional integrity in the neural circuitry for behavioral regulation in children with FASD.
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Affiliation(s)
- Kelly Nash
- Psychiatry Department, The Hospital for Sick Children, Toronto, ON M5G1X8, Canada.
| | - Sara Stevens
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON M4G1R8, Canada.
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON M4G1R8, Canada.
| | - Hayyah Clairman
- Neurosciences and Mental Health Program, The Hospital for Sick Children, Toronto, ON M5G1A0, Canada.
| | - Joanne Rovet
- Neurosciences and Mental Health Program, The Hospital for Sick Children, Toronto, ON M5G1A0, Canada.
- Department of Pediatrics, University of Toronto, Toronto, ON M5G1X8, Canada.
- Psychology Department, University of Toronto, Toronto, ON M5S3G3, Canada.
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15
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Fetal alcohol spectrum disorders: Zebrafish in the analysis of the milder and more prevalent form of the disease. Behav Brain Res 2017; 352:125-132. [PMID: 28988969 DOI: 10.1016/j.bbr.2017.10.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 02/08/2023]
Abstract
Fetal Alcohol Spectrum Disorders (FASD) represent a large unmet medical need. Exposure of the developing human embryo to alcohol can lead to life-long suffering. Despite the well documented deleterious effects of alcohol on the developing fetus, pregnant women continue to drink alcohol, and FASD remains the leading cause of preventable mental retardation and other behavioral abnormalities. Particularly prevalent are the milder forms of the disease cluster, representing children who do not show obvious physical signs and who may be undiagnosed or misdiagnosed. To develop treatment and diagnostic tools, researchers have turned to animal models. The zebrafish is becoming one of the leading biomedical research organisms that may facilitate discovery of the biological mechanisms underlying this disease and the identification of biomarkers that may be used for diagnosis. Here we review the latest advances of this field, mostly focussing on the discoveries made in our own laboratory and others with zebrafish employed to analyze the effects of moderate to low level of exposure to alcohol. We argue that the zebrafish represents unique advantages, and adding information obtained with this species to the mix of other animal models will significantly increase translational relevance of animal biomedical research for the analysis of human FASD.
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Treit S, Chen Z, Zhou D, Baugh L, Rasmussen C, Andrew G, Pei J, Beaulieu C. Sexual dimorphism of volume reduction but not cognitive deficit in fetal alcohol spectrum disorders: A combined diffusion tensor imaging, cortical thickness and brain volume study. NEUROIMAGE-CLINICAL 2017; 15:284-297. [PMID: 28560153 PMCID: PMC5440763 DOI: 10.1016/j.nicl.2017.05.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 02/17/2017] [Accepted: 05/08/2017] [Indexed: 02/08/2023]
Abstract
Quantitative magnetic resonance imaging (MRI) has revealed abnormalities in brain volumes, cortical thickness and white matter microstructure in fetal alcohol spectrum disorders (FASD); however, no study has reported all three measures within the same cohort to assess the relative magnitude of deficits, and few studies have examined sex differences. Participants with FASD (n = 70; 30 females; 5-32 years) and healthy controls (n = 74; 35 females; 5-32 years) underwent cognitive testing and MRI to assess cortical thickness, regional brain volumes and fractional anisotropy (FA)/mean diffusivity (MD) of white matter tracts. A significant effect of group, age-by-group, or sex-by-group was found for 9/9 volumes, 7/39 cortical thickness regions, 3/9 white matter tracts, and 9/10 cognitive tests, indicating group differences that in some cases differ by age or sex. Volume reductions for several structures were larger in males than females, despite similar deficits of cognition in both sexes. Correlations between brain structure and cognitive scores were found in females of both groups, but were notably absent in males. Correlations within a given MRI modality (e.g. total brain volume and caudate volume) were prevalent in both the control and FASD groups, and were more numerous than correlations between measurement types (e.g. volumes and diffusion tensor imaging) in either cohort. This multi-modal MRI study finds widespread differences of brain structure in participants with prenatal alcohol exposure, and to a greater extent in males than females which may suggest attenuation of the expected process of sexual dimorphism of brain structure during typical development.
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Affiliation(s)
- Sarah Treit
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G-2R3, Canada; Department of Biomedical Engineering, University of Alberta, Edmonton, AB T6G-2R3, Canada
| | - Zhang Chen
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB T6G-2R3, Canada
| | - Dongming Zhou
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB T6G-2R3, Canada
| | - Lauren Baugh
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G-2R3, Canada
| | - Carmen Rasmussen
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G-2R3, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB T6G-2R3, Canada
| | - Gail Andrew
- Department of Pediatrics, University of Alberta, Edmonton, AB T6G-2R3, Canada; FASD Diagnostic Clinic, Glenrose Rehabilitation Hospital, Edmonton, AB T6G-0B7, Canada
| | - Jacqueline Pei
- Department of Educational Psychology, University of Alberta, Edmonton, AB T6G-2R3, Canada
| | - Christian Beaulieu
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G-2R3, Canada; Department of Biomedical Engineering, University of Alberta, Edmonton, AB T6G-2R3, Canada.
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17
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Tunc-Ozcan E, Harper KM, Graf EN, Redei EE. Thyroxine administration prevents matrilineal intergenerational consequences of in utero ethanol exposure in rats. Horm Behav 2016; 82:1-10. [PMID: 27090562 PMCID: PMC4902747 DOI: 10.1016/j.yhbeh.2016.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/23/2016] [Accepted: 04/14/2016] [Indexed: 01/15/2023]
Abstract
The neurodevelopmental fetal alcohol spectrum disorder (FASD) is characterized by cognitive and behavioral deficits in the offspring. Conferring the deficits to the next generation would increase overall FASD disease burden and prevention of this transmission could be highly significant. Prior studies showed the reversal of these behavioral deficits by low dose thyroxine (T4) supplementation to the ethanol-consuming mothers. Here we aim to identify whether prenatal ethanol (PE) exposure impairs hippocampus-dependent learning and memory in the second-generation (F2) progeny, and whether T4 administration to the ethanol-consuming dam can prevent it. Sprague-Dawley (S) dams received control diets (ad libitum and nutritional control) or ethanol containing liquid diet with and without simultaneous T4 (0.3mg/L diet) administration. Their offspring (SS F1) were mated with naive Brown Norway (B) males and females generating the SB F2 and BS F2 progeny. Hippocampus-dependent contextual fear memory and hippocampal expression of the thyroid hormone-regulated type 3 deiodinase, (Dio3) and neurogranin (Nrgn) were assessed. SS F1 PE-exposed females and their SB F2 progeny exhibited fear memory deficits. T4 administration to the mothers of F1 females reversed these deficits. Although SS F1 PE-exposed males also experienced fear memory deficit, this was neither transmitted to their BS F2 offspring nor reversed by prenatal T4 treatment. Hippocampal Dio3 and Nrgn expression showed similar pattern of changes. Grandmaternal ethanol consumption during pregnancy affects fear memory of the matrilineal second-generation progeny. Low dose T4 supplementation prevents this process likely via altering allele-specific and total expression of Dio3 in the hippocampus.
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Affiliation(s)
- Elif Tunc-Ozcan
- The Asher Center, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, United States
| | - Kathryn M Harper
- The Asher Center, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, United States
| | - Evan N Graf
- The Asher Center, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, United States
| | - Eva E Redei
- The Asher Center, Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, United States.
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