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Lu S, Tian J, Zhao S, Song X, Meng X, Ma G, Liu D, Shen Z, Chang B. Amide proton transfer weighted contrast has diagnostic capacity in detecting diabetic foot: an MRI-based case-control study. Front Endocrinol (Lausanne) 2024; 15:1287930. [PMID: 38577572 PMCID: PMC10991844 DOI: 10.3389/fendo.2024.1287930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Abstract
Objective To evaluate the role of foot muscle amide proton transfer weighted (APTw) contrast and tissue rest perfusion in quantifying diabetic foot (DF) infection and its correlation with blood parameters. Materials and methods With approval from an ethical review board, this study included 40 diabetes mellitus (DM) patients with DF and 31 DM patients without DF or other lower extremity arterial disease. All subjects underwent MRI, which included foot sagittal APTw and coronal arterial spin labeling (ASL) imaging. The normalized MTRasym (3.5 ppm) and the ratio of blood flow (rBF) in rest status of the affected side lesions to the non-affected contralateral side were determined. The inter-group differences of these variables were evaluated. Furthermore, the association between normalized MTRasym (3.5 ppm), rBF, and blood parameters [fasting blood glucose (FBG), glycosylated hemoglobin content, C-reactive protein, neutrophil percentage, and white blood cell count] was explored. Using an ROC curve, the diagnostic capacity of normalized MTRasym (3.5 ppm), BF, and blood biochemical markers in differentiating with or without DF in DM was assessed. Results In the DF group, MTRasym (3.5 ppm) and BF in lesion and normalized MTRasym (3.5 ppm) were higher than those in the control group (p < 0.05). In addition, correlations were identified between normalized MTRasym (3.5 ppm) and blood parameters, such as C-reactive protein, glycosylated hemoglobin content, FBG, neutrophil ratio, and white blood cell (p < 0.001). Meanwhile, association between BF in lesion and blood parameters, such as C-reactive protein, neutrophil percentage, and FBG (p < 0.01). AUC of normalized MTRasym (3.5 ppm) in identifying with/without DF in patients with DM is 0.986 (95% CI, 0.918-1.00) with the sensitivity of 97.22% and the specificity of 100%. Conclusion Normalized MTRasym (3.5 ppm) and the BF in lesion may be treated as a safer and more convenient new indicator to evaluate the tissue infection without using a contrast agent, which may be useful in monitoring and preoperatively assessing DF patients with renal insufficiency.
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Affiliation(s)
- Shan Lu
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
| | - Jiwei Tian
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
| | - Shiyu Zhao
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
| | - Xueyan Song
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
| | - Xianglu Meng
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
| | - Guangyang Ma
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
| | - Dengping Liu
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
| | - Zhiwei Shen
- Clinical Science, Philips Healthcare, Beijing, China
| | - Baocheng Chang
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Department of Radiology, Tianjin Medical University, Tianjin, China
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Nippert AR, Chiang PP, Newman EA. Whisker-evoked neurovascular coupling is preserved during hypoglycemia in mouse cortical arterioles and capillaries. J Cereb Blood Flow Metab 2024; 44:155-168. [PMID: 37728791 PMCID: PMC10993878 DOI: 10.1177/0271678x231201241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/12/2023] [Accepted: 08/15/2023] [Indexed: 09/21/2023]
Abstract
Hypoglycemia is a serious complication of insulin treatment of diabetes that can lead to coma and death. Neurovascular coupling, which mediates increased local blood flow in response to neuronal activity, increases glucose availability to active neurons. This mechanism could be essential for neuronal health during hypoglycemia, when total glucose supplies are low. Previous studies suggest, however, that neurovascular coupling (a transient blood flow increase in response to an increase in neuronal activity) may be reduced during hypoglycemia. Such a reduction in blood flow increase would exacerbate the effects of hypoglycemia, depriving active neurons of glucose. We have reexamined the effects of hypoglycemia on neurovascular coupling by simultaneously monitoring neuronal and vascular responses to whisker stimulation in the awake mouse somatosensory cortex. We find that neurovascular coupling at both penetrating arterioles and at 2nd order capillaries did not change significantly during insulin-induced hypoglycemia compared to euglycemia. In addition, we show that the basal diameter of both arterioles and capillaries increases during hypoglycemia (10.3 and 9.7% increases, respectively). Our results demonstrate that both neurovascular coupling and basal increases in vessel diameter are active mechanisms which help to maintain an adequate supply of glucose to the brain during hypoglycemia.
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Affiliation(s)
| | | | - Eric A Newman
- Department of Neuroscience, University of Minnesota, Minneapolis, Minnesota, USA
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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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4
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Koeneman M, Olde Bekkink M, van Meijel L, Bredie S, de Galan B. Effect of Hypoglycemia on Heart Rate Variability in People with Type 1 Diabetes and Impaired Awareness of Hypoglycemia. J Diabetes Sci Technol 2022; 16:1144-1149. [PMID: 33855894 PMCID: PMC9445333 DOI: 10.1177/19322968211007485] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND People with impaired awareness of hypoglycemia (IAH) are at elevated risk of severe, potentially hazardous, hypoglycemia and would benefit from a device alerting to hypoglycemia. Heart rate variability (HRV) changes with hypoglycemia due to sympathetic activity. Since IAH is associated with suppressed sympathetic activity, we investigated whether hypoglycemia elicits a measurable change in HRV in patients with T1D and IAH. METHOD Eligible participants underwent a modified hyperinsulinemic euglycemic hypoglycemic clamp (glucose nadir, 43.1 ± 0.90 mg/dl), while HRV was measured by a VitalConnect HealthPatch. Measurements of HRV included Root Mean Square of the Successive Differences (RMSSD) and low to high frequency (LF:HF) ratio. Wilcoxon rank-sum test was used for testing within-subject HRV changes. RESULTS We included 12 participants (8 female, mean age 57 ± 12 years, mean HbA1c 57 ± 5 mmol/mol (7.4 ± 0.4%)). Symptoms increased from 4.0 (1.5-7.0) at euglycemia to 7.5 (5.0-11.0) during hypoglycemia (P = .003). In response to hypoglycemia, the LF:HF ratio and RMSSD increased when normalized for data obtained during euglycemia (both P < .01). The LF:HF ratio increased in 6 participants (50%) and declined in one other participant (8%). The RMSSD decreased in 3 (25%) and increased in 4 (33%) participants. In 2 patients, no change in HRV could be detected in response to hypoglycemia. CONCLUSIONS This study reveals that hypoglycemia-induced changes in HRV are retained in the majority of people with T1D and IAH, and that these changes can be detected by a wearable device. Real-time HRV seems usable for detection of hypoglycemia in patients with IAH.
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Affiliation(s)
- Mats Koeneman
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- REshape Innovation Center, Radboud University Medical Center, Nijmegen, The Netherlands
- Mats Koeneman, Radboud University Medical Center, Geert Grooteplein Zuid 10, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | - Marleen Olde Bekkink
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lian van Meijel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sebastian Bredie
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- REshape Innovation Center, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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Jacob P, Nwokolo M, Cordon SM, Macdonald IA, Zelaya FO, Amiel SA, O'Daly O, Choudhary P. Altered functional connectivity during hypoglycaemia in type 1 diabetes. J Cereb Blood Flow Metab 2022; 42:1451-1462. [PMID: 35209745 PMCID: PMC9274862 DOI: 10.1177/0271678x221082911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Behavioural responses to hypoglycaemia require coordinated recruitment of broadly distributed networks of interacting brain regions. We investigated hypoglycaemia-related changes in brain connectivity in people without diabetes (ND) and with type 1 diabetes with normal (NAH) or impaired (IAH) hypoglycaemia awareness. Two-step hyperinsulinaemic hypoglycaemic clamps were performed in 14 ND, 15 NAH and 22 IAH participants. BOLD timeseries were acquired at euglycaemia (5.0 mmol/L) and hypoglycaemia (2.6 mmol/L), with symptom and counter-regulatory hormone measurements. We investigated hypoglycaemia-related connectivity changes using established seed regions for the default mode (DMN), salience (SN) and central executive (CEN) networks and regions whose activity is modulated by hypoglycaemia: the thalamus and right inferior frontal gyrus (RIFG). Hypoglycaemia-induced changes in the DMN, SN and CEN were evident in NAH (all p < 0.05), with no changes in ND or IAH. However, in IAH there was a reduction in connectivity between regions within the RIFG (p = 0.001), not evident in the ND or NAH groups. We conclude that hypoglycaemia induces coordinated recruitment of the DMN and SN in diabetes with preserved hypoglycaemia awareness which is absent in IAH and ND. Changes in connectivity in the RIFG, a region associated with attentional modulation, may be key in impaired hypoglycaemia awareness.
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Affiliation(s)
- Peter Jacob
- Diabetes Research Group (Denmark Hill), Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Munachiso Nwokolo
- Diabetes Research Group (Denmark Hill), Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sally M Cordon
- School of Life Sciences, MRC-ARUK Centre of Excellence in Musculoskeletal Ageing, Nottingham University Medical School, Queen's Medical Centre, Nottingham, UK
| | - Ian A Macdonald
- School of Life Sciences, MRC-ARUK Centre of Excellence in Musculoskeletal Ageing, Nottingham University Medical School, Queen's Medical Centre, Nottingham, UK
| | - Fernando O Zelaya
- Centre for Neuroimaging Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Stephanie A Amiel
- Diabetes Research Group (Denmark Hill), Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Owen O'Daly
- Centre for Neuroimaging Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Pratik Choudhary
- Diabetes Research Group (Denmark Hill), Faculty of Life Sciences and Medicine, King's College London, London, UK
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Nippert AR, Chiang PP, Del Franco AP, Newman EA. Astrocyte regulation of cerebral blood flow during hypoglycemia. J Cereb Blood Flow Metab 2022; 42:1534-1546. [PMID: 35296178 PMCID: PMC9274859 DOI: 10.1177/0271678x221089091] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 12/13/2022]
Abstract
Hypoglycemia triggers increases in cerebral blood flow (CBF), augmenting glucose supply to the brain. We have tested whether astrocytes, which can regulate vessel tone, contribute to this CBF increase. We hypothesized that hypoglycemia-induced adenosine signaling acts to increase astrocyte Ca2+ activity, which then causes the release of prostaglandins (PGs) and epoxyeicosatrienoic acids (EETs), leading to the dilation of brain arterioles and blood flow increases. We used an awake mouse model to investigate the effects of insulin-induced hypoglycemia on arterioles and astrocytes in the somatosensory cortex. During insulin-induced hypoglycemia, penetrating arterioles dilated and astrocyte Ca2+ signaling increased when blood glucose dropped below a threshold of ∼50 mg/dL. Application of the A2A adenosine receptor antagonist ZM-241385 eliminated hypoglycemia-evoked astrocyte Ca2+ increases and reduced arteriole dilations by 44% (p < 0.05). SC-560 and miconazole, which block the production of the astrocyte vasodilators PGs and EETs respectively, reduced arteriole dilations in response to hypoglycemia by 89% (p < 0.001) and 76% (p < 0.001). Hypoglycemia-induced arteriole dilations were decreased by 65% (p < 0.001) in IP3R2 knockout mice, which have reduced astrocyte Ca2+ signaling compared to wild-type. These results support the hypothesis that astrocytes contribute to hypoglycemia-induced increases in CBF by releasing vasodilators in a Ca2+-dependent manner.
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Affiliation(s)
- Amy R Nippert
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, USA
| | - Pei-Pei Chiang
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, USA
| | | | - Eric A Newman
- Department of Neuroscience, University of Minnesota, Minneapolis, MN, USA
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7
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van Meijel LA, van Asten JJA, Grandjean J, Heerschap A, Tack CJ, van der Graaf M, Wiegers EC, de Galan BE. Effect of lactate administration on cerebral blood flow during hypoglycemia in people with type 1 diabetes. BMJ Open Diabetes Res Care 2022; 10:10/2/e002401. [PMID: 35321886 PMCID: PMC8943734 DOI: 10.1136/bmjdrc-2021-002401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/22/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Impaired awareness of hypoglycemia, clinically reflected by the inability to timely detect hypoglycemia, affects approximately 25% of the people with type 1 diabetes. Both altered brain lactate handling and increased cerebral blood flow (CBF) during hypoglycemia appear to be involved in the pathogenesis of impaired awareness of hypoglycemia. Here we examine the effect of lactate on CBF during hypoglycemia. RESEARCH DESIGN AND METHODS Nine people with type 1 diabetes and normal awareness of hypoglycemia underwent two hyperinsulinemic euglycemic-hypoglycemic (3.0 mmol/L) glucose clamps in a 3T MR system, once with sodium lactate infusion and once with sodium chloride infusion. Global and regional changes in CBF were determined using pseudocontinuous arterial spin labeling. RESULTS Lactate (3.3±0.6 vs 0.9±0.2 mmol/L during lactate infusion vs placebo infusion, respectively) suppressed the counter-regulatory hormone responses to hypoglycemia. Global CBF increased considerably in response to intravenous lactate infusion but did not further increase during hypoglycemia. Lactate also blunted the hypoglycemia-induced regional redistribution of CBF towards the thalamus. CONCLUSIONS Elevated lactate levels enhance global CBF and blunt the thalamic CBF response during hypoglycemia in patients with type 1 diabetes, mimicking observations of impaired awareness of hypoglycemia. These findings suggest that alteration of CBF associated with lactate may play a role in some aspects of the development of impaired awareness of hypoglycemia. TRIAL REGISTRATION NUMBER NCT03730909.
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Affiliation(s)
- Lian A van Meijel
- Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
- Department of Internal Medicine, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Jack J A van Asten
- Department of Medical Imaging/Radiology, Radboudumc, Nijmegen, The Netherlands
| | - Joanes Grandjean
- Department of Medical Imaging/Radiology, Radboudumc, Nijmegen, The Netherlands
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, Radboudumc, Nijmegen, The Netherlands
| | - Arend Heerschap
- Department of Medical Imaging/Radiology, Radboudumc, Nijmegen, The Netherlands
| | - Cornelis J Tack
- Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Marinette van der Graaf
- Department of Medical Imaging/Radiology, Radboudumc, Nijmegen, The Netherlands
- Department of Pediatrics, Radboudumc, Nijmegen, The Netherlands
| | - Evita C Wiegers
- Department of Medical Imaging/Radiology, Radboudumc, Nijmegen, The Netherlands
- High Field MR Research Group, Department of Radiology, University Medical Center Utrecht Imaging Division, Utrecht, The Netherlands
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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Powers WJ, An H, Diringer MN. Cerebral Blood Flow and Metabolism. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Warner SO, Wadian AM, Smith M, Farmer B, Dai Y, Sheanon N, Edgerton DS, Winnick JJ. Liver glycogen-induced enhancements in hypoglycemic counterregulation require neuroglucopenia. Am J Physiol Endocrinol Metab 2021; 320:E914-E924. [PMID: 33779306 PMCID: PMC8424545 DOI: 10.1152/ajpendo.00501.2020] [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: 10/13/2020] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 01/24/2023]
Abstract
Iatrogenic hypoglycemia is a prominent barrier to achieving optimal glycemic control in patients with diabetes, in part due to dampened counterregulatory hormone responses. It has been demonstrated that elevated liver glycogen content can enhance these hormonal responses through signaling to the brain via afferent nerves, but the role that hypoglycemia in the brain plays in this liver glycogen effect remains unclear. During the first 4 h of each study, the liver glycogen content of dogs was increased by using an intraportal infusion of fructose to stimulate hepatic glucose uptake (HG; n = 13), or glycogen was maintained near fasting levels with a saline infusion (NG; n = 6). After a 2-h control period, during which the fructose/saline infusion was discontinued, insulin was infused intravenously for an additional 2 h to bring about systemic hypoglycemia in all animals, whereas brain euglycemia was maintained in a subset of the HG group by infusing glucose bilaterally into the carotid and vertebral arteries (HG-HeadEu; n = 7). Liver glycogen content was markedly elevated in the two HG groups (43 ± 4, 73 ± 3, and 75 ± 7 mg/g in NG, HG, and HG-HeadEu, respectively). During the hypoglycemic period, arterial plasma glucose levels were indistinguishable between groups (53 ± 2, 52 ± 1, and 51 ± 1 mg/dL, respectively), but jugular vein glucose levels were kept euglycemic (88 ± 5 mg/dL) only in the HG-HeadEu group. Glucagon and epinephrine responses to hypoglycemia were higher in HG compared with NG, whereas despite the increase in liver glycogen, neither increased above basal in HG-HeadEu. These data demonstrate that the enhanced counterregulatory hormone secretion that accompanies increased liver glycogen content requires hypoglycemia in the brain.NEW & NOTEWORTHY It is well known that iatrogenic hypoglycemia is a barrier to optimal glycemic regulation in patients with diabetes. Our data confirm that increasing liver glycogen content 75% above fasting levels enhances hormonal responses to insulin-induced hypoglycemia and demonstrate that this enhanced hormonal response does not occur in the absence of hypoglycemia in the brain. These data demonstrate that information from the liver regarding glycogen availability is integrated in the brain to optimize the counterregulatory response.
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Affiliation(s)
- Shana O Warner
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Abby M Wadian
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marta Smith
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ben Farmer
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yufei Dai
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Nicole Sheanon
- Department of Endocrinology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dale S Edgerton
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jason J Winnick
- Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Nwokolo M, Amiel SA, O'Daly O, Macdonald IA, Zelaya FO, Choudhary P. Restoration of Hypoglycemia Awareness Alters Brain Activity in Type 1 Diabetes. Diabetes Care 2021; 44:533-540. [PMID: 33328282 DOI: 10.2337/dc20-1250] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 11/12/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Impaired awareness of hypoglycemia (IAH) in type 1 diabetes (T1D) is a major risk factor for severe hypoglycemia (SH) and is associated with atypical responses to hypoglycemia in brain regions involved in arousal, decision making, and memory. Whether restoration of hypoglycemia awareness alters these responses is unknown. We sought to investigate the impact of awareness restoration on brain responses to hypoglycemia. RESEARCH DESIGN AND METHODS Twelve adults with T1D and IAH underwent pseudocontinuous arterial spin labeling functional MRI during a hypoglycemic clamp (5-2.6 mmol/L) before and after a hypoglycemia avoidance program of structured education (Dose Adjustment for Normal Eating), specialist support, and sensor-augmented pump therapy (Medtronic MiniMed 640G). Hypoglycemic cerebral blood flow (CBF) responses were compared pre- and postintervention using predefined region-of-interest analysis of the thalamus, anterior cingulate cortex (ACC), orbitofrontal cortex (OFC), and hippocampus. RESULTS Postintervention, Gold and Clarke scores fell (6.0 ± 1.0 to 4.0 ± 1.6, P = 0.0002, and 5.7 ± 1.7 to 3.4 ± 1.8, P = 0.0008, respectively), SH rates reduced (1.5 ± 2 to 0.3 ± 0.5 episodes per year, P = 0.03), hypoglycemic symptom scores increased (18.8 ± 6.3 to 27.3 ± 12.7, P = 0.02), and epinephrine responses did not change (P = 0.2). Postintervention, hypoglycemia induced greater increases in ACC CBF (P = 0.01, peak voxel coordinates [6, 40, -2]), while thalamic and OFC activity did not change. CONCLUSIONS Increased blood flow is seen within brain pathways involved in internal self-awareness and decision making (ACC) after restoration of hypoglycemia awareness, suggesting partial recovery of brain responses lost in IAH. Resistance of frontothalamic networks, involved in arousal and emotion processing, may explain why not all individuals with IAH achieve awareness restoration with education and technology alone.
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Affiliation(s)
- Munachiso Nwokolo
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K. .,King's College Hospital NHS Foundation Trust, London, U.K
| | - Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K.,King's College Hospital NHS Foundation Trust, London, U.K
| | - Owen O'Daly
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
| | - Ian A Macdonald
- School of Life Sciences, MRC-Arthritis Research UK Centre of Excellence in Musculoskeletal Ageing, Nottingham University Medical School, Queen's Medical Centre, Nottingham, U.K
| | - Fernando O Zelaya
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
| | - Pratik Choudhary
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K.,King's College Hospital NHS Foundation Trust, London, U.K
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Stantonyonge N, Sampedro F, Méndez J, Martínez-Horta S, Chico A, Gómez-Anson B. Structural Gray and White Matter Differences in Patients With Type 1 Diabetes and Impaired Awareness of Hypoglycemia. J Clin Endocrinol Metab 2021; 106:450-458. [PMID: 33180907 DOI: 10.1210/clinem/dgaa832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Type 1 diabetes (T1D) is associated with an increased risk of cognitive decline, where severe hypoglycemia (SH) and impaired awareness of hypoglycemia (IAH) may play a role. While there is evidence of a possible association between IAH and brain damage, the potential brain changes remain poorly characterized by magnetic resonance imaging (MRI). OBJECTIVE To investigate whether there are structural brain differences in a group of T1D patients with IAH compared with normal awareness of hypoglycemia (NAH). DESIGN General practice, population-based, cross-sectional study (July 2018 to July 2019). SETTING Endocrinology Department, Hospital Santa Creu i Sant Pau. PARTICIPANTS A total of 40 T1D patients (20 each with IAH and NAH) matched for age, sex, T1D duration, and education level. MAIN OUTCOME MEASURES Using different neuroimaging techniques, we compared whole-brain gray matter (GM) and white matter (WM) differences. We used voxel-based morphometry and cortical surface area analysis methods to assess GM differences, and fractional anisotropy (FA) to assess WM differences. RESULTS Compared with patients with T1D-NAH, patients with T1D-IAH had reduced GM volumes and cortical surface areas, especially in frontal and parietal regions (P < 0.05 corrected), and also showed reduced FA values in major WM tracts. The observed MRI differences correlated with both SH frequency and IAH severity. CONCLUSIONS MRI for patients with T1D show that IAH is associated with brain changes involving both GM and WM. Further research is needed to elucidate whether the observed differences are a consequence of increased SH episode frequency and increased IAH severity.
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Affiliation(s)
- Nicole Stantonyonge
- Department of Endocrinology and Nutrition, Hospital de Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Frederic Sampedro
- Institut d'Investigacions Biomèdiques Sant Pau (IIB-Sant Pau), Barcelona, Spain
- CIBER-Neurodegenerative Diseases (CIBER-NED), Madrid, Spain
- Department of Neurology, Movement Disorders Unit, Hospital de Santa Creu i Sant Pau, Barcelona, Spain
| | - Jorge Méndez
- Neuroradiology, Radiology Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Saül Martínez-Horta
- Institut d'Investigacions Biomèdiques Sant Pau (IIB-Sant Pau), Barcelona, Spain
- CIBER-Neurodegenerative Diseases (CIBER-NED), Madrid, Spain
- Department of Neurology, Movement Disorders Unit, Hospital de Santa Creu i Sant Pau, Barcelona, Spain
| | - Ana Chico
- Department of Endocrinology and Nutrition, Hospital de Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- CIBER-Bioengineering, Biomaterials and Nanotechnology (CIBER-BBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Gómez-Anson
- Neuroradiology, Radiology Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
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12
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Joosten L, Boss M, Jansen T, Brom M, Buitinga M, Aarntzen E, Eriksson O, Johansson L, de Galan B, Gotthardt M. Molecular Imaging of Diabetes. Mol Imaging 2021. [DOI: 10.1016/b978-0-12-816386-3.00041-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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13
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McManus R, Ioussoufovitch S, Froats E, St Lawrence K, Van Uum S, Diop M. Dynamic response of cerebral blood flow to insulin-induced hypoglycemia. Sci Rep 2020; 10:21300. [PMID: 33277531 PMCID: PMC7718270 DOI: 10.1038/s41598-020-77626-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022] Open
Abstract
The dynamics of cerebral blood flow (CBF) at the onset of hypoglycemia may play a key role in hypoglycemia unawareness; however, there is currently a paucity of techniques that can monitor adult CBF with high temporal resolution. Herein, we investigated the use of diffuse correlation spectroscopy (DCS) to monitor the dynamics of CBF during insulin-induced hypoglycemia in adults. Plasma glucose concentrations, cortisol levels, and changes in CBF were measured before and during hypoglycemia in 8 healthy subjects. Cerebral blood flow increased by 42% following insulin injection with a delay of 17 ± 10 min, while the onset of hypoglycemia symptoms was delayed by 24 ± 11 min. The findings suggest that the onset of CBF increments precedes the appearance of hypoglycemia symptoms in nondiabetic subjects with normal awareness to hypoglycemia, and DCS could be a valuable tool for investigating the role of CBF in hypoglycemia unawareness.
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Affiliation(s)
- Ruth McManus
- St. Joseph's Health Care, London, ON, N6A 4V2, Canada
| | - Seva Ioussoufovitch
- Department of Biomedical Engineering, Western University, London, ON, N6A 5C1, Canada
| | | | - Keith St Lawrence
- St. Joseph's Health Care, London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, London, ON, N6A 5C1, Canada
| | - Stan Van Uum
- St. Joseph's Health Care, London, ON, N6A 4V2, Canada
| | - Mamadou Diop
- St. Joseph's Health Care, London, ON, N6A 4V2, Canada.
- Department of Biomedical Engineering, Western University, London, ON, N6A 5C1, Canada.
- Department of Medical Biophysics, Western University, London, ON, N6A 5C1, Canada.
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14
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Ma WX, Tang J, Lei ZW, Li CY, Zhao LQ, Lin C, Sun T, Li ZY, Jiang YH, Jia JT, Liang CZ, Liu JH, Yan LJ. Potential Biochemical Mechanisms of Brain Injury in Diabetes Mellitus. Aging Dis 2020; 11:978-987. [PMID: 32765958 PMCID: PMC7390528 DOI: 10.14336/ad.2019.0910] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/10/2019] [Indexed: 01/07/2023] Open
Abstract
The goal of this review was to summarize current biochemical mechanisms of and risk factors for diabetic brain injury. We mainly summarized mechanisms published in the past three years and focused on diabetes induced cognitive impairment, diabetes-linked Alzheimer’s disease, and diabetic stroke. We think there is a need to conduct further studies with increased sample sizes and prolonged period of follow-ups to clarify the effect of DM on brain dysfunction. Additionally, we also think that enhancing experimental reproducibility using animal models in conjunction with application of advanced devices should be considered when new experiments are designed. It is expected that further investigation of the underlying mechanisms of diabetic cognitive impairment will provide novel insights into therapeutic approaches for ameliorating diabetes-associated injury in the brain.
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Affiliation(s)
- Wei-Xing Ma
- 1Department of Pharmaceutical, University of North Texas Health Science Center, Fort Worth, Texas, USA.,2Chemical Engineering Institute, Qingdao University of Science and Technology, Qingdao, Shandong, China.,3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Jing Tang
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Zhi-Wen Lei
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Chun-Yan Li
- 1Department of Pharmaceutical, University of North Texas Health Science Center, Fort Worth, Texas, USA.,4Shantou University Medical College, Shantou, Guangdong, China
| | - Li-Qing Zhao
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Chao Lin
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Tao Sun
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Zheng-Yi Li
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Ying-Hui Jiang
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Jun-Tao Jia
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Cheng-Zhu Liang
- 3Technological Center, Qingdao Customs, Qingdao, Shandong, China
| | - Jun-Hong Liu
- 2Chemical Engineering Institute, Qingdao University of Science and Technology, Qingdao, Shandong, China
| | - Liang-Jun Yan
- 1Department of Pharmaceutical, University of North Texas Health Science Center, Fort Worth, Texas, USA
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15
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Lei H, Gruetter R. Metabolic and perfusion responses to acute hypoglycemia in the rat cortex: A non-invasive magnetic resonance approach. J Neurochem 2020; 154:71-83. [PMID: 32306383 DOI: 10.1111/jnc.15028] [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: 11/24/2019] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
Abstract
Hypoglycemia is critical condition during diabetic treatment that involves intensive insulin therapy, and it may impair brain function. We aimed to compare cortical responses of three hypoglycemic phases and the restoration of glycemia to control levels after a severe episode in rats using non-invasive perfusion magnetic resonance (MR) imaging and localized 1 H MR spectroscopy. Under light α-chloralose anesthesia, cortical blood flow (cCBF) was 42 ± 3 ml/100 g/min at euglycemia (~ 5 mM plasma glucose), was not altered at mild hypoglycemia I (42 ± 4 ml/100 g/min, 2-3.5 mM), increased to 60 ± 8 ml/100 g/min under moderate hypoglycemia II (1-2 mM) and amplified to 190 ± 35 ml/100 g/min at severe hypoglycemia III (< 1 mM). 1 H MRS revealed metabolic changes at hypoglycemia I without any perfusion alteration. At hypoglycemia III, glutamine and glutamate decreased, whereas aspartate increased. When animals subsequently regained glycemic control, not all metabolites returned to their control levels, for example, glutamine. Meanwhile, ascorbate was increased with amplified hypoglycemic severity, whereas glutathione was reduced; these compounds did not return to normal levels upon the restoration of glycemia. Our study is the first to report cCBF and neurochemical changes in cortex upon five glycemic stages. The cortical responses of different hypoglycemic phases would explain variable neuronal damages after hypoglycemia and might help identify the degrees of hypoglycemic insults and further improve alternative therapies.
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Affiliation(s)
- Hongxia Lei
- Animal Imaging Technology (AIT), Center for Biomedical Imaging Research (CIBM), Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland
| | - Rolf Gruetter
- Animal Imaging Technology (AIT), Center for Biomedical Imaging Research (CIBM), Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland.,Wuhan United Imaging Life Science Instruments Ltd., Wuhan, P.R.China.,Laboratory of Functional and Metabolic Imaging (LIFMET), Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland.,Department of Radiology, University of Geneva, Geneva, Switzerland
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16
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Nwokolo M, Amiel SA, O'Daly O, Byrne ML, Wilson BM, Pernet A, Cordon SM, Macdonald IA, Zelaya FO, Choudhary P. Hypoglycemic thalamic activation in type 1 diabetes is associated with preserved symptoms despite reduced epinephrine. J Cereb Blood Flow Metab 2020; 40:787-798. [PMID: 31006309 PMCID: PMC7168783 DOI: 10.1177/0271678x19842680] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Brain responses to low plasma glucose may be key to understanding the behaviors that prevent severe hypoglycemia in type 1 diabetes. This study investigated the impact of long duration, hypoglycemia aware type 1 diabetes on cerebral blood flow responses to hypoglycemia. Three-dimensional pseudo-continuous arterial spin labeling magnetic resonance imaging was performed in 15 individuals with type 1 diabetes and 15 non-diabetic controls during a two-step hyperinsulinemic glucose clamp. Symptom, hormone, global cerebral blood flow and regional cerebral blood flow responses to hypoglycemia were measured. Epinephrine release during hypoglycemia was attenuated in type 1 diabetes, but symptom score rose comparably in both groups. A rise in global cerebral blood flow did not differ between groups. Regional cerebral blood flow increased in the thalamus and fell in the hippocampus and temporal cortex in both groups. Type 1 diabetes demonstrated lesser anterior cingulate cortex activation; however, this difference did not survive correction for multiple comparisons. Thalamic cerebral blood flow change correlated with autonomic symptoms, and anterior cingulate cortex cerebral blood flow change correlated with epinephrine response across groups. The thalamus may thus be involved in symptom responses to hypoglycemia, independent of epinephrine action, while anterior cingulate cortex activation may be linked to counterregulation. Activation of these regions may have a role in hypoglycemia awareness and avoidance of problematic hypoglycemia.
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Affiliation(s)
- Munachiso Nwokolo
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK.,King's College Hospital, NHS Foundation Trust, London, UK
| | - Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK.,King's College Hospital, NHS Foundation Trust, London, UK
| | - Owen O'Daly
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Megan L Byrne
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK
| | - Bula M Wilson
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK
| | - Andrew Pernet
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK
| | - Sally M Cordon
- School of Life Sciences, MRC-ARUK Centre of Excellence in Musculoskeletal Ageing, Nottingham University Medical School, Queen's Medical Centre, Nottingham, UK
| | - Ian A Macdonald
- School of Life Sciences, MRC-ARUK Centre of Excellence in Musculoskeletal Ageing, Nottingham University Medical School, Queen's Medical Centre, Nottingham, UK
| | - Fernando O Zelaya
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Pratik Choudhary
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK.,King's College Hospital, NHS Foundation Trust, London, UK
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17
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Nwokolo M, Amiel SA, O'Daly O, Byrne ML, Wilson BM, Pernet A, Cordon SM, Macdonald IA, Zelaya FO, Choudhary P. Impaired Awareness of Hypoglycemia Disrupts Blood Flow to Brain Regions Involved in Arousal and Decision Making in Type 1 Diabetes. Diabetes Care 2019; 42:2127-2135. [PMID: 31455689 DOI: 10.2337/dc19-0337] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/07/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Impaired awareness of hypoglycemia (IAH) affects one-quarter of adults with type 1 diabetes and significantly increases the risk of severe hypoglycemia. Differences in regional brain responses to hypoglycemia may contribute to the susceptibility of this group to problematic hypoglycemia. This study investigated brain responses to hypoglycemia in hypoglycemia aware (HA) and IAH adults with type 1 diabetes, using three-dimensional pseudo-continuous arterial spin labeling (3D pCASL) functional MRI to measure changes in regional cerebral blood flow (CBF). RESEARCH DESIGN AND METHODS Fifteen HA and 19 IAH individuals underwent 3D pCASL functional MRI during a two-step hyperinsulinemic glucose clamp. Symptom, hormone, global, and regional CBF responses to hypoglycemia (47 mg/dL [2.6 mmol/L]) were measured. RESULTS In response to hypoglycemia, total symptom score did not change in those with IAH (P = 0.25) but rose in HA participants (P < 0.001). Epinephrine, cortisol, and growth hormone responses to hypoglycemia were lower in the IAH group (P < 0.05). Hypoglycemia induced a rise in global CBF (HA P = 0.01, IAH P = 0.04) but was not different between groups (P = 0.99). IAH participants showed reduced regional CBF responses within the thalamus (P = 0.002), right lateral orbitofrontal cortex (OFC) (P = 0.002), and right dorsolateral prefrontal cortex (P = 0.036) and a lesser decrease of CBF in the left hippocampus (P = 0.023) compared with the HA group. Thalamic and right lateral OFC differences survived Bonferroni correction. CONCLUSIONS Responses to hypoglycemia of brain regions involved in arousal, decision making, and reward are altered in IAH. Changes in these pathways may disrupt IAH individuals' ability to recognize hypoglycemia, impairing their capacity to manage hypoglycemia effectively and benefit fully from conventional therapeutic pathways to restore awareness.
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Affiliation(s)
- Munachiso Nwokolo
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K. .,King's College Hospital NHS Foundation Trust, London, U.K
| | - Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K.,King's College Hospital NHS Foundation Trust, London, U.K
| | - Owen O'Daly
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
| | - Megan L Byrne
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K
| | - Bula M Wilson
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K
| | - Andrew Pernet
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K
| | - Sally M Cordon
- School of Life Sciences, MRC Arthritis Research UK Centre of Excellence in Musculoskeletal Ageing, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, U.K
| | - Ian A Macdonald
- School of Life Sciences, MRC Arthritis Research UK Centre of Excellence in Musculoskeletal Ageing, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, U.K
| | - Fernando O Zelaya
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
| | - Pratik Choudhary
- Department of Diabetes, School of Life Course Sciences, King's College London, London, U.K.,King's College Hospital NHS Foundation Trust, London, U.K
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18
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González-Garrido AA, Gallardo-Moreno GB, Romo-Vázquez R, Vélez-Pérez H, Flores-Saiffe-Farías A, Mendizabal-Ruiz G, Santos-Arce SR, Ruiz-Stovel VD, Gómez-Velázquez FR, Ramos-Loyo J. Is sex an influential factor in type-1 diabetes neurofunctional development? A preliminary study. J Neurosci Res 2018; 96:1699-1706. [PMID: 30027655 DOI: 10.1002/jnr.24268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 01/29/2023]
Abstract
The aim of the study was to evaluate the neurofunctional effect of gender in Type-1 Diabetes Mellitus (T1DM) patients during a Visual Spatial Working Memory (VSWM) task. The study included 28 participants with ages ranging from 17-28 years. Fourteen well-controlled T1DM patients (7 female) and 14 controls matched by age, sex, and education level were scanned performing a block-design VSWM paradigm. Behavioral descriptive analyses and mean comparisons were done, and between-group and condition functional activation patterns were also compared. Whole-brain cumulative BOLD signal (CumBS), voxel-wise BOLD level frequency, Euclidean distance, and divergence indices were also calculated. There were no significant differences between or within-group sex differences for correct responses and reaction times. Functional activation analyses showed that females had activation in more brain regions, and with larger clusters of cortical activations than males. Furthermore, BOLD activation was higher in males. Despite the preliminary nature of the present study given the relatively small sample size, current results acknowledge for the first time that sex might contribute to differences in functional activation in T1DM patients. Findings suggest that sex differences should be considered when studying T1DM-disease development.
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Affiliation(s)
- Andrés A González-Garrido
- Instituto de Neurociencias. Universidad de Guadalajara. Francisco de Quevedo 180. Col. Arcos Vallarta, Guadalajara, Jalisco, 44130, México
| | - Geisa B Gallardo-Moreno
- Instituto de Neurociencias. Universidad de Guadalajara. Francisco de Quevedo 180. Col. Arcos Vallarta, Guadalajara, Jalisco, 44130, México
| | - Rebeca Romo-Vázquez
- Departamento de Ciencias Computacionales, CUCEI, Universidad de Guadalajara. Blvd. Marcelino García Barragán #1421, esq. Calzada Olímpica, C.P. 44430, Guadalajara, Jalisco, México
| | - Hugo Vélez-Pérez
- Departamento de Ciencias Computacionales, CUCEI, Universidad de Guadalajara. Blvd. Marcelino García Barragán #1421, esq. Calzada Olímpica, C.P. 44430, Guadalajara, Jalisco, México
| | - Adolfo Flores-Saiffe-Farías
- Departamento de Ciencias Computacionales, CUCEI, Universidad de Guadalajara. Blvd. Marcelino García Barragán #1421, esq. Calzada Olímpica, C.P. 44430, Guadalajara, Jalisco, México
| | - Gerardo Mendizabal-Ruiz
- Departamento de Ciencias Computacionales, CUCEI, Universidad de Guadalajara. Blvd. Marcelino García Barragán #1421, esq. Calzada Olímpica, C.P. 44430, Guadalajara, Jalisco, México
| | - Stewart R Santos-Arce
- Departamento de Electrónica, CUCEI, Universidad de Guadalajara. Blvd. Marcelino García Barragán #1421, esq. Calzada Olímpica, C.P. 44430, Guadalajara, Jalisco, México
| | - Vanessa D Ruiz-Stovel
- Instituto de Neurociencias. Universidad de Guadalajara. Francisco de Quevedo 180. Col. Arcos Vallarta, Guadalajara, Jalisco, 44130, México
| | - Fabiola R Gómez-Velázquez
- Instituto de Neurociencias. Universidad de Guadalajara. Francisco de Quevedo 180. Col. Arcos Vallarta, Guadalajara, Jalisco, 44130, México
| | - Julieta Ramos-Loyo
- Instituto de Neurociencias. Universidad de Guadalajara. Francisco de Quevedo 180. Col. Arcos Vallarta, Guadalajara, Jalisco, 44130, México
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19
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Dunn JT, Choudhary P, Teh MM, Macdonald I, Hunt KF, Marsden PK, Amiel SA. The impact of hypoglycaemia awareness status on regional brain responses to acute hypoglycaemia in men with type 1 diabetes. Diabetologia 2018; 61:1676-1687. [PMID: 29754288 PMCID: PMC6445483 DOI: 10.1007/s00125-018-4622-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/05/2018] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS Impaired awareness of hypoglycaemia (IAH) in type 1 diabetes increases the risk of severe hypoglycaemia sixfold and can be resistant to intervention. We explored the impact of IAH on central responses to hypoglycaemia to investigate the mechanisms underlying barriers to therapeutic intervention. METHODS We conducted [15O]water positron emission tomography studies of regional brain perfusion during euglycaemia (target 5 mmol/l), hypoglycaemia (achieved level, 2.4 mmol/l) and recovery (target 5 mmol/l) in 17 men with type 1 diabetes: eight with IAH, and nine with intact hypoglycaemia awareness (HA). RESULTS Hypoglycaemia with HA was associated with increased activation in brain regions including the thalamus, insula, globus pallidus (GP), anterior cingulate cortex (ACC), orbital cortex, dorsolateral frontal (DLF) cortex, angular gyrus and amygdala; deactivation occurred in the temporal and parahippocampal regions. IAH was associated with reduced catecholamine and symptom responses to hypoglycaemia vs HA (incremental AUC: autonomic scores, 26.2 ± 35.5 vs 422.7 ± 237.1; neuroglycopenic scores, 34.8 ± 88.8 vs 478.9 ± 311.1; both p < 0.002). There were subtle differences (p < 0.005, k ≥ 50 voxels) in brain activation at hypoglycaemia, including early differences in the right central operculum, bilateral medial orbital (MO) cortex, and left posterior DLF cortex, with additional differences in the ACC, right GP and post- and pre-central gyri in established hypoglycaemia, and lack of deactivation in temporal regions in established hypoglycaemia. CONCLUSIONS/INTERPRETATION Differences in activation in the post- and pre-central gyri may be expected in people with reduced subjective responses to hypoglycaemia. Alterations in the activity of regions involved in the drive to eat (operculum), emotional salience (MO cortex), aversion (GP) and recall (temporal) suggest differences in the perceived importance and urgency of responses to hypoglycaemia in IAH compared with HA, which may be key to the persistence of the condition.
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Affiliation(s)
- Joel T Dunn
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Pratik Choudhary
- Diabetes Research Group, King's College London, King's College Hospital Campus, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
- Institute of Diabetes and Obesity, King's Health Partners, London, UK
| | - Ming Ming Teh
- Diabetes Research Group, King's College London, King's College Hospital Campus, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
- Singapore General Hospital, Singapore, Republic of Singapore
| | - Ian Macdonald
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Katharine F Hunt
- Diabetes Research Group, King's College London, King's College Hospital Campus, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
- Institute of Diabetes and Obesity, King's Health Partners, London, UK
| | - Paul K Marsden
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Stephanie A Amiel
- Diabetes Research Group, King's College London, King's College Hospital Campus, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK.
- Institute of Diabetes and Obesity, King's Health Partners, London, UK.
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20
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Hwang JJ, Parikh L, Lacadie C, Seo D, Lam W, Hamza M, Schmidt C, Dai F, Sejling AS, Belfort-DeAguiar R, Constable RT, Sinha R, Sherwin R. Hypoglycemia unawareness in type 1 diabetes suppresses brain responses to hypoglycemia. J Clin Invest 2018; 128:1485-1495. [PMID: 29381484 DOI: 10.1172/jci97696] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/23/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Among nondiabetic individuals, mild glucose decrements alter brain activity in regions linked to reward, motivation, and executive control. Whether these effects differ in type 1 diabetes mellitus (T1DM) patients with and without hypoglycemia awareness remains unclear. METHODS Forty-two individuals (13 healthy control [HC] subjects, 16 T1DM individuals with hypoglycemia awareness [T1DM-Aware], and 13 T1DM individuals with hypoglycemia unawareness [T1DM-Unaware]) underwent blood oxygen level-dependent functional MRI brain imaging during a 2-step hyperinsulinemic euglycemic (90 mg/dl)-hypoglycemic (60 mg/dl) clamp for assessment of neural responses to mild hypoglycemia. RESULTS Mild hypoglycemia in HC subjects altered activity in the caudate, insula, prefrontal cortex, and angular gyrus, whereas T1DM-Aware subjects showed no caudate and insula changes, but showed altered activation patterns in the prefrontal cortex and angular gyrus. Most strikingly, in direct contrast to HC and T1DM-Aware subjects, T1DM-Unaware subjects failed to show any hypoglycemia-induced changes in brain activity. These findings were also associated with blunted hormonal counterregulatory responses and hypoglycemia symptom scores during mild hypoglycemia. CONCLUSION In T1DM, and in particular T1DM-Unaware patients, there is a progressive blunting of brain responses in cortico-striatal and fronto-parietal neurocircuits in response to mild-moderate hypoglycemia. These findings have implications for understanding why individuals with impaired hypoglycemia awareness fail to respond appropriately to falling blood glucose levels. FUNDING This study was supported in part by NIH grants R01DK020495, P30 DK045735, K23DK109284, K08AA023545. The Yale Center for Clinical Investigation is supported by an NIH Clinical Translational Science Award (UL1 RR024139).
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Affiliation(s)
| | | | | | - Dongju Seo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Feng Dai
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Anne-Sophie Sejling
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital, Hillerød, Denmark
| | | | | | - Rajita Sinha
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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