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Mott J, Gilor C. Glucose Counterregulation: Clinical Consequences of Impaired Sympathetic Responses in Diabetic Dogs and Cats. Vet Clin North Am Small Anim Pract 2023; 53:551-564. [PMID: 36898860 DOI: 10.1016/j.cvsm.2023.01.001] [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: 03/10/2023]
Abstract
Insulin induced hypoglycemia (IIH) is common in veterinary patients and limits the clinician's ability to obtain adequate glycemic control with insulin therapy. Not all diabetic dogs and cats with IIH exhibit clinical signs and hypoglycemia might be missed by routine blood glucose curve monitoring. In diabetic patients, counterregulatory responses to hypoglycemia are impaired (lack of decrease in insulin levels, lack of increase in glucagon, and attenuation of the parasympathetic and sympathoadrenal autonomic nervous systems) and have been documented in people and in dogs but not yet in cats. Antecedent hypoglycemic episodes increase the patient's risk for future severe hypoglycemia.
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Affiliation(s)
- Jocelyn Mott
- College of Veterinary Medicine, University of Florida, 2015 Southwest 16th Avenue, Gainesville, FL 32610-0126, USA
| | - Chen Gilor
- Small Animal Internal Medicine, College of Veterinary Medicine, University of Florida, 2015 Southwest 16th Avenue, Gainesville, FL 32610-0126, USA.
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2
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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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3
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Bisgaard Bengtsen M, Møller N. Review: experimentally induced hypoglycemia-associated autonomic failure in humans: determinants, designs and drawbacks. J Endocr Soc 2022; 6:bvac123. [PMID: 36042977 PMCID: PMC9419494 DOI: 10.1210/jendso/bvac123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 11/19/2022] Open
Abstract
Context Iatrogenic hypoglycemia remains one of the leading hindrances of optimal glycemic management in insulin-treated diabetes. Recurring hypoglycemia leads to a condition of hypoglycemia-associated autonomic failure (HAAF). HAAF refers to a combination of (i) impaired hormonal counterregulatory responses and (ii) hypoglycemia unawareness to subsequent hypoglycemia, substantially increasing the risk of severe hypoglycemia. Several studies since the 1990s have experimentally induced HAAF, yielding variable results. Objective The aim of this review was to assess the varying designs, clinical outcomes, potential assets, and drawbacks related to these studies. Method A systemic literature search was conducted on PubMed and Embase in winter 2021 to include all human studies attempting to experimentally induce HAAF. In different combinations, the search terms used were “hypoglycemia-associated autonomic failure,” “HAAF,” “hypoglycemia,” “recurring,” “recurrent,” “repeated,” “consecutive,” and “unawareness,” yielding 1565 publications. Inclusion criteria were studies that had aimed at experimentally inducing HAAF and measuring outcomes of hormonal counterregulation and awareness of hypoglycemia. Results The literature search yielded 27 eligible publications, of which 20 were successful in inducing HAAF while statistical significantly impairing both hormonal counterregulation and impairing awareness of hypoglycemia to subsequent hypoglycemia. Several factors were of significance as regards inducing HAAF: Foremost, the duration of antecedent hypoglycemia should be at least 90 minutes and blood glucose should be maintained below 3.4 mmol/L. Other important factors to consider are the type of participants, insulin dosage, and the risk of unintended hypoglycemia prior to the study. Conclusion Here we have outlined the most important factors to take into consideration when designing a study aimed at inducing HAAF, including to take into consideration other disease states susceptible to hypoglycemia, thus hopefully clarifying the field and allowing qualified studies in the future.
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Affiliation(s)
| | - Niels Møller
- Department of Endocrinology and Internal Medicine , Aarhus University Hospital, Denmark
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Gilor C, Duesberg C, Elliott DA, Feldman EC, Mundinger TO, Taborsky GJ, Nelson RW, Havel PJ. Co-impairment of autonomic and glucagon responses to insulin-induced hypoglycemia in dogs with naturally occurring insulin-dependent diabetes mellitus. Am J Physiol Endocrinol Metab 2020; 319:E1074-E1083. [PMID: 33044845 PMCID: PMC7792666 DOI: 10.1152/ajpendo.00379.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This study aimed to investigate the contributions of two factors potentially impairing glucagon response to insulin-induced hypoglycemia (IIH) in insulin-deficient diabetes: 1) loss of paracrine disinhibition by intra-islet insulin and 2) defects in the activation of the autonomic inputs to the islet. Plasma glucagon responses during hyperinsulinemic-hypoglycemic clamps ([Formula: see text]40 mg/dL) were assessed in dogs with spontaneous diabetes (n = 13) and in healthy nondiabetic dogs (n = 6). Plasma C-peptide responses to intravenous glucagon were measured to assess endogenous insulin secretion. Plasma pancreatic polypeptide, epinephrine, and norepinephrine were measured as indices of parasympathetic and sympathoadrenal autonomic responses to IIH. In 8 of the 13 diabetic dogs, glucagon did not increase during IIH (diabetic nonresponder [DMN]; ∆ = -6 ± 12 pg/mL). In five other diabetic dogs (diabetic responder [DMR]), glucagon responses (∆ = +26 ± 12) were within the range of nondiabetic control dogs (∆ = +27 ± 16 pg/mL). C-peptide responses to intravenous glucagon were absent in diabetic dogs. Activation of all three autonomic responses were impaired in DMN dogs but remained intact in DMR dogs. Each of the three autonomic responses to IIH was positively correlated with glucagon responses across the three groups. The study conclusions are as follows: 1) Impairment of glucagon responses in DMN dogs is not due to generalized impairment of α-cell function. 2) Loss of tonic inhibition of glucagon secretion by insulin is not sufficient to produce loss of the glucagon response; impairment of autonomic activation is also required. 3) In dogs with major β-cell function loss, activation of the autonomic inputs is sufficient to mediate an intact glucagon response to IIH.NEW & NOTEWORTHY In dogs with naturally occurring, insulin-dependent (C-peptide negative) diabetes mellitus, impairment of glucagon responses is not due to generalized impairment of α-cell function. Loss of tonic inhibition of glucagon secretion by insulin is not sufficient, by itself, to produce loss of the glucagon response. Rather, impaired activation of the parasympathetic and sympathoadrenal autonomic inputs to the pancreas is also required. Activation of the autonomic inputs to the pancreas is sufficient to mediate an intact glucagon response to insulin-induced hypoglycemia in dogs with naturally occurring diabetes mellitus. These results have important implications that include leading to a greater understanding and insight into the pathophysiology, prevention, and treatment of hypoglycemia during insulin treatment of diabetes in companion dogs and in human patients.
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Affiliation(s)
- Chen Gilor
- Department of Veterinary Medicine and Epidemiology, University of California, Davis, California
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida
| | - Cynthia Duesberg
- Department of Veterinary Medicine and Epidemiology, University of California, Davis, California
| | - Denise A Elliott
- Department of Veterinary Medicine and Epidemiology, University of California, Davis, California
| | - Edward C Feldman
- Department of Veterinary Medicine and Epidemiology, University of California, Davis, California
| | | | - Gerald J Taborsky
- Department of Medicine, University of Washington, Seattle, Washington
| | - Richard W Nelson
- Department of Veterinary Medicine and Epidemiology, University of California, Davis, California
| | - Peter J Havel
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California
- Department of Nutrition, School of Veterinary Medicine, University of California, Davis, California
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Lontchi-Yimagou E, Aleksic S, Hulkower R, Gospin R, Goyal A, Kuo B, Mitchell WG, You JY, Upadhyay L, Carey M, Sandu OA, Gabriely I, Shamoon H, Hawkins M. Plasma Epinephrine Contributes to the Development of Experimental Hypoglycemia-Associated Autonomic Failure. J Clin Endocrinol Metab 2020; 105:5903847. [PMID: 32915987 PMCID: PMC7678732 DOI: 10.1210/clinem/dgaa539] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/04/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recurrent hypoglycemia blunts counter-regulatory responses to subsequent hypoglycemic episodes, a syndrome known as hypoglycemia-associated autonomic failure (HAAF). Since adrenergic receptor blockade has been reported to prevent HAAF, we investigated whether the hypoglycemia-associated rise in plasma epinephrine contributes to pathophysiology and reported interindividual differences in susceptibility to HAAF. METHODS To assess the role of hypoglycemia-associated epinephrine responses in the susceptibility to HAAF, 24 adult nondiabetic subjects underwent two 2-hour hyperinsulinemic hypoglycemic clamp studies (nadir 54 mg/dL; 0-2 hours and 4-6 hours) on Day 1, followed by a third identical clamp on Day 2. We challenged an additional 7 subjects with two 2-hour infusions of epinephrine (0.03 μg/kg/min; 0-2 hours and 4-6 hours) vs saline on Day 1 followed by a 200-minute stepped hypoglycemic clamp (90, 80, 70, and 60 mg/dL) on Day 2. RESULTS Thirteen out of 24 subjects developed HAAF, defined by ≥20% reduction in average epinephrine levels during the final 30 minutes of the third compared with the first hypoglycemic episode (P < 0.001). Average epinephrine levels during the final 30 minutes of the first hypoglycemic episode were 2.3 times higher in subjects who developed HAAF compared with those who did not (P = 0.006).Compared to saline, epinephrine infusion on Day 1 reduced the epinephrine responses by 27% at the 70 and 60 mg/dL glucose steps combined (P = 0.04), with a parallel reduction in hypoglycemic symptoms (P = 0.03) on Day 2. CONCLUSIONS Increases in plasma epinephrine reproduce key features of HAAF in nondiabetic subjects. Marked interindividual variability in epinephrine responses to hypoglycemia may explain an individual's susceptibility to developing HAAF.
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Affiliation(s)
| | | | | | | | - Akankasha Goyal
- New York University Langone Medical Center, New York, New York
| | - Bryan Kuo
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Jee Young You
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Michelle Carey
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Oana A Sandu
- Albert Einstein College of Medicine, Bronx, New York
| | - Ilan Gabriely
- Albert Einstein College of Medicine, Bronx, New York
| | - Harry Shamoon
- Albert Einstein College of Medicine, Bronx, New York
| | - Meredith Hawkins
- Albert Einstein College of Medicine, Bronx, New York
- Correspondence and Reprint Requests: Dr. Meredith Hawkins, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA. E-mail:
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Moheet A, Kumar A, Zhang Y, Eberly L, Coles LD, Seaquist ER. Infusion of N-acetyl cysteine during hypoglycaemia in humans does not preserve the counterregulatory response to subsequent hypoglycaemia. Endocrinol Diabetes Metab 2020; 3:e00144. [PMID: 32704565 PMCID: PMC7375074 DOI: 10.1002/edm2.144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/07/2020] [Accepted: 04/11/2020] [Indexed: 12/05/2022] Open
Abstract
AIM Administration of N-acetyl cysteine (NAC) during hypoglycaemia will preserve the counterregulatory response to subsequent hypoglycaemia in healthy humans. METHODS This was a randomized double-blind cross over study where humans were given either a 60-minute infusion of NAC (150 mg/kg) followed by a 4-hour infusion of NAC (50 mg/kg) or saline starting 30 minutes before the initiation of a 2-hour hypoglycaemic (HG) clamp at 8 am. After rest at euglycaemia for ~2 hours, subjects were exposed to a 2nd HG clamp at 2 pm and discharged home in euglycaemia. They returned the following day for a 3rd HG clamp at 8 am. RESULTS Twenty-two subjects were enrolled. Eighteen subjects completed the entire protocol. The epinephrine response during clamp 3 (171 ± 247 pg/mL) following clamp 1 NAC infusion was lower than the response during the clamp 1 NAC infusion (538 ± 392 pg/mL) (clamp 3 to clamp 1 NAC: P = .0013). The symptom response during clamp 3 (7 ± 5) following clamp 1 NAC infusion was lower than the response during the clamp 1 NAC infusion (16 ± 10) (clamp 3 to clamp 1 NAC: P = .0003). Nine subjects experienced rash, pruritus or nausea during NAC infusion. CONCLUSION We found no difference in the hormone and symptom response to experimental hypoglycaemia measured in subjects who were administered NAC as opposed to saline the day before. This observation suggests that further development of NAC as a therapy for impaired awareness of hypoglycaemia in patients with diabetes may be unwarranted.
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Affiliation(s)
- Amir Moheet
- Division of Diabetes, Endocrinology and MetabolismDepartment of MedicineUniversity of MinnesotaMinneapolisMNUSA
| | - Anjali Kumar
- Division of Diabetes, Endocrinology and MetabolismDepartment of MedicineUniversity of MinnesotaMinneapolisMNUSA
| | - Yuan Zhang
- Division of BiostatisticsSchool of Public HealthUniversity of MinnesotaMinneapolisMNUSA
| | - Lynn Eberly
- Division of BiostatisticsSchool of Public HealthUniversity of MinnesotaMinneapolisMNUSA
| | - Lisa D. Coles
- Department of Experimental and Clinical PharmacologyCollege of PharmacyUniversity of MinnesotaMinneapolisMNUSA
| | - Elizabeth R. Seaquist
- Division of Diabetes, Endocrinology and MetabolismDepartment of MedicineUniversity of MinnesotaMinneapolisMNUSA
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Bednařík P, Henry PG, Khowaja A, Rubin N, Kumar A, Deelchand D, Eberly LE, Seaquist E, Öz G, Moheet A. Hippocampal Neurochemical Profile and Glucose Transport Kinetics in Patients With Type 1 Diabetes. J Clin Endocrinol Metab 2020; 105:5601935. [PMID: 31637440 PMCID: PMC7046023 DOI: 10.1210/clinem/dgz062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/27/2019] [Indexed: 01/28/2023]
Abstract
CONTEXT Longstanding type 1 diabetes (T1D) may lead to alterations in hippocampal neurochemical profile. Upregulation of hippocampal glucose transport as a result of recurrent exposure to hypoglycemia may preserve cognitive function during future hypoglycemia in subjects with T1D and impaired awareness of hypoglycemia (IAH). The effect of T1D on hippocampal neurochemical profile and glucose transport is unknown. OBJECTIVE To test the hypothesis that hippocampal neurochemical composition is altered in T1D and glucose transport is upregulated in T1D with IAH. DESIGN AND PARTICIPANTS Hippocampal neurochemical profile was measured with single-voxel magnetic resonance spectroscopy at 3T during euglycemia in 18 healthy controls (HC), 10 T1D with IAH, and 12 T1D with normal awareness to hypoglycemia (NAH). Additionally, 12 HC, 8 T1D-IAH, and 6 T1D-NAH were scanned during hyperglycemia to assess hippocampal glucose transport with metabolic modeling. SETTING University medical center. MAIN OUTCOME MEASURES Concentrations of hippocampal neurochemicals measured during euglycemia and ratios of maximal transport rate to cerebral metabolic rate of glucose (Tmax/CMRGlc), derived from magnetic resonance spectroscopy-measured hippocampal glucose as a function of plasma glucose. RESULTS Comparison of hippocampal neurochemical profile revealed no group differences (HC, T1D, T1D-IAH, and T1D-NAH). The ratio Tmax/CMRGlc was not significantly different between the groups, T1D-IAH (1.58 ± 0.09) and HC (1.65 ± 0.07, P = 0.54), between T1D-NAH (1.50 ± 0.09) and HC (P = 0.19), and between T1D-IAH and T1D-NAH (P = 0.53). CONCLUSIONS Subjects with T1D with sufficient exposure to recurrent hypoglycemia to create IAH did not have alteration of Tmax/CMRglc or neurochemical profile compared with participants with T1D-NAH or HC.
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Affiliation(s)
- Petr Bednařík
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, Minnesota
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- High Field MR Centre, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Imaging Methods, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Pierre-Gilles Henry
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Amir Khowaja
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Nathan Rubin
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Anjali Kumar
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Dinesh Deelchand
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Lynn E Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Elizabeth Seaquist
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Gülin Öz
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Amir Moheet
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Correspondence and Reprint Requests: Amir Moheet, MBBS, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota, MMC 101, 420 Delaware St. SE, Minneapolis, MN 55455. E-mail:
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Öz G, Deelchand DK, Wijnen JP, Mlynárik V, Xin L, Mekle R, Noeske R, Scheenen TWJ, Tkáč I. Advanced single voxel 1 H magnetic resonance spectroscopy techniques in humans: Experts' consensus recommendations. NMR IN BIOMEDICINE 2020; 34:e4236. [PMID: 31922301 PMCID: PMC7347431 DOI: 10.1002/nbm.4236] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 10/29/2019] [Accepted: 11/07/2019] [Indexed: 05/06/2023]
Abstract
Conventional proton MRS has been successfully utilized to noninvasively assess tissue biochemistry in conditions that result in large changes in metabolite levels. For more challenging applications, namely, in conditions which result in subtle metabolite changes, the limitations of vendor-provided MRS protocols are increasingly recognized, especially when used at high fields (≥3 T) where chemical shift displacement errors, B0 and B1 inhomogeneities and limitations in the transmit B1 field become prominent. To overcome the limitations of conventional MRS protocols at 3 and 7 T, the use of advanced MRS methodology, including pulse sequences and adjustment procedures, is recommended. Specifically, the semiadiabatic LASER sequence is recommended when TE values of 25-30 ms are acceptable, and the semiadiabatic SPECIAL sequence is suggested as an alternative when shorter TE values are critical. The magnetic field B0 homogeneity should be optimized and RF pulses should be calibrated for each voxel. Unsuppressed water signal should be acquired for eddy current correction and preferably also for metabolite quantification. Metabolite and water data should be saved in single shots to facilitate phase and frequency alignment and to exclude motion-corrupted shots. Final averaged spectra should be evaluated for SNR, linewidth, water suppression efficiency and the presence of unwanted coherences. Spectra that do not fit predefined quality criteria should be excluded from further analysis. Commercially available tools to acquire all data in consistent anatomical locations are recommended for voxel prescriptions, in particular in longitudinal studies. To enable the larger MRS community to take advantage of these advanced methods, a list of resources for these advanced protocols on the major clinical platforms is provided. Finally, a set of recommendations are provided for vendors to enable development of advanced MRS on standard platforms, including implementation of advanced localization sequences, tools for quality assurance on the scanner, and tools for prospective volume tracking and dynamic linear shim corrections.
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Affiliation(s)
- Gülin Öz
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN 55455, United States
| | - Dinesh K. Deelchand
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN 55455, United States
| | - Jannie P. Wijnen
- High field MR Research group, Department of Radiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Vladimír Mlynárik
- High Field MR Centre, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Lijing Xin
- Animal Imaging and Technology Core (AIT), Center for Biomedical Imaging (CIBM), École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Ralf Mekle
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tom W. J. Scheenen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Erwin L Hahn Institute for Magnetic Resonance Imaging, UNESCO World Cultural Heritage Zollverein, Essen, Germany
| | - Ivan Tkáč
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN 55455, United States
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Parikh L, Seo D, Lacadie C, Belfort-Deaguiar R, Groskreutz D, Hamza M, Dai F, Scheinost D, Sinha R, Todd Constable R, Sherwin R, Hwang JJ. Differential Resting State Connectivity Responses to Glycemic State in Type 1 Diabetes. J Clin Endocrinol Metab 2020; 105:5568225. [PMID: 31511876 PMCID: PMC6936965 DOI: 10.1210/clinem/dgz004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/28/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022]
Abstract
CONTEXT Individuals with type 1 diabetes mellitus (T1DM) have alterations in brain activity that have been postulated to contribute to the adverse neurocognitive consequences of T1DM; however, the impact of T1DM and hypoglycemic unawareness on the brain's resting state activity remains unclear. OBJECTIVE To determine whether individuals with T1DM and hypoglycemia unawareness (T1DM-Unaware) had changes in the brain resting state functional connectivity compared to healthy controls (HC) and those with T1DM and hypoglycemia awareness (T1DM-Aware). DESIGN Observational study. SETTING Academic medical center. PARTICIPANTS 27 individuals with T1DM and 12 HC volunteers participated in the study. INTERVENTION All participants underwent blood oxygenation level dependent (BOLD) resting state functional magnetic brain imaging during a 2-step hyperinsulinemic euglycemic (90 mg/dL)-hypoglycemic (60 mg/dL) clamp. OUTCOME Changes in resting state functional connectivity. RESULTS Using 2 separate methods of functional connectivity analysis, we identified distinct differences in the resting state brain responses to mild hypoglycemia between HC, T1DM-Aware, and T1DM-Unaware participants, particularly in the angular gyrus, an integral component of the default mode network (DMN). Furthermore, changes in angular gyrus connectivity also correlated with greater symptoms of hypoglycemia (r = 0.461, P = 0.003) as well as higher scores of perceived stress (r = 0.531, P = 0.016). CONCLUSION These findings provide evidence that individuals with T1DM have changes in the brain's resting state connectivity patterns, which may be further associated with differences in awareness to hypoglycemia. These changes in connectivity may be associated with alterations in functional outcomes among individuals with T1DM.
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Affiliation(s)
- Lisa Parikh
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, US
| | - Dongju Seo
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
| | - Cheryl Lacadie
- Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, US
| | | | - Derek Groskreutz
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, US
| | - Muhammad Hamza
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, US
| | - Feng Dai
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, US
| | - Dustin Scheinost
- Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, US
| | - Rajita Sinha
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, US
| | - R Todd Constable
- Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, US
| | - Robert Sherwin
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, US
| | - Janice Jin Hwang
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, US
- Correspondence and Reprint Requests: Janice Hwang, The Anylan Center, TAC 119S, New Haven, CT 06520, USA. E-mail:
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10
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Stanley S, Moheet A, Seaquist ER. Central Mechanisms of Glucose Sensing and Counterregulation in Defense of Hypoglycemia. Endocr Rev 2019; 40:768-788. [PMID: 30689785 PMCID: PMC6505456 DOI: 10.1210/er.2018-00226] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
Glucose homeostasis requires an organism to rapidly respond to changes in plasma glucose concentrations. Iatrogenic hypoglycemia as a result of treatment with insulin or sulfonylureas is the most common cause of hypoglycemia in humans and is generally only seen in patients with diabetes who take these medications. The first response to a fall in glucose is the detection of impending hypoglycemia by hypoglycemia-detecting sensors, including glucose-sensing neurons in the hypothalamus and other regions. This detection is then linked to a series of neural and hormonal responses that serve to prevent the fall in blood glucose and restore euglycemia. In this review, we discuss the current state of knowledge about central glucose sensing and how detection of a fall in glucose leads to the stimulation of counterregulatory hormone and behavior responses. We also review how diabetes and recurrent hypoglycemia impact glucose sensing and counterregulation, leading to development of impaired awareness of hypoglycemia in diabetes.
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Affiliation(s)
- Sarah Stanley
- Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amir Moheet
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Elizabeth R Seaquist
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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11
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Lundqvist MH, Almby K, Abrahamsson N, Eriksson JW. Is the Brain a Key Player in Glucose Regulation and Development of Type 2 Diabetes? Front Physiol 2019; 10:457. [PMID: 31133864 PMCID: PMC6524713 DOI: 10.3389/fphys.2019.00457] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/01/2019] [Indexed: 01/08/2023] Open
Abstract
Ever since Claude Bernards discovery in the mid 19th-century that a lesion in the floor of the third ventricle in dogs led to altered systemic glucose levels, a role of the CNS in whole-body glucose regulation has been acknowledged. However, this finding was later overshadowed by the isolation of pancreatic hormones in the 20th century. Since then, the understanding of glucose homeostasis and pathology has primarily evolved around peripheral mechanism. Due to scientific advances over these last few decades, however, increasing attention has been given to the possibility of the brain as a key player in glucose regulation and the pathogenesis of metabolic disorders such as type 2 diabetes. Studies of animals have enabled detailed neuroanatomical mapping of CNS structures involved in glucose regulation and key neuronal circuits and intracellular pathways have been identified. Furthermore, the development of neuroimaging techniques has provided methods to measure changes of activity in specific CNS regions upon diverse metabolic challenges in humans. In this narrative review, we discuss the available evidence on the topic. We conclude that there is much evidence in favor of active CNS involvement in glucose homeostasis but the relative importance of central vs. peripheral mechanisms remains to be elucidated. An increased understanding of this field may lead to new CNS-focusing pharmacologic strategies in the treatment of type 2 diabetes.
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Affiliation(s)
| | - Kristina Almby
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Jan W Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Hwang JJ, Jiang L, Sanchez Rangel E, Fan X, Ding Y, Lam W, Leventhal J, Dai F, Rothman DL, Mason GF, Sherwin RS. Glycemic Variability and Brain Glucose Levels in Type 1 Diabetes. Diabetes 2019; 68:163-171. [PMID: 30327383 PMCID: PMC6302539 DOI: 10.2337/db18-0722] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/09/2018] [Indexed: 02/06/2023]
Abstract
The impact of glycemic variability on brain glucose transport kinetics among individuals with type 1 diabetes mellitus (T1DM) remains unclear. Fourteen individuals with T1DM (age 35 ± 4 years; BMI 26.0 ± 1.4 kg/m2; HbA1c 7.6 ± 0.3) and nine healthy control participants (age 32 ± 4; BMI 23.1 ± 0.8; HbA1c 5.0 ± 0.1) wore a continuous glucose monitor (Dexcom) to measure hypoglycemia, hyperglycemia, and glycemic variability for 5 days followed by 1H MRS scanning in the occipital lobe to measure the change in intracerebral glucose levels during a 2-h glucose clamp (target glucose concentration 220 mg/dL). Hyperglycemic clamps were also performed in a rat model of T1DM to assess regional differences in brain glucose transport and metabolism. Despite a similar change in plasma glucose levels during the hyperglycemic clamp, individuals with T1DM had significantly smaller increments in intracerebral glucose levels (P = 0.0002). Moreover, among individuals with T1DM, the change in brain glucose correlated positively with the lability index (r = 0.67, P = 0.006). Consistent with findings in humans, streptozotocin-treated rats had lower brain glucose levels in the cortex, hippocampus, and striatum compared with control rats. These findings that glycemic variability is associated with brain glucose levels highlight the need for future studies to investigate the impact of glycemic variability on brain glucose kinetics.
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Affiliation(s)
- Janice J Hwang
- Section of Endocrinology, Yale School of Medicine, New Haven, CT
| | - Lihong Jiang
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | | | - Xiaoning Fan
- Section of Endocrinology, Yale School of Medicine, New Haven, CT
| | - Yuyan Ding
- Section of Endocrinology, Yale School of Medicine, New Haven, CT
| | - Wai Lam
- Section of Endocrinology, Yale School of Medicine, New Haven, CT
| | | | - Feng Dai
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT
| | - Douglas L Rothman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
| | - Graeme F Mason
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Robert S Sherwin
- Section of Endocrinology, Yale School of Medicine, New Haven, CT
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Dienel GA. Metabolomic Assays of Postmortem Brain Extracts: Pitfalls in Extrapolation of Concentrations of Glucose and Amino Acids to Metabolic Dysregulation In Vivo in Neurological Diseases. Neurochem Res 2018; 44:2239-2260. [DOI: 10.1007/s11064-018-2611-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/05/2018] [Accepted: 08/06/2018] [Indexed: 01/03/2023]
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