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Chow E, Iqbal A, Walkinshaw E, Phoenix F, Macdonald IA, Storey RF, Ajjan R, Heller SR. Prolonged Prothrombotic Effects of Antecedent Hypoglycemia in Individuals With Type 2 Diabetes. Diabetes Care 2018; 41:2625-2633. [PMID: 30327358 DOI: 10.2337/dc18-0050] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 09/17/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hypoglycemia has been linked to persistent increases in cardiovascular (CV) mortality in type 2 diabetes after the event. Our aim was to examine acute and downstream effects of hypoglycemia on markers of thrombosis risk and inflammation in type 2 diabetes. RESEARCH DESIGN AND METHODS Twelve individuals with type 2 diabetes with no history of CV disease and 11 age- and BMI-matched volunteers without diabetes underwent paired hyperinsulinemic-euglycemic (glucose 6 mmol/L for two 60-min periods) and hypoglycemic (glucose 2.5 mmol/L for two 60-min periods) clamps on separate occasions on day 0. Fibrin clot properties, platelet reactivity, and inflammatory markers were measured at baseline, end of and after recovery from the initial clamp, day 1, and day 7 using validated assays and electron microscopy. RESULTS Euglycemic hyperinsulinemia reduced platelet reactivity, decreased fibrin clot density, and improved fibrinolytic efficiency in both groups. Platelet reactivity and aggregation increased during acute hypoglycemia in both groups, resolving at recovery. In type 2 diabetes, clot lysis times and clot maximum absorbance increased up to day 7 (P = 0.002 and 0.001 vs. euglycemia, respectively), but clots from control subjects without diabetes showed limited changes. Fibrin network density increased Δ 1.15 ± 0.28 fibers/μm2 at day 7 after the hypoglycemic clamp (P < 0.01 for glycemic arm), whereas fibrinogen and complement C3 increased after hypoglycemia up to day 7 in type 2 diabetes only. CONCLUSIONS Antecedent hypoglycemia has acute and persistent prothrombotic effects, lasting at least 7 days, that were enhanced in individuals with type 2 diabetes. These findings identify mechanisms by which hypoglycemia might increase short- and medium-term risk of CV mortality.
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Affiliation(s)
- Elaine Chow
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, U.K.,Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K
| | - Ahmed Iqbal
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, U.K.,Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K
| | - Emma Walkinshaw
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Fladia Phoenix
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Ian A Macdonald
- School of Life Sciences, University of Nottingham, Nottingham, U.K
| | - Robert F Storey
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, U.K.,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Ramzi Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K. .,Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
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Sejling AS, Kjaer TW, Pedersen-Bjergaard U, Remvig LS, Frandsen CS, Hilsted L, Faber J, Holst JJ, Tarnow L, Møller JS, Nielsen MN, Thorsteinsson B, Juhl CB. Hypoglycemia-Associated EEG Changes Following Antecedent Hypoglycemia in Type 1 Diabetes Mellitus. Diabetes Technol Ther 2017; 19:85-90. [PMID: 28118048 DOI: 10.1089/dia.2016.0331] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Recurrent hypoglycemia has been shown to blunt hypoglycemia symptom scores and counterregulatory hormonal responses during subsequent hypoglycemia. We therefore studied whether hypoglycemia-associated electroencephalogram (EEG) changes are affected by an antecedent episode of hypoglycemia. METHODS Twenty-four patients with type 1 diabetes mellitus (10 with normal hypoglycemia awareness, 14 with hypoglycemia unawareness) were studied on 2 consecutive days by hyperinsulinemic glucose clamp at hypoglycemia (2.0-2.5 mmol/L) during a 1-h period. EEG was recorded, cognitive function assessed, and hypoglycemia symptom scores and counterregulatory hormonal responses were obtained. RESULTS Twenty-one patients completed the study. Hypoglycemia-associated EEG changes were identified on both days with no differences in power or frequency distribution in the theta, alpha, or the combined theta-alpha band during hypoglycemia on the 2 days. Similar degree of cognitive dysfunction was also present during hypoglycemia on both days. When comparing the aware and unaware group, there were no differences in the hypoglycemia-associated EEG changes. There were very subtle differences in cognitive function between the two groups on day 2. The symptom response was higher in the aware group on both days, while only subtle differences were seen in the counterregulatory hormonal response. CONCLUSION Antecedent hypoglycemia does not affect hypoglycemia-associated EEG changes in patients with type 1 diabetes mellitus.
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Affiliation(s)
- Anne-Sophie Sejling
- 1 Faculty of Health, University of Southern Denmark , Odense, Denmark
- 2 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital , Hillerød, Denmark
| | - Troels W Kjaer
- 3 Department of Neurology, Roskilde Hospital , Roskilde, Denmark
- 4 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
- 5 Department of Neurophysiology, Rigshospitalet , Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- 2 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital , Hillerød, Denmark
- 4 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | | | - Christian S Frandsen
- 2 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital , Hillerød, Denmark
- 7 Department of Endocrinology, Hvidovre Hospital , Hvidovre, Denmark
| | - Linda Hilsted
- 8 Department of Clinical Biochemistry, Rigshospitalet , Copenhagen, Denmark
| | - Jens Faber
- 4 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
- 9 Department of Endocrinology, Herlev Hospital , Herlev, Denmark
| | - Jens Juul Holst
- 10 NNF Center for Basic Metabolic Research, University of Copenhagen , Copenhagen, Denmark
| | - Lise Tarnow
- 11 Health, Aarhus University , Aarhus, Denmark
- 12 Steno Diabetes Center , Gentofte, Denmark
- 13 The Research Unit, Nordsjællands Hospital , Hillerød, Denmark
| | | | - Martin N Nielsen
- 5 Department of Neurophysiology, Rigshospitalet , Copenhagen, Denmark
| | - Birger Thorsteinsson
- 2 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital , Hillerød, Denmark
- 4 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Claus B Juhl
- 1 Faculty of Health, University of Southern Denmark , Odense, Denmark
- 6 HypoSafe A/S , Lyngby, Denmark
- 14 Department of Medicine, Hospital of South West Jutland , Esbjerg, Denmark
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Abstract
Hypoglycaemia is a frequent adverse effect of treatment of diabetes mellitus with insulin and sulphonylureas. Fear of hypoglycaemia alters self-management of diabetes mellitus and prevents optimal glycaemic control. Mild (self-treated) and severe (requiring help) hypoglycaemia episodes are more common in type 1 diabetes mellitus but people with insulin-treated type 2 diabetes mellitus are also exposed to frequent hypoglycaemic events, many of which occur during sleep. Hypoglycaemia can disrupt many everyday activities such as driving, work performance and leisure pursuits. In addition to accidents and physical injury, the morbidity of hypoglycaemia involves the cardiovascular and central nervous systems. Whereas coma and seizures are well-recognized neurological sequelae of hypoglycaemia, much interest is currently focused on the potential for hypoglycaemia to cause dangerous and life-threatening cardiac complications, such as arrhythmias and myocardial ischaemia, and whether recurrent severe hypoglycaemia can cause permanent cognitive impairment or promote cognitive decline and accelerate the onset of dementia in middle-aged and elderly people with diabetes mellitus. Prevention of hypoglycaemia is an important part of diabetes mellitus management and strategies include patient education, glucose monitoring, appropriate adjustment of diet and medications in relation to everyday circumstances including physical exercise, and the application of new technologies such as real-time continuous glucose monitoring, modified insulin pumps and the artificial pancreas.
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Affiliation(s)
- Brian M Frier
- BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK
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Abstract
Tight glycaemic control (TGC) for patients treated in an intensive care unit ICU is associated with an increased risk for hypoglycaemia. Since hypoglycaemia mainly occurs in the sickest patients, no matter whether TGC is applied or not, it might be a marker for severity of illness or a harmful event in itself. Furthermore, it remains a matter of debate whether harmful effects of hypoglycaemia outbalance the clinical benefits of TGC. This review focusses on the clinical manifestations of hypoglycaemia in the critically ill and highlights its potential short- and long-term consequences specifically concerning neurocognitive function.
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Affiliation(s)
- Thomas Duning
- Department of Neurology, University Hospital of Münster, Albert-Schweitzer-Strafle 33, D-48149 Münster, Germany.
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Driesen NR, Goldberg PA, Anderson AW, Tang L, Flanagan DE, Sherwin RS, Gore JC. Hypoglycemia reduces the blood-oxygenation level dependent signal in primary auditory and visual cortex: a functional magnetic resonance imaging study. J Neurosci Res 2007; 85:575-82. [PMID: 17154420 DOI: 10.1002/jnr.21146] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Studies of the effects of hypoglycemia on the brain using neurocognitive testing have suggested that mainly complex functions subserved by secondary and tertiary cortex are affected by mild to moderate hypoglycemia and that intensively treated patients with Type I diabetes mellitus (T1DM) may have altered sensitivity to the central nervous system effects of hypoglycemia. Functional magnetic resonance imaging provides a sensitive, regionally-specific probe of possible neurophysiologic changes related to hypoglycemia in the brain. Eleven intensively-treated T1DM patients and 11 matched non-diabetic controls took part in a 2-day protocol in which functional magnetic resonance imaging (MRI) was used to measure changes in the patterns of brain activation produced by simple auditory and visual stimuli in different conditions. On one day, participants were euglycemic the entire time. On the other day, an initial 50-min euglycemic period was followed by a 50-min hypoglycemic period. Results indicated that hypoglycemia reduced the amplitude of the blood-oxygenation level dependent response in primary auditory and visual cortex to simple auditory and visual stimuli. The latency and duration of the transient hemodynamic response function were not affected. Responses to hypoglycemia were similar in diabetic and non-diabetic participants. These results suggest that mild to moderate hypoglycemia may alter the balance of blood flow and oxygen extraction when glucose levels are lowered. Intensively-treated T1DM, with its attendant frequent hypoglycemic episodes, did not seem to alter hypoglycemic responses in primary visual and auditory cortex.
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Affiliation(s)
- Naomi R Driesen
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
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Tkacs NC, Thompson HJ. From bedside to bench and back again: research issues in animal models of human disease. Biol Res Nurs 2006; 8:78-88. [PMID: 16766631 PMCID: PMC2366101 DOI: 10.1177/1099800406289717] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To improve outcomes for patients with many serious clinical problems, multifactorial research approaches by nurse scientists, including the use of animal models, are necessary. Animal models serve as analogies for clinical problems seen in humans and must meet certain criteria, including validity and reliability, to be useful in moving research efforts forward. This article describes research considerations in the development of rodent models. As the standard of diabetes care evolves to emphasize intensive insulin therapy, rates of severe hypoglycemia are increasing among patients with type 1 and type 2 diabetes mellitus. A consequence of this change in clinical practice is an increase in rates of two hypoglycemia-related diabetes complications: hypoglycemia-associated autonomic failure (HAAF) and resulting hypoglycemia unawareness. Work on an animal model of HAAF is in an early developmental stage, with several labs reporting different approaches to model this complication of type 1 diabetes mellitus. This emerging model serves as an example illustrating how evaluation of validity and reliability is critically important at each stage of developing and testing animal models to support inquiry into human disease.
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Schultes B, Kern W, Oltmanns K, Peters A, Gais S, Fehm HL, Born J. Differential adaptation of neurocognitive brain functions to recurrent hypoglycemia in healthy men. Psychoneuroendocrinology 2005; 30:149-61. [PMID: 15471613 DOI: 10.1016/j.psyneuen.2004.06.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Revised: 06/18/2004] [Accepted: 06/19/2004] [Indexed: 11/23/2022]
Abstract
Antecedent hypoglycemia is known to attenuate hormonal and symptomatic responses to subsequent hypoglycemia. Whether this pertains also to hypoglycemia-induced cognitive dysfunction is controversially discussed. Neurocognitive adaptation might essentially depend on the type of function. Here, we compared the influence of recurrent hypoglycemia in 15 healthy men on counterregulatory hormones, subjective symptoms of hypoglycemia, short-term memory performance (word recall), and performance on an auditory attention task (oddball). The attention task was also used to record event-related brain potential (ERP) indicators of stimulus processing. In each subject, three consecutive hypoglycemic clamps were performed, two on day 1 and the third on day 2. Neurocognitive testing was performed during baseline and at two different hypoglycemic plateaus (2.8 and 2.5 mmol/l) during the first and last clamp. As expected, hormonal responses were significantly reduced to the last as compared to the first hypoglycemia indicating adaptation. Subjective symptoms also decreased in response to recurrent hypoglycemia. Short-term memory performance deteriorated distinctly on the first hypoglycemic clamp, but maintained the normal level on the last clamp (P=0.006). Likewise, the impairment in reaction time (P=0.022) and response accuracy (P=0.005) was distinctly smaller on the last than first hypoglycemia. In parallel, the hypoglycemia-induced decrease in P3 amplitude (P=0.019) and the increase in P3 latency (P=0.049) were diminished with recurrent hypoglycemia, indicating that late stages of controlled stimulus processing likewise adapted. In contrast, the distinct decrease in amplitudes of the N1 and P2 components of the ERP (preceding the P3) was closely comparable in response to the first and last hypoglycemia (P>0.3). Together results indicate an adaptation to recurrent hypoglycemia for signs of controlled stimulus processing presumably involving hippocampo-prefrontocortical circuitry, while earlier automatic stages of processing appear to be spared.
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Affiliation(s)
- B Schultes
- Department of Internal Medicine I, University of Luebeck, Ratzeburger Allee 160, D-23538 Luebeck, Germany.
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Levin BE, Dunn-Meynell AA, Routh VH. CNS sensing and regulation of peripheral glucose levels. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2003; 51:219-58. [PMID: 12420361 DOI: 10.1016/s0074-7742(02)51007-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It is clear that the brain has evolved a mechanism for sensing levels of ambient glucose. Teleologically, this is likely to be a function of its requirement for glucose as a primary metabolic substrate. There is no question that the brain can sense and mount a counterregulatory response to restore very low levels of plasma and brain glucose. But it is less clear that the changes in glucose associated with normal diurnal rhythms and feeding cycles are sufficient to influence either ingestive behavior or the physiologic responses involved in regulating plasma glucose levels. Glucosensing neurons are clearly a distinct class of metabolic sensors with the capacity to respond to a variety of intero- and exteroceptive stimuli. This makes it likely that these glucosensing neurons do participate in physiologically relevant homeostatic mechanisms involving energy balance and the regulation of peripheral glucose levels. It is our challenge to identify the mechanisms by which these neurons sense and respond to these metabolic cues.
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Affiliation(s)
- Barry E Levin
- Neurology Service, VA Medical Center, East Orange, New Jersey 07018, USA
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Broers S, Van Vliet KP, Everaerd W, Le Cessie S, Radder JK. Modest contribution of psychosocial variables to hypoglycaemic awareness in Type 1 diabetes. J Psychosom Res 2002; 52:97-106. [PMID: 11832255 DOI: 10.1016/s0022-3999(01)00301-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To assess relationships between hypoglycaemic awareness and diabetes-related, psychosocial and demographic characteristics. METHOD Ninety-eight type 1 diabetic patients completed questionnaires on somatic awareness (Somatic Awareness Questionnaire, SAQ), negative affectivity (Positive And Negative Affectivity Schedule, PANAS), symptom beliefs, bustle and variety of daily life. They then performed up to 70 measurements on a hand-held computer, during 4 to 6 weeks, at home. During every measurement, they rated the presence of 20 symptoms on a 0-6 scale, and estimated and measured their blood glucose level. The percentage of recognised hypoglycaemic episodes was calculated from these data, and used as a measure of hypoglycaemic awareness. RESULTS Hypoglycaemic awareness was negatively associated with disease duration and antecedent hypoglycaemia, and positively associated with the use of an insulin pump instead of injections, variety in the daily life, somatic awareness, sensitivity of the symptom beliefs and female gender. However, only 17% of the variance in hypoglycaemic awareness was explained. CONCLUSIONS Psychosocial variables contribute to hypoglycaemic awareness, to a moderate but statistically significant extent.
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Affiliation(s)
- Sandra Broers
- Section Medical Psychology, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
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MacDonald IA. Strategies for maintaining good glycaemia control without recurrent hypoglycaemia. Proc Nutr Soc 1997; 56:281-90. [PMID: 9168539 DOI: 10.1079/pns19970032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- I A MacDonald
- Department of Physiology & Pharmacology, University of Nottingham Medical School, Queen's Medical Centre
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