Cognitive function and event-related potentials in children with type 1 diabetes mellitus

Acute effects of physical exercise on cognitive function and neurotrophins in patients with type 1 diabetes: A systematic review

Background

Type 1 diabetes mellitus (T1DM) is associated with cognitive decline. In contrast, higher levels of neurotrophins, such as brain-derived neurotrophic factor (BDNF), may be associated with better brain health. Physical exercise has been associated with elevated levels of BDNF and consequently improved cognitive function, but whether this association is found in T1DM remains unresolved. The aim of this systematic review was to evaluate the acute effect of physical exercise on cognitive function and BDNF levels in patients affected by T1DM.

Methods

MEDLINE, Cochrane Library (CENTRAL database), EMBASE and SPORTDiscus were screened by 2 independent reviewers, who selected studies that analysed acute effects of physical exercise in patients with T1DM on BDNF levels or cognitive function tests before and after exercise. Studies in humans and English written were included. The quality of these studies was assessed using the respective Cochrane Risk of Bias tool.

Results

After identifying 507 articles, 4 studies including 78 participants were analysed. Two studies were non-randomized clinical trials, the others were crossover trials. Selected studies performed different exercise intervention protocols, evaluating both high and moderate intensity training. BDNF levels were found higher after exercise in all studies. Cognitive function tests resulted also improved after the training intervention.

Conclusions

In subjects with T1DM, preliminary evidence suggests that exercise training might increase plasma BDNF levels and ameliorate cognitive deficits. However, scientific evidence is still very limited and there is a significant need for further research to clarify the possible positive neurocognitive effects of exercise in T1DM.

Evaluation of Event-Related Potentials in Somatic Diseases - Systematic Review

Many somatic illnesses (e.g. hypertension, diabetes, pulmonary and cardiac diseases, hepatitis C, kidney and heart failure, HIV infection, Sjogren's disease) may impact central nervous system functions resulting in emotional, sensory, cognitive or even personality impairments. Event-related potential (ERP) methodology allows for monitoring neurocognitive processes and thus can provide a valuable window into these cognitive processes that are influenced, or brought about, by somatic disorders. The current review aims to present published studies on the relationships between somatic illness and brain function as assessed with ERP methodology, with the goal to discuss where this field of study is right now and suggest future directions.

Subclinical neural hearing alterations in school children with type 1 diabetes mellitus

BACKGROUND AND OBJECTIVES

Evidence has shown a cause-and-effect relationship between type 1 diabetes mellitus and auditory and cognitive dysfunctions. This study aimed to investigate the effect of type 1 diabetes mellitus (T1DM) on central auditory and cognitive functions in school-age children and adolescents.

METHODS

The study sample consisted of 101 children and adolescents, 50 with T1DM, of both sexes, aged between 7 and 18 years. All participants were selected for a structured interview on hearing, behavioral, and cognitive health and assessment of brainstem auditory evoked potentials (BAEP) and event-related potentials (P300).

RESULTS

Significant differences were observed in memory (p=0.002) and attention (p=0.021) complaints between participants with and without T1DM. In the BAEP responses, there were differences between wave III latencies in the right (p=0.017) and left (p=0.019) ears and in wave V latencies in the left ear (p=0.001) between the evaluated groups. In addition, there was an association between BAEP findings and metabolic control in the T1DM group in the left ear in waves III (p=0.006) and V (p=0.005) and in the right ear in wave V (p=0.026). No differences were observed in the latencies of P300 between the evaluated groups.

CONCLUSION

This study demonstrated the existence of a subclinical finding in the central auditory pathway, offering an increased risk for retrocollear alterations, which may be a consequence of poor metabolic control.

Effect of metabolic control on cognitive functions in children and adolescents with type 1 diabetes mellitus

OBJECTIVES

Neurocognitive functions of children with type 1 diabetes mellitus (T1D) are reported to be poorer than those of healthy peers. The aim was to investigate the effects of age of onset of diabetes, metabolic control, and type of insulin regimen on neurocognitive functions in children and adolescents with T1D.

METHODS

Forty-seven children aged 6-18 years, with T1D for at least five years, were included. Children with a known psychiatric disorder or chronic diseases other than T1D were excluded. Intelligence via the Wechsler children's intelligence scale (WISC-R), short-term memory via the audio-auditory digits form B (GISD-B) test, visual motor perception via the Bender Gestalt test, and attention via the Moxo continuous attention and performance test, timing, hyperactivity, and impulsivity (Moxo-dCPT) were assessed.

RESULTS

Compared with the T1D group, healthy controls had higher scores in terms of verbal intelligence quotient (IQ), performance IQ, and total IQ mean scores on WISC-R (p=0.01, p=0.05 and p=0.01, respectively). On the MOXO-dCPT test, the T1D group had higher impulsivity compared to the control group (p=0.04). Verbal IQ was better in the moderate control group than in the poorer metabolic control (p=0.01). Patients with no history of diabetic ketoacidosis (DKA) had higher performance, verbal and total intelligence scores than the group with history of DKA.

CONCLUSIONS

Poor metabolic control and a history of DKA in children with T1D adversely affected neurocognitive functions. It would be beneficial to consider the assessment of neurocognitive functions in T1D and to take the necessary precautions in follow-up.

Evaluación del desempeño cognitivo en escolares y adolescentes con diabetes mellitus tipo 1

The study aimedto evaluate the cognitive functioning of children and adolescents with type 1 diabetes mellitus (T1DM) recruited from the IAHULA Endocrinology Outpatient Unit and to compare it to that of non-diabetics as to investigate the influence on cognition of factors re-lated to the disease. An analytical, cross-sectional observational study was carried out on a group of 30 patients with T1DM between 8 and 16 years of age and on a control group of 30 individuals matched by age, gender, education, and socioeconomic status. Interrogation and review of medi-cal records to obtain data on the clinical characteristics and treatment of T1DM were conducted. The WISC IV test was then applied to evaluate cognition and intellectual coefficient (IQ). The average age of the diabetic patients was 13.27±2.31 years, and half of them were male. Lower scores were found in the different domains of the WISC IV in the group with T1DM (p<0.01). The IQ was found to be lower in children with T1DM than in con-trols (75.47±13.87 vs. 88.57±11.06; p=0.0001). Likewise, a higher fre-quency of IQ scores below the 10th percentile was observed in the diabetic children (63.3% vs. 33.3%; p=0.02; Odds ratio: 3.45; 95%CI: 1.19-9.99). It was concluded that T1DM negatively impacts the cognitive performance of children and adolescents. Cognitive evaluation of these patients is recom-mended, as it could affect their daily life.

Increased Use of Hyperosmolar Therapy for Suspected Clinically Apparent Brain Injury in Pediatric Patients with Diabetic Ketoacidosis during the Peak of the COVID-19 Pandemic

The incidence of pediatric diabetic ketoacidosis (DKA) increased during the peak of the COVID-19 pandemic. The objective of this study was to investigate whether rates of hyperosmolar therapy administration for suspected clinically apparent brain injury (CABI) complicating DKA also increased during this period as compared to the three years immediately preceding the pandemic and to compare the characteristics of patients with suspected CABI before the pandemic, patients with suspected CABI during the peak of the pandemic, and those with DKA but without suspected CABI during the pandemic. Patients aged ≤18 years presenting with DKA before (March 11, 2017-March 10, 2020) and during the peak of the pandemic (March 11, 2020-March 10, 2021) were identified through a rigorous search of two databases. Predefined criteria were used to diagnose suspected CABI. Biochemical, clinical, and sociodemographic data were collected from a comprehensive review of the electronic medical record. The proportion of patients with DKA who received hyperosmolar therapy was significantly higher (P = 0.014) during the pandemic compared to the prepandemic period; however, this was only significant among patients with newly diagnosed diabetes. Both groups with suspected CABI had more severe acidosis, lower Glasgow Coma Scale scores, and longer hospital admissions (P< 0.001 for all) than cases without suspected CABI. During the pandemic, the blood urea nitrogen concentration was significantly higher in patients with suspected CABI than those without suspected CABI, suggesting they were more severely dehydrated. The clinical, biochemical, and sociodemographic characteristics of patients with suspected CABI were indistinguishable before and during the pandemic. In conclusion, administration of hyperosmolar therapy for suspected CABI was more common during the peak of the COVID-19 pandemic, possibly a result of delayed presentation, highlighting the need for increased awareness and early recognition of the signs and symptoms of diabetes and DKA, especially during future surges of highly transmissible infections.

Intellectual Functioning of Pediatric Patients with Chronic Kidney Disease: Results from the KNOW-Ped CKD

BACKGROUND

Chronic kidney disease (CKD) has a negative impact on growth and development in children and is a risk factor for neurocognitive impairment; however, there is limited research on the cognitive function of children and adolescents with CKD. This study therefore aimed to investigate the mean intelligence and risk factors for low intelligence in children and adolescents with CKD.

METHODS

Eighty-one patients with CKD under 18 years old were included in the KoreaN cohort study for Outcomes in patients With Pediatric Chronic Kidney Disease (KNOW-Ped CKD). Participants completed either the Wechsler Intelligence Scale for Children (6-16 years), or Wechsler Adult Intelligence Scale (> 16 years).

RESULTS

The mean full-scale intelligence quotient (IQ) was 91 ± 19; 24.7% of participants scored a full-scale IQ below 80. Participants with a short stature (height Z scores < -1.88), failure to thrive (weight Z scores < -1.65), more severe CKD stage (≥ IIIb), longer duration of CKD (≥ 5 years), and those who were Medicare or Medicaid beneficiaries, had significantly lower mean full-scale IQs.

CONCLUSION

On linear regression analysis, the association between the full-scale IQ, and longer duration of CKD and growth failure, remained significant after controlling for demographic and clinical variables. It is therefore necessary to investigate cognitive impairment in pediatric patients with CKD who exhibit growth failure or for a longer postmorbid period. It is believed that early interventions, such as kidney transplantation, will have a positive effect on IQ in children with CKD, as the disease negatively affects IQ due to poor glomerular filtration rate over time.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02165878.

Brain injury in children with diabetic ketoacidosis: Review of the literature and a proposed pathophysiologic pathway for the development of cerebral edema

Cerebral edema (CE) is a potentially devastating complication of diabetic ketoacidosis (DKA) that almost exclusively occurs in children. Since its first description in 1936, numerous risk factors have been identified; however, there continues to be uncertainty concerning the mechanisms that lead to its development. Currently, the most widely accepted hypothesis posits that CE occurs as a result of ischemia-reperfusion injury, with inflammation and impaired cerebrovascular autoregulation contributing to its pathogenesis. The role of specific aspects of DKA treatment in the development of CE continues to be controversial. This review critically examines the literature on the pathophysiology of CE and attempts to categorize the findings by types of brain injury that contribute to its development: cytotoxic, vasogenic, and osmotic. Utilizing this scheme, we propose a multifactorial pathway for the development of CE in patients with DKA.

Diabetes-induced auditory complications: are they preventable? a comprehensive review of interventions

Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels, which, over time, lead to major chronic complications in various organs of the body. A growing body of research suggests that diabetes could also result in degenerative changes in the auditory system. To date, several attempts have been made to prevent and reduce diabetes-induced auditory complications. Such attempts have generally focused on disease modifying as well as other pharmacological treatments involving several herbal and non-herbal agents such as vitamins C and E, rutin, resveratrol, coffee, trigonelline, Dioscorea nipponica, red ginseng, Pterostilbene Bofutsushosan, Daisaikoto, tolrestat, ACE inhibitors (enalapril), Ca antagonists (nimodipine), Lipo-prostaglandin E1, methylprednisolone, dexamethasone, and chlorogenic acid and also other strategies like acupuncture. However, there is no consensus about which are the most effective strategies for preventing and reducing auditory complications in diabetic patients with few side effects and maximum efficacy. This paper provides a comprehensive review of interventions for preventing and treating diabetes-induced auditory complications to help therapists.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.

A systematic review of the effect of prior hypoglycaemia on cognitive function in type 1 diabetes

BACKGROUND

The effect of prior hypoglycaemia on cognitive function in type 1 diabetes is an important unresolved clinical question. In this systematic review, we aimed to summarize the studies exploring the impact of prior hypoglycaemia on any aspect of cognitive function in type 1 diabetes.

METHODS

We used a multidatabase search platform Healthcare Database Advanced Search to search Medline, PubMed, EMBASE, EMCARE, CINAHL, PsycINFO, BNI, HMIC, and AMED from inception until 1 May 2019. We included studies on type 1 diabetes of any age. The outcome measure was any aspect of cognitive function.

RESULTS

The 62 studies identified were grouped as severe hypoglycaemia (SH) in childhood (⩽18 years) and adult-onset (>18 years) diabetes, nonsevere hypoglycaemia (NSH) and nocturnal hypoglycaemia (NH). SH in early childhood-onset diabetes, especially seizures and coma, was associated with poorer memory (verbal and visuospatial), as well as verbal intelligence. Among adult-onset diabetes, SH was associated with poorer cognitive performance in the older age (>55 years) group only. Early versus late exposure to SH had a significant association with cognitive dysfunction (CD). NSH and NH did not have any significant association with CD, while impaired awareness of hypoglycaemia was associated with poorer memory and cognitive-processing speeds.

CONCLUSION

The effect of SH on cognitive function is age dependent. Exposure to SH in early childhood (<10 years) and older age groups (>55 years) was associated with a moderate effect on the decrease in cognitive function in type 1 diabetes [PROSPERO ID: CRD42019141321].

Neurophysiological Evidence for a Compensatory Activity during a Simple Oddball Task in Adolescents with Type 1 Diabetes Mellitus

OBJECTIVE

The poor metabolic control in type 1 diabetes mellitus (T1D) has a negative impact on the developing brain. Hyperglycemia and glycemic fluctuations disrupt mainly executive functions. To assess a hypothesized deficit of the executive functions, we evaluated visual processing and reaction time in an oddball task.

METHODS

Oddball visual event-related potentials (ERPs), reaction time, and pattern-reversal visual evoked potentials (VEPs) were examined in a cohort of twenty-two 12- to 18-year-old T1D patients without diabetic retinopathy at normal glycemia and in nineteen 10- to 21-year-old healthy controls.

RESULTS

The P100 peak time of the VEPs was significantly prolonged in T1D patients compared with the control group (p < 0.017). In contrast to the deteriorated sensory response, the area under the curve of the P3b component of the ERPs was significantly larger (p = 0.035) in patients, while reaction time in the same task did not differ between groups (p = 0.713).

CONCLUSIONS

The deterioration on a sensory level, enhanced activity during cognitive processing, and balanced behavioral response support the view that neuroplasticity counterbalances the neural impairment by enhanced cognitive processing to achieve normal behavioral performance in T1D adolescents.

Prolonged episodes of hypoglycaemia in HNF4A-MODY mutation carriers with IGT. Evidence of persistent hyperinsulinism into early adulthood

AIMS

HNF4A is an established cause of maturity onset diabetes of the young (MODY). Congenital hyperinsulinism can also be associated with mutations in the HNF4A gene. A dual phenotype is observed in HNF4A-MODY with hyperinsulinaemic hypoglycaemia in the neonatal period progressing to diabetes in adulthood. The nature and timing of the transition remain poorly defined. We performed an observational study to establish changes in glycaemia and insulin secretion over a 6-year period. We investigated glycaemic variability and hypoglycaemia in HNF4A-MODY using a continuous glucose monitoring system (CGMS).

METHODS

An OGTT with measurement of glucose, insulin and C-peptide was performed in HNF4A participants with diabetes mellitus (DM) (n = 14), HNF4A-IGT (n = 7) and age- and BMI-matched MODY negative family members (n = 10). Serial assessment was performed in the HNF4A-IGT cohort. In a subset of HNF4A-MODY mutation carriers (n = 10), CGMS was applied over a 72-h period.

RESULTS

There was no deterioration in glycaemic control in the HNF4A-IGT cohort. The fasting glucose-to-insulin ratio was significantly lower in the HNF4A-IGT cohort when compared to the normal control group (0.13 vs. 0.24, p = 0.03). CGMS profiling demonstrated prolonged periods of hypoglycaemia in the HNF4A-IGT group when compared to the HNF4A-DM group (432 vs. 138 min p = 0.04).

CONCLUSIONS

In a young adult HNF4A-IGT cohort, we demonstrate preserved glucose, insulin and C-peptide secretory responses to oral glucose. Utilising CGMS, prolonged periods of hypoglycaemia are evident despite a median age of 21 years. We propose a prolonged hyperinsulinaemic phase into adulthood is responsible for the notable hypoglycaemic episodes.

Diabetic ketoacidosis and electroencephalographic changes in newly diagnosed pediatric patients

OBJECTIVE

To document electroencephalogram (EEG) changes and their correlation with clinical parameters in a newly diagnosed pediatric cohort of type 1 diabetes mellitus (T1DM) patients with and without diabetic ketoacidosis (DKA) and to define their medium term utility and significance.

RESEARCH DESIGN AND METHODS

Prospective longitudinal study of children presenting with T1DM. EEGs were performed within 24 h of diagnosis, day 5, and at 6 months post-diagnosis and reviewed by a neurologist blinded to clinical status. Severity of encephalopathy was graded from 1 to 5 using the Aoki and Lombroso encephalopathy scale. Cognitive abilities were assessed using standardized tests of attention, memory, and intelligence.

RESULTS

Eighty eight children were recruited; 34 presented with DKA. Abnormal background slowing was more often observed in the first 24 h in children with DKA (p = 0.01). Encephalopathy scores on day 1 correlated with initial pH, CO2 , HCO3 , base excess, respiratory rate, heart rate, diastolic blood pressure, and IV fluid intake (all parameters p < 0.05). EEG scores at day 1 did not correlate with contemporaneous mental state or cognition in the medium term.

CONCLUSIONS

DKA was associated with significant clinical and neurophysiologic signs of brain dysfunction at presentation. While EEG is sensitive to the detection of encephalopathy in newly diagnosed T1DM, it has limited use in identifying children at risk of later cognitive deficits.

Epidemiology of diabetic ketoacidosis in Arab patients with type 1 diabetes: a systematic review

AIMS

Diabetic ketoacidosis (DKA) is an acute and risky complication of type 1 diabetes. The aim of this study is to build the overall rate of DKA in Arab patients with type 1 diabetes in the 22 Arab nations. This is expected to tailor the healthcare approaches in Arab countries where attention is needed to save lives from the devastating consequences of DKA.

METHODS

The study here is a quantitative analysis of the articles indexed in four different scientific literature databases: Web of Science, PubMed, Science Direct and Scopus, from inception to June 2015. Arab patients with type 1 diabetes who presented with DKA have been captured. Key information was possible to extract for patients belong to only 12 Arab countries out of the 22 Arab patients.

RESULTS

Twenty-nine studies in 12 different Arab countries captured 4,688 type 1 diabetes patients with overall rates of 46.7% patients presented with DKA, ranging from a low of 17% in Egypt to a high of 100% in Morocco, Algeria and Tunisia.

CONCLUSION

This is the first descriptive quantitative study to determine the overall DKA rate in 46 years of studies in the Arab world of patients with type 1 diabetes; DKA rates were found to range from 17% to 100% with overall rate of 46.7%.

Effects of Diabetic Ketoacidosis on Visual and Verbal Neurocognitive Function in Young Patients Presenting with New-Onset Type 1 Diabetes

OBJECTIVE

To evaluate the effects of diabetic ketoacidosis (DKA) on neurocognitive functions in children and adolescents presenting with new-onset type 1 diabetes.

METHODS

Newly diagnosed patients were divided into two groups: those with DKA and those without DKA (non-DKA). Following metabolic stabilization, the patients took a mini-mental status exam prior to undergoing a baseline battery of cognitive tests that evaluated visual and verbal cognitive tasks. Follow-up testing was performed 8-12 weeks after diagnosis. Patients completed an IQ test at follow-up.

RESULTS

There was no statistical difference between the DKA and non-DKA groups neither in alertness at baseline testing nor in an IQ test at follow-up. The DKA group had significantly lower baseline scores than the non-DKA group for the visual cognitive tasks of design recognition, design memory and the composite visual memory index (VMI). At follow-up, Design Recognition remained statistically lower in the DKA group, but the design memory and the VMI tasks returned to statistical parity between the two groups. No significant differences were found in verbal cognitive tasks at baseline or follow-up between the two groups. Direct correlations were present for the admission CO2 and the visual cognitive tasks of VMI, design memory and design recognition. Direct correlations were also present for admission pH and VMI, design memory and picture memory.

CONCLUSION

Pediatric patients presenting with newly diagnosed type 1 diabetes and severe but uncomplicated DKA showed a definite trend for lower cognitive functioning when compared to the age-matched patients without DKA.

Cognitive function and endogenous cytokine levels in children with chronic hepatitis C

Little is known about how hepatitis C (HCV) infection affects cognitive function in children. The aim of the study was to assess the impact of HCV infection on cognitive function of children with normal liver functions and their relationships to endogenous IFN-α, IL-6 and TNF-α. IFN-α, IL-6 and TNF-α were measured and the Arabic version of the Stanford-Binet test used to assess cognitive functions in 35 children with HCV infection and 23 controls. Serum levels of IL-6 and IFN-α were significantly higher in patients compared to controls. There was a significant effect on vocabulary, comprehension, and abstract visual reasoning, quantitative reasoning and bead memory tests, as well as total short-term memory and intelligence quotient in patients compared to controls. There was a significant positive correlation between IFN-α and IL-6. Also there were significant negative correlations between IFN-α and Abstract visual reasoning test, Quantitative reasoning test, Bead memory test, Total short-term memory and Intelligence quotient; and between IL-6 and Abstract visual reasoning test, Quantitative reasoning test and Intelligence quotient. There was no significant correlation between TNF-α and any of the cognitive functions. Cytokine levels were not related to demographic characteristics of the patients or viral load (PCR). Children with chronic hepatitis C infection in its early stages showed signs of cognitive impairment, with the memory tasks being mostly affected. There was a significant correlation between endogenous cytokines and cognitive impairment in these children. Further studies are needed to define the effect of successful antiviral treatment.

The Impact of Diabetes on Brain Function in Childhood and Adolescence

A constant supply of glucose to the brain is critical for normal cerebral metabolism. The dysglycemia of type 1 diabetes (T1D) can affect activity, survival, and function of neural cells. Clinical studies in T1D have shown impairments in brain morphology and function. The most neurotoxic milieu seems to be young age and/or diabetic ketoacidosis at onset, severe hypoglycemia under the age of 6 years followed by chronic hyperglycemia. Adverse cognitive outcomes seem to be associated with poorer mental health outcomes. It is imperative to improve outcomes by investigating the mechanisms of injury so that neuroprotective strategies independent of glycemia can be identified.

VEGF can protect against blood brain barrier dysfunction, dendritic spine loss and spatial memory impairment in an experimental model of diabetes

Clinical and experimental studies have shown a clear link between diabetes, vascular dysfunction and cognitive impairment. However, the molecular underpinnings of this association remain unclear. Since vascular endothelial growth factor (VEGF) signaling is important for maintaining vascular integrity and function, we hypothesized that vascular and cognitive impairment in the diabetic brain could be related to a deficiency in VEGF signaling. Here we show that chronic hyperglycemia (~8weeks) in a mouse model of type 1 diabetes leads to a selective reduction in the expression of VEGF and its cognate receptor (VEGF-R2) in the hippocampus. Correlating with this, diabetic mice showed selective deficits in spatial memory in the Morris water maze, increased vessel area, width and permeability in the dentate gyrus/CA1 region of the hippocampus and reduced spine densities in CA1 neurons. Chronic low dose infusion of VEGF in diabetic mice was sufficient to restore VEGF signaling, protect them from memory deficits, as well as vascular and synaptic abnormalities in the hippocampus. These findings suggest that a hippocampal specific reduction in VEGF signaling and resultant vascular/neuronal defects may underlie early manifestations of cognitive impairment commonly associated with diabetes. Furthermore, restoring VEGF signaling may be a useful strategy for preserving hippocampal-related brain circuitry in degenerative vascular diseases.

Type 1 Diabetes Modifies Brain Activation in Young Patients While Performing Visuospatial Working Memory Tasks

In recent years, increasing attention has been paid to the effects of Type 1 Diabetes (T1D) on cognitive functions. T1D onset usually occurs during childhood, so it is possible that the brain could be affected during neurodevelopment. We selected young patients of normal intelligence with T1D onset during neurodevelopment, no complications from diabetes, and adequate glycemic control. The purpose of this study was to compare the neural BOLD activation pattern in a group of patients with T1D versus healthy control subjects while performing a visuospatial working memory task. Sixteen patients and 16 matched healthy control subjects participated. There was no significant statistical difference in behavioral performance between the groups, but, in accordance with our hypothesis, results showed distinct brain activation patterns. Control subjects presented the expected activations related to the task, whereas the patients had greater activation in the prefrontal inferior cortex, basal ganglia, posterior cerebellum, and substantia nigra. These different patterns could be due to compensation mechanisms that allow them to maintain a behavioral performance similar to that of control subjects.

Type 1 diabetes-associated cognitive decline: a meta-analysis and update of the current literature

BACKGROUND

Type 1 diabetes (T1D) can have a significant impact on brain structure and function, which is referred to as T1D-associated cognitive decline (T1DACD). Diabetes duration, early onset disease, and diabetes-associated complications are all proposed as factors contributing to T1DACD. However, there have been no comparisons in T1DACD between children and adults with T1D. To obtain a better insight into the occurrence and effects of T1DACD in T1D, the aim of the present meta-analysis was to investigate differences between children and adults and to analyse factors contributing T1DACD.

METHODS

Two electronic databases were consulted: PubMed and ISI Web of Knowledge. Literature published up until the end of 2013 was included in the analysis. Effect sizes (Cohen's d), which are standardized differences between experimental and control groups, were calculated.

RESULTS

There was a small to modest decrease in cognitive performance in T1D patients compared with non-diabetic controls. Children with T1D performed worse while testing for executive function, full intelligence quotient (IQ), and motor speed, whereas adults with T1D performed worse while testing the full, verbal and performance IQ, part of the executive function, memory, spatial memory, and motor speed. Episodes of severe hypoglycemia, chronic hyperglycemia, and age of onset can be significant factors influencing cognitive function in T1D.

CONCLUSIONS

The findings in the literature suggest that T1DACD is more severe in adults than children, indicating that age and diabetes duration contribute to this T1DACD.

Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children

OBJECTIVE

To investigate the impact of new-onset diabetic ketoacidosis (DKA) during childhood on brain morphology and function.

RESEARCH DESIGN AND METHODS

Patients aged 6-18 years with and without DKA at diagnosis were studied at four time points: <48 h, 5 days, 28 days, and 6 months postdiagnosis. Patients underwent magnetic resonance imaging (MRI) and spectroscopy with cognitive assessment at each time point. Relationships between clinical characteristics at presentation and MRI and neurologic outcomes were examined using multiple linear regression, repeated-measures, and ANCOVA analyses.

RESULTS

Thirty-six DKA and 59 non-DKA patients were recruited between 2004 and 2009. With DKA, cerebral white matter showed the greatest alterations with increased total white matter volume and higher mean diffusivity in the frontal, temporal, and parietal white matter. Total white matter volume decreased over the first 6 months. For gray matter in DKA patients, total volume was lower at baseline and increased over 6 months. Lower levels of N-acetylaspartate were noted at baseline in the frontal gray matter and basal ganglia. Mental state scores were lower at baseline and at 5 days. Of note, although changes in total and regional brain volumes over the first 5 days resolved, they were associated with poorer delayed memory recall and poorer sustained and divided attention at 6 months. Age at time of presentation and pH level were predictors of neuroimaging and functional outcomes.

CONCLUSIONS

DKA at type 1 diabetes diagnosis results in morphologic and functional brain changes. These changes are associated with adverse neurocognitive outcomes in the medium term.

Hypoglycemia induced by insulin as a triggering factor of cognitive deficit in diabetic children

This paper provides an overview of insulin-induced hypoglycemia as a triggering factor of cognitive deficit in children with type 1 diabetes mellitus. For this purpose, databases from 1961 to 2013 were used with the objective of detecting the primary publications that address the impact of hypoglycemia on cognitive performance of diabetic children. The results obtained from experimental animals were excluded. The majority of studies demonstrated that the cognitive deficit in diabetic children involves multiple factors including duration, intensity, severity, and frequency of hypoglycemia episodes. Additionally, age at the onset of type 1 diabetes also influences the cognitive performance, considering that early inception of the disease is a predisposing factor for severe hypoglycemia. Furthermore, the results suggest that there is a strong correlation between brain damage caused by hypoglycemia and cognitive deterioration. Therefore, a more cautious follow-up and education are needed to impede and treat hypoglycemia in children with diabetes mellitus.

Academic skills in children with early-onset type 1 diabetes: the effects of diabetes-related risk factors

AIM

The study aimed to assess the effects of diabetes-related risk factors, especially severe hypoglycaemia,on the academic skills of children with early-onset type 1 diabetes mellitus (T1DM).

METHOD

The study comprised 63 children with T1DM (31 females, 32 males; mean age 9 y 11 mo,SD 4 mo) and 92 comparison children without diabetes (40 females, 52 males;mean age 9 y 9 mo,SD 3 mo). Children were included if T1DM had been diagnosed before the age of 5 years and if they were aged between 9 and 10 years at the time of study. Children were not included if their native language was not Finnish and if they had a diagnosed neurological disorder that affected their cognitive development. Among the T1DM group, 37 had and 26 had not experienced severe hypoglycaemia and 26 had avoided severe hypoglycaemia. Severe hypoglycaemia, diabetic ketoacidosis(DKA), and glycaemic control were used as T1DM-related factors. Task performance in reading, spelling, and mathematics was compared among the three groups, and the effects of the T1DM-related factors were analysed with general linear models.

RESULTS

The groups with (p<0.001) and without (p=0.001) severe hypoglycaemia demonstrated a poorer performance than the comparison group in spelling, and the group without severe hypoglycaemia showed a poorer performance than the comparison group in mathematics (p=0.003).Severe hypoglycaemia, DKA, and recent glycaemic control were not associated with poorer skills,but poorer first-year glycaemic control was associated with poorer spelling (p=0.013).

INTERPRETATION

An early onset of T1DM can increase the risk of learning problems, independently of the history of severe hypoglycaemia or DKA. Poorer glycaemic control after the first year of T1DM is associated with a poorer acquisition of academic skills indicating the effect of the timing of metabolic aberrations on cognitive development.

Change in mean transit time, apparent diffusion coefficient, and cerebral blood volume during pediatric diabetic ketoacidosis treatment

OBJECTIVES

Cerebral edema is a devastating complication of pediatric diabetic ketoacidosis. We examined measures describing potential causes of whole brain and regional brain edema (mean transit time, apparent diffusion coefficient, and relative cerebral blood volume) during treatment of diabetic ketoacidosis in children.

DESIGN

Prospective observational study.

SETTING

Regional children's hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After Institutional Review Board approval, children admitted with diabetic ketoacidosis (pH <7.3, HCO3 <15 mEq/L, glucose >300 mg/dL, and ketosis) underwent two serial paired contrast-enhanced (gadolinium) and diffusion magnetic resonance imaging scans. Change in whole brain and regional (frontal lobe, occipital lobe, and basal ganglia) mean transit time, apparent diffusion coefficient, and relative cerebral blood volume between the two time periods (12-24 hrs) and (36-72 hrs) after start of insulin treatment (time 0) were determined. Thirteen children (median age, 10.3 ± 1.1 yrs; 7 female) with diabetic ketoacidosis were examined. Overall, whole brain and regional mean transit time decreased from time 1 (first magnetic resonance imaging after time 0) to time 2 (second magnetic resonance imaging after time 0) by 51% ± 59% (p = .01), without differences between the brain regions examined. Whole brain apparent diffusion coefficient increased by 4.7% ± 3.4% (p = .001), without differences between the brain regions examined. There was no change in relative cerebral blood volume for the whole brain and for the three brain regions examined.

CONCLUSIONS

In this study, whole brain mean transit time decreased and apparent diffusion coefficient increased, suggesting a vasogenic process between the two study periods during diabetic ketoacidosis treatment.