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Purpose of the Study: The National Health Service is experiencing a recruitment crisis across many medical specialties. Diabetes and endocrinology (D&E) is failing to fill training posts with only 77%, 83% and 73% of posts filled overall in 2016, 2017 and 2018, respectively., Study Design: We surveyed 316 final-year medical students and undifferentiated trainees (from foundation programme doctors to core medical trainees), across the South Thames, Northern and West Midlands deaneries in England to gain an understanding of perceptions of the specialty., Results: 9% of respondents were considering a career in D&E. Factors such as 'being the medical registrar' (27%), being a 'non-procedural specialty' (23%) and 'looking after majority of general medical admissions' (22%) were cited as the most common reasons why D&E is an unattractive career choice. 51% reported inadequate exposure to D&E. Factors that made respondents more likely to want to pursue a career in D&E included having undertaken a placement in the specialty and having exposure to outpatient clinics. Methods to improve awareness and uptake, such as increased teaching and clinical exposure, and the opportunity to attend taster events were frequently highlighted., Conclusions: The results from this survey, the first of its kind on perceptions of D&E as a career pathway, reveal a worrying lack of interest in, and exposure to, D&E among current final-year medical students and undifferentiated trainees. These issues must be addressed in order to improve D&E recruitment rates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Brain responses to low plasma glucose may be key to understanding the behaviors that prevent severe hypoglycemia in type 1 diabetes. This study investigated the impact of long duration, hypoglycemia aware type 1 diabetes on cerebral blood flow responses to hypoglycemia. Three-dimensional pseudo-continuous arterial spin labeling magnetic resonance imaging was performed in 15 individuals with type 1 diabetes and 15 non-diabetic controls during a two-step hyperinsulinemic glucose clamp. Symptom, hormone, global cerebral blood flow and regional cerebral blood flow responses to hypoglycemia were measured. Epinephrine release during hypoglycemia was attenuated in type 1 diabetes, but symptom score rose comparably in both groups. A rise in global cerebral blood flow did not differ between groups. Regional cerebral blood flow increased in the thalamus and fell in the hippocampus and temporal cortex in both groups. Type 1 diabetes demonstrated lesser anterior cingulate cortex activation; however, this difference did not survive correction for multiple comparisons. Thalamic cerebral blood flow change correlated with autonomic symptoms, and anterior cingulate cortex cerebral blood flow change correlated with epinephrine response across groups. The thalamus may thus be involved in symptom responses to hypoglycemia, independent of epinephrine action, while anterior cingulate cortex activation may be linked to counterregulation. Activation of these regions may have a role in hypoglycemia awareness and avoidance of problematic hypoglycemia.

Objective: Impaired awareness of hypoglycemia (IAH) affects one-quarter of adults with type 1 diabetes and significantly increases the risk of severe hypoglycemia. Differences in regional brain responses to hypoglycemia may contribute to the susceptibility of this group to problematic hypoglycemia. This study investigated brain responses to hypoglycemia in hypoglycemia aware (HA) and IAH adults with type 1 diabetes, using three-dimensional pseudo-continuous arterial spin labeling (3D pCASL) functional MRI to measure changes in regional cerebral blood flow (CBF)., Research Design and Methods: Fifteen HA and 19 IAH individuals underwent 3D pCASL functional MRI during a two-step hyperinsulinemic glucose clamp. Symptom, hormone, global, and regional CBF responses to hypoglycemia (47 mg/dL [2.6 mmol/L]) were measured., Results: In response to hypoglycemia, total symptom score did not change in those with IAH ( P = 0.25) but rose in HA participants ( P < 0.001). Epinephrine, cortisol, and growth hormone responses to hypoglycemia were lower in the IAH group ( P < 0.05). Hypoglycemia induced a rise in global CBF (HA P = 0.01, IAH P = 0.04) but was not different between groups ( P = 0.99). IAH participants showed reduced regional CBF responses within the thalamus ( P = 0.002), right lateral orbitofrontal cortex (OFC) ( P = 0.002), and right dorsolateral prefrontal cortex ( P = 0.036) and a lesser decrease of CBF in the left hippocampus ( P = 0.023) compared with the HA group. Thalamic and right lateral OFC differences survived Bonferroni correction., Conclusions: Responses to hypoglycemia of brain regions involved in arousal, decision making, and reward are altered in IAH. Changes in these pathways may disrupt IAH individuals' ability to recognize hypoglycemia, impairing their capacity to manage hypoglycemia effectively and benefit fully from conventional therapeutic pathways to restore awareness., (© 2019 by the American Diabetes Association.)