Assessment of the effect of the COVID-19 lockdown on glycaemic control in people with type 1 diabetes using flash glucose monitoring.

AIM: To describe the effect of the stringent lockdown measures, introduced in the UK on 23 March 2020 to curtail the transmission of COVID-19, on glycaemic control in people with type 1 diabetes using flash glucose monitoring. METHODS: We undertook an observational study of 572 individuals with type 1 diabetes for whom paired flash glucose monitoring data were available between early March and May 2020. The primary outcome was change in flash glucose monitoring variables. We also assessed clinical variables associated with change in glycaemic control. RESULTS: Percentage of time in range increased between March and May 2020 [median (interquartile range) 53 (41-64)% vs 56 (45-68)%; P < 0.001], with associated improvements in standard deviation of glucose (P <0.001) and estimated HbA1c (P <0.001). There was a small reduction in the number of individuals meeting the hypoglycaemia target of <5% per day (64% vs 58%; P = 0.004). Comparing changes in flash glucose monitoring data from March to May in 2019 with the same period in 2020 confirmed that these differences were confined to 2020. Socio-economic deprivation was an independent predictor of a ≥5% reduction in time in range during lockdown (odds ratio 0.45 for people in the two most affluent Scottish Index of Multiple Deprivation quintiles; P <0.001). CONCLUSIONS: Lockdown was not associated with a significant deterioration in glycaemic control in people with type 1 diabetes using flash glucose monitoring. However, socio-economic deprivation appeared to increase the risk of decline in glycaemic control, which has implications for how support is focused in challenging times.

Altered metabolic parameters in association with antipsychotic medication use in diabetes: A population based case-control study.

AIMS: This study assess differences in clinical variables in diabetes patients prescribed antipsychotic medication and determines relative schizophrenia prevalence in the diabetes population. METHODS: This population-based case-control study utilizing Scotland's national diabetes registry (SCI-diabetes) and linked psychiatric hospital discharge data (SMR04) established diabetes phenotypes in a patient cohort prescribed long term antipsychotic medication (n=2362) (cases). Cases were matched 1:10 to diabetes patients not prescribed antipsychotic medication (controls) for BMI, gender; diabetes type; birth year; diagnosis date; smoking status. Sub-groups with defined schizophrenia (n=196) or bipolar disorder (n=190) were further examined. Schizophrenia prevalence in the diabetes versus general population was compared. RESULTS: During follow up, antipsychotic prescription was associated with lower HbA1c (55.1 (95% CI 54.5-55.8) or 7.2 (95% CI 7.1-7.3)% vs 58.2 (58.0-58.4) mmol or 7.5 (95% CI 7.5-7.5)% p<0.001) lower serum total cholesterol, 4.2 (4.1-4.2) vs 4.3 (4.2-4.3) mmol/l, p<0.001, lower blood pressure (systolic 130 (130.17-131.29) vs 134 (134.3-134.7) mmHg, p<0.001), higher prescription of oral hypoglycaemic medication (42% (40-45) vs 38% (37-39) p<0.001), similar statin prescriptions (85% (81-89) vs 85% (84-86), p=0.55), and lower retinopathy rates (28% (25.6-30.5) vs 32% (31.5-33.1), p<0.001). HbA1c at diagnosis was similar (p=0.27). Schizophrenia prevalence was higher in the diabetes versus general population with differences across age groups (Scottish population versus diabetic population rate of 522.2 (522.1-522.3) versus 717.4 (703.4-731.9) per 100,000). CONCLUSIONS: We confirm higher diabetes rates in schizophrenia up to age 70, similar attendance rates and clinical measurements that are not worse in a large well-matched population-based Scottish sample prescribed antipsychotic medication versus matched general diabetes patients.

Blood transfusion in developing countries: problems, priorities and practicalities.

The acute medical services could not exist without blood transfusions--life-savers in many situations. But transfusions can also be a quick and easy route for the transmission of infectious agents such as HIV, HBV, HCV and malaria. Infection through blood supply is a major issue in all countries but particularly in those with economic constraints which limit safety. This study was carried out in India (March-May 1997) and involved centres in Delhi, Calcutta and Vellore. It examined many aspects of blood transfusion including donor screening, use of professional donors, blood testing and criteria for blood use. The many problems in Indian blood transfusion services are mirrored in other countries. Here we examine the problems, priorities and practicalities of blood transfusion particularly in developing countries.

PIP: HIV and hepatitis transmission through blood transfusion is a major concern in developing countries where economic constraints limit blood supply safety. Blood transfusion may account for up to 15% of HIV transmission in developing countries. Only 66% of developing and 46% of the least developed countries screen blood for HIV since such testing can double the basic cost of a unit of blood. Blood banks in the private sector tend to be driven by commercial interests, and both public and private programs rely on high-risk professional donors given a shortage of voluntary donors. The following measures are recommended to improve blood transfusion services in India and other developing countries: 1) thorough donor screening to eliminate high-risk donors; 2) the availability of cheaper, more sensitive HIV tests; 3) assumption of responsibility for blood safety by physicians giving the transfusions; 4) adaptation of guidelines for blood administration to local needs; 5) avoidance of unnecessary transfusions; 6) more widespread use of autologous transfusions and intra- and postoperative blood salvage; 7) cost-benefit analyses of blood safety procedures; 8) monitoring of implementation of blood safety legislation; 9) use of an independent authority for blood bank licensing and monitoring; and 10) promotion of voluntary donation as a public responsibility.

Glucocorticoid metabolism within superficial subcutaneous rather than visceral adipose tissue is associated with features of the metabolic syndrome in South African women.

OBJECTIVE: Glucocorticoid hyperactivity in adipose tissue, due to up-regulation of local glucocorticoid reactivation by 11beta-hydroxysteroid dehydrogenase-1 (11HSD1) or of glucocorticoid receptors (GR), may underpin susceptibility to the metabolic syndrome. This hypothesis has been tested extensively in subcutaneous adipose tissue (SAT) but inadequately in visceral adipose tissue (VAT). The aim of the study was therefore to examine expression of 11HSD1, GRalpha and hexose-6-phosphate dehydrogenase (H6PDH), which supplies cofactor for 11HSD1, in abdominal adipose tissue compartments and to characterize their relation to metabolic syndrome parameters. DESIGN AND SUBJECTS: A cross-sectional study including 26 premenopausal South African women. MEASUREMENTS: Biopsies were taken for measurement of mRNA levels by real-time polymerase chain reaction (RT-PCR) and 11HSD1 activity from VAT, and deep and superficial SAT compartments during elective surgery. Prior to surgery, blood pressure, blood lipid profile, body composition [by dual X-ray absorptiometry (DEXA) scan], body fat distribution [by computed tomography (CT) scan], and glucose tolerance were determined. RESULTS: 11HSD1 activity (P < 0.01) was higher in VAT than SAT, but 11HSD1 and GRalpha mRNA levels were not statistically different between compartments. 11HSD1 mRNA levels in superficial SAT correlated with VAT volume (R = 0.57, P < 0.01), insulin sensitivity calculated from the oral glucose tolerance test (OGTT) (R = -0.52, P < 0.016) and blood pressure (R = 0.48, P < 0.016). Apart from a correlation between deep SAT 11HSD1 activity and blood pressure (R = 0.72, P < 0.01), glucocorticoid action in deep SAT and VAT depots was not significantly associated with any metabolic syndrome parameters. CONCLUSION: Increased capacity for glucocorticoid regeneration in superficial SAT but not VAT is associated with visceral adiposity and other features of the metabolic syndrome in women.

In the lipodystrophy associated with highly active antiretroviral therapy, pseudo-Cushing's syndrome is associated with increased regeneration of cortisol by 11beta-hydroxysteroid dehydrogenase type 1 in adipose tissue.

AIMS/HYPOTHESIS: Highly active antiretroviral therapy (HAART) in patients infected with human immunodeficiency virus (HIV) is associated with a poorly understood lipodystrophic and hypertriglyceridaemic syndrome, which resembles Cushing's syndrome, but in which plasma cortisol is not elevated. We tested the hypothesis that this HAART-associated lipodystrophy is explained by increased local regeneration of cortisol from inactive cortisone within adipose tissue, catalysed by the enzyme 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1). METHODS: In this cross-sectional study, a previously described cohort of 30 HIV-infected patients with lipodystrophy were compared with 13 HIV-infected patients without lipodystrophy. Intra-abdominal and subcutaneous adipose tissue were quantified using magnetic resonance imaging. Gene expression in subcutaneous fat was measured using real-time PCR. Urine cortisol and its metabolites were analysed by gas chromatography/mass spectrometry. RESULTS: Patients with lipodystrophy had significantly higher 11beta-HSD1 mRNA concentrations (relative to beta2-microglobulin mRNA) in subcutaneous adipose tissue than non-lipodystrophic patients (0.29+/-0.20 vs 0.09+/-0.07, p=0.0004) and higher ratios of urinary cortisol : cortisone metabolites. Adipose tissue 11beta-HSD1 mRNA correlated with multiple features of insulin resistance and with mRNA concentrations for glucocorticoid receptor and angiotensinogen. CONCLUSIONS/INTERPRETATION: In adipose tissue of patients with HAART-associated lipodystrophy, 11beta-HSD1 mRNA is increased and its concentration is correlated with features of insulin resistance. We suggest that increased adipose tissue 11beta-HSD1 may explain the pseudo-Cushing's features in patients with HAART-associated lipodystrophy, and is a potential therapeutic target.