Gender incongruence in primary care: are GPs trained?

BACKGROUND: GP confidence and competence in relation to gender diversity and the discussion of related matters remains relatively unknown. Despite increasing demand on primary care in dealing with matters of gender identity; contention and confusion are unfortunately widely reported amongst doctors. AIM: We sought to formally evaluate the level of GP training and gauge desire for further training in relation to the discussion of pronouns with patients. METHOD: We used a structured questionnaire that was sent out to GPs in Oxfordshire, facilitated by a mailing list used by the Primary Care Undergraduate Teaching Department at the University of Oxford. Additionally, we performed structured individual interviews with GPs in Oxford, who provided their contact details and expressed interest when completing the questionnaire. RESULTS: Fourty-four GPs responded and completed the questionnaire, five of whom agreed to participate in a structured interview. Most GPs (61%) had not received any formal training. Despite this, 68% of GPs did not want more formal training in the field of gender incongruence and pronoun usage. Only one GP routinely asked patients their pronouns (2%). CONCLUSION: Our findings highlight that a significant proportion of GPs have no formal training in relation to discussing pronouns and gender incongruence. We believe GPs should have the skills necessary to appreciate, understand and provide structured support to those with concerns in relation to their gender identity. With waiting times for gender clinics frequently exceeding 2 years, our findings emphasise the increasing importance of GP specific training in the field of gender identity.

Prolonged remission followed by low insulin requirements in a patient with type 1 diabetes on a very low-carbohydrate diet.

Summary: The use of a low-carbohydrate diet (LCD) reduces insulin requirements in insulinopenic states such as type 1 diabetes mellitus (T1DM). However, the use of potentially ketogenic diets in this clinical setting is contentious and the mechanisms underlying their impact on glycaemic control are poorly understood. We report a case of a patient with a late-onset classic presentation of T1DM who adopted a very low-carbohydrate diet and completely avoided insulin therapy for 18 months, followed by tight glycaemic control on minimal insulin doses. The observations suggest that adherence to an LCD in T1DM, implemented soon after diagnosis, can facilitate an improved and less variable glycaemic profile in conjunction with temporary remission in some individuals. Importantly, these changes occurred in a manner that did not lead to a significant increase in blood ketone (beta-hydroxybutyrate) concentrations. This case highlights the need for further research in the form of randomised controlled trials to assess the long-term safety and sustainability of carbohydrate-reduced diets in T1DM. Learning points: This case highlights the potential of low-carbohydrate diets (LCDs) in type 1 diabetes mellitus (T1DM) to mediate improved diabetes control and possible remission soon after diagnosis. Could carbohydrate-reduced diets implemented early in the course of T1DM delay the decline in endogenous insulin production? Adherence to an LCD in T1DM can facilitate an improved and less variable glycaemic profile. This case suggests that LCDs in T1DM may not be associated with a concerning supraphysiological ketonaemia.

Astrocytes and Alpha-Synuclein: Friend or Foe?

Despite its devastating disease burden and alarming prevalence, the etiology of Parkinson's disease (PD) remains to be completely elucidated. PD is characterized by the degeneration of dopaminergic neurons in the substantia nigra pars compacta and this correlates with the accumulation of misfolded α-synuclein. While the aggregation of α-synuclein in the form of Lewy bodies or Lewy neurites is a well-established intraneuronal hallmark of the disease process, our understanding of the glial contribution to aberrant α-synuclein proteostasis is lacking. In this regard, restoring astrocyte function during early PD could offer a promising therapeutic avenue and understanding the involvement of astrocytes in handling/mishandling of α-synuclein is of particular interest. Here, we explore the growing body of scientific literature implicating aberrant astrocytic α-synuclein proteostasis with the seemingly inexorable pathological sequelae typifying PD. We also provide a perspective on how heterogeneity in the morphological relationship between astrocytes and neurons will need to be considered in the context of PD pathogenesis.

Type 1 diabetes and low carbohydrate diets-Defining the degree of nutritional ketosis.

AIMS: Adopting a low- or very low-carbohydrate (LCD or VLCD) diet in type 1 diabetes mellitus (T1D) is a controversial intervention. The main fear is that these diets may increase the risk of diabetic ketoacidosis. However, there is little data about the ketoacidosis risk and the level of physiological nutritional ketosis in individuals following these diets. We aimed to define the level of ketosis in those with T1D following carbohydrate restricted diets in a real-world observational study. METHODS: Patients with T1D who had self-selected dietary carbohydrate restriction were enrolled from local clinics and were compared to those following an unrestricted regular carbohydrate control diet (RCCD). Participants completed a 3-day diary, documenting food intake, ketones, and blood/interstitial glucose concentrations. RESULTS: Participants were divided into three groups according to mean carbohydrate intake: VLCD (<50 g carbohydrates/day) n = 6, LCD (50-130 g carbohydrates/day) n = 6, and RCCD (>130 g carbohydrates/day) n = 3. Mean beta-hydroxybutyrate (BOHB) concentrations were 1.2 mmol/l (SD 0.14), 0.3 mmol/l (SD 0.12) and 0.1mmol/l (SD 0.05) in the VLCD, LCD and RCCD groups, respectively (p = 0.02). Post hoc Dunn test demonstrated this reached statistical significance between the VLCD and RCCD groups (p = 0.02). CONCLUSION: Carbohydrate restricted diets, in particular VLCDs, are associated with a higher BOHB level. However, the degree of ketosis seen is much lower than we expected, and significantly lower than the level typically associated with diabetic ketoacidosis. This may suggest the risk of ketoacidosis is lower than feared, although safety will need to be evaluated further in large scale randomised trials.