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Additional file 3. Data items. Data items extracted for outcomes studies (Supplementary Table 2) and views studies (Supplementary Table 3).

Additional file 5. Views studies’ characteristics and findings. Characteristics and findings of the included views studies (Supplementary Table 5).

Additional file 1. PRISMA checklist. Completed PRISMA checklist (Supplementary Table 1).

Additional file 4. Outcomes studies’ characteristics and results. Characteristics and results of the included outcomes studies (Supplementary Table 4).

Additional file 2. Database search strategies. Search strategies employed for all electronic databases searched.

Additional file 9: Detailed importance ratings results. Detailed importance rating results for Round 1 (Supplementary Tables 6–10), Round 2 (Supplementary Tables 11–15) and Round 3 (Supplementary Tables 16–20).

Additional file 3: Formative categorisation matrix. Formative categorisation matrix developed from the Round 1 survey (Supplementary Table 2).

Additional file 2. Round 1 survey. Round 1 survey administered during the study.

Additional file 4: Recruitment flow charts. Patient recruitment flow chart (Supplementary Fig. 1) and professional recruitment flow chart (Supplementary Fig. 2).

Additional file 7: Round 2 new items. New items generated from panellists’ Round 1 free-text responses and included in the Round 2 survey (Supplementary Table 5).

Additional file 6: Inductively generated main category. Inductively generated main category developed during the content analysis of panellists’ Round 1 free-text responses (Supplementary Table 4).

Additional file 8. Final list of recommendations. Final list of recommendations developed from the Round 3 results.

Additional file 1: Sampling strategy. Sampling strategy used to select panellists for inclusion in the study (Supplementary Table 1).

Additional file 10: Prioritised list of recommendations. Prioritised list of recommendations developed from the Round 3 results (Supplementary Tables 21–25).

Glucocorticoid excess as a result of Cushing’s syndrome or pharmacological treatment can result in the development of obesity and type 2 diabetes mellitus (T2DM). The reactivation of cortisone to cortisol is catalysed by 11βHSD1 which is expressed widely but notably in adipose tissue and liver. Studies have shown dysregulation of cortisol in these tissues with obesity potentially promoting the development of T2DM. Inhibition of 11βHSD1 has been attempted as a novel treatment for T2DM with observed improvement in glycaemic control, body weight and blood pressure. The efficacy of such agents has been disappointing with few reaching phase 2 trials. With recent evidence of bidirectional activity of 11βHSD1 in vivo it becomes apparent that dysregulation may occur at an intracellular rather than tissue level. In this thesis I address several key outstanding questions concerning the physiology and regulation of 11βHSD1 including: 1. Whether combined therapy with metformin alters 11βHSD1 activity and obscures the efficacy of 11βHSD1inhibitors; 2. Whether the contribution of 11βHSD1 to local cortisol concentrations has been under-estimated by considering total rather than free cortisol turnover; and 3. Whether recycling between cortisol and cortisone in adipose tissue and skeletal muscle in obesity is a neglected feature of 11βHSD1 biochemistry and function. Eight obese healthy men with and without type 2 diabetes were recruited to a randomised placebo controlled cross over trial. They received 4 weeks treatment with metformin and placebo. Participants with T2DM additionally received gliclazide as a further control. Using the deuterated tracer D4-cortisol 11βHSD1 activity was measured. Metformin treatment increased whole body 11βHSD1 in both groups postulated as a result of improved insulin sensitivity. 11βHSD1 is located within cells and so contributes to free tissue cortisol concentrations but perhaps less so to total (protein-bound) cortisol in plasma. It has been shown that 11βHSD1 contributes almost half of total circulating cortisol concentrations at rest. This measurement relied upon blood sampling during steady state deuterated cortisol (D4-cortisol) infusion with measurements of total (free plus protein bound) cortisol which may have underestimated true 11βHSD1 activity. This was therefore investigated by comparing 11βHSD1 activity as calculated using total compared with free cortisol tracer enrichments. Equilibrium dialysis was performed separating free from bound portions in plasma samples taken from healthy volunteers who received D4-cortisol infusion. Analysis revealed similar measurements of 11βHSD1 activity using free compared with total cortisol implicating rapid turnover of glucocorticoids between the free and bound pools. On first discovery 11βHSD1 was seen to be a dehydrogenase enzyme in vitro. Later work recognised reductase activity in vivo and up until recently 11βHSD1 has been viewed as a predominantly reductase enzyme. As with other enzymes in the same family, the ability to catalyse both reductase and dehydrogenase depends upon the availability of substrate and co substrate. Whether dysregulation of 11βHSD1 in the settings of obesity and T2DM is the result of alteration in directionality at a cellular level is not known. Firstly bidirectional activity of 11βHSD1 was confirmed in vitro using HEK-293 cells stably transfected with 11βHSD1. The influence of obesity and acute perturbation with hyperinsulinaemia was subsequently investigated in vivo in a random order cross over single blinded case control study involving ten normal weight and ten obese healthy male volunteers. D4-cortisol and deuterated cortisone (D2-cortisone) were infused for the measurement of reductase and dehydrogenase activity of 11βHSD1 respectively with measurements taken across forearm muscle and abdominal subcutaneous adipose tissue. Across whole body, lean and obese individuals displayed similar 11β-reductase and 11β-dehydrogenase activity. Across tissue, 11β-reductase and 11β-dehydrogenase activity was different from zero across adipose tissue in obese individuals and across skeletal muscle in lean individuals providing further evidence of tissue specific differences in 11βHSD1 with obesity. With the addition of hyperinsulinaemia, reductase and dehydrogenase activity was somewhat increased in lean individuals although there was no statistically significant difference between lean and obese individuals. Across tissue there was a trend for obese individuals to display increased 11β-reductase activity across adipose tissue with hyperinsulinaemia. Comparing the rates of reductase and dehydrogenase activity revealed predominantly reductase activity across tissue in obese and dehydrogenase activity in lean individuals. The development of direction specific inhibitors targeting reductase activity by 11βHSD1 may prove efficacious for the treatment of obesity. In conclusion, 11βHSD1 acts as a bidirectional enzyme in vitro and in vivo. Overall directionality of enzyme activity is altered in a tissue specific manner in the setting of obesity. We have shown that this intracellular regulation of cortisol is reflected equally in the metabolically active free pool and total plasma pool. The efficacy of 11βHSD1 inhibitors as novel agents for the treatment of T2DM and coexisting obesity is not diminished by co-prescription with metformin but may prove more efficacious through the development of reductase specific inhibitors.

Hair cortisol concentration (HCC) is a promising measure of long-term hypothalamus-pituitary-adrenal (HPA) axis activity. Previous research has suggested an association between HCC and psychological variables, and initial studies of inter-individual variance in HCC have implicated genetic factors. However, whether HCC and psychological variables share genetic risk factors remains unclear. The aims of the present twin study were to: (i) assess the heritability of HCC; (ii) estimate the phenotypic and genetic correlation between HPA axis activity and the psychological variables perceived stress, depressive symptoms, and neuroticism; using formal genetic twin models and molecular genetic methods, i.e. polygenic risk scores (PRS). HCC was measured in 671 adolescents and young adults. These included 115 monozygotic and 183 dizygotic twin-pairs. For 432 subjects PRS scores for plasma cortisol, major depression, and neuroticism were calculated using data from large genome wide association studies. The twin model revealed a heritability for HCC of 72%. No significant phenotypic or genetic correlation was found between HCC and the three psychological variables of interest. PRS did not explain variance in HCC. The present data suggest that HCC is highly heritable. However, the data do not support a strong biological link between HCC and any of the investigated psychological variables. Consortia CORtisolNETwork (CORNET) Consortium Jennifer L. Bolton21 Caroline Hayward23 Nese Direk24,25 Anna Anderson21 Jennifer Huffman23 James F. Wilson26 Harry Campbell26 Igor Rudan26 Alan Wright23 Nicholas Hastie23 Sarah H. Wild26 Fleur P. Velders24 Albert Hofman24 Andre G. Uitterlinden24,27 Jari Lahti28 Katri Räikkönen28 Eero Kajantie29 Elisabeth Widen30 Aarno Palotie30,31 Johan G. Eriksson29,32,33,34,35 Marika Kaakinen36 Marjo-Riitta Järvelin36,37,38,39 Nicholas J. Timpson40 George Davey Smith40 Susan M. Ring41 David M. Evans40 Beate St Pourcain41 Toshiko Tanaka42 Yuri Milaneschi42,43 Stefania Bandinelli44 Luigi Ferrucci42 Pim van der Harst45,46,47 Judith GM Rosmalen48 Stephen JL Bakker49 Niek Verweij45 Robin PF Dullaart49 Anubha Mahajan50 Cecilia M. Lindgren50 Andrew Morris50 Lars Lind51 Erik Ingelsson51 Laura N. Anderson52 Craig E. Pennell53 Stephen J. Lye52 Stephen G. Matthews54 Joel Eriksson55 Dan Mellstrom55 Claes Ohlsson55 Jackie F. Price26 Mark WJ Strachan21 Rebecca M. Reynolds21 Henning Tiemeier24,56,57 Major Depressive Disorder Working Group of the Psychiatric Genomics Consortium (PGC) Stephan Ripke58,59,60 Manuel Mattheisen61,62,63 Abdel Abdellaoui64 Mark J. Adams65 Esben Agerbo66,8,67 Tracy M. Air68 Till FM Andlauer69,70 Silviu-Alin Bacanu71 Marie Bækvad-Hansen67,72 Aartjan TF Beekman43 David A. Bennett73 Klaus Berger74 Tim B. Bigdeli71,11 Jonas Bybjerg-Grauholm67,72 Enda M. Byrne5 Na Cai75 Enrique Castelao76 Toni-Kim Clarke65 Jonathan RI Coleman77 Converge Consortium78 Nick Craddock79 Udo Dannlowski80,81 Gareth Davies82 Gail Davies83 Eco. J. C. de Geus64,84 Philip De Jager85 Ian J. Deary83 Franziska Degenhardt12,13 Erin C. Dunn86,87,88 Erik A. Ehli82 Thalia C. Eley77 Valentina Escott-Price89 Tõnu Esko58,90,91,92 Hilary K. Finucane93,94 Michael Gill95 Scott D. Gordon96 Jakob Grove61,62,67,97 Lynsey S. Hall65,98 Thomas F. Hansen99,100 Christine Søholm Hansen67,72 Thomas F. Hansen101 Andrew C. Heath102 Anjali K. Henders5 Stefan Herms12,13,15 Per Hoffmann12,13,15 Georg Homuth103 Carsten Horn104 Jouke- Jan Hottenga64 David Hougaard67,72 Hailiang Huang59,86,105 Marcus Ising106 Rick Jansen43 Eric Jorgenson107 Stefan Kloiber108,109 James A Knowles110 Warren W. Kretzschmar50 Jesper Krogh111 Zoltán Kutalik112,113 Maren Lang3 Glyn Lewis114 Yihan Li50 Donald J. MacIntyre115,116 Pamela AF Madden102 Jonathan Marchine117 Hamdi Mbarek118,64 Peter McGuffin77 Divya Mehta119 Andres Metspalu92,120 Christel M. Middeldorp64 Evelin Mihailov92,121 Lili Milani92 Grant W. Montgomery122 Sara Mostafavi123,124 Niamh Mullins77 Matthias Nauck125,126 Bernard Ng124 Merete Nordentoft67,127 Dale R. Nyholt128 Michael C. O’Donovan129 Paul F. O’Reilly77 Hogni Oskarsson130 Michael J. Owen129 Sara A. Paciga131 Carsten Bøcker Pedersen66,67,8 Marianne Giørtz Pedersen66,67,8 Nancy L. Pedersen132 Michele L. Pergadia133 Roseann E. Peterson11,71 Erik Pettersson134 Wouter J. Peyrot43 David J. Porteous135 Danielle Posthuma136,137 James B. Potash138 Jorge A. Quiroz139 John P. Rice102 Brien P. Riley71 Margarita Rivera77,140 Douglas M. Ruderfer141 Saira Saeed Mirza24 Robert Schoevers142 Ling Shen107 Jianxin Shi143 Engilbert Sigurdsson144 Grant CB Sinnamon145 Johannes H. Smit43 Daniel J. Smith146 Jordan W. Smoller86 Hreinn Stephansson147 Stacy Steinberg147 Jana Strohmaier3 Katherine E. Tansey148 Alexander Teumer149 Wesley Thompson100,135,150,151,152 Pippa A. Thomson135 Thorgeir E. Thorgeirsson147 Jens Treutlein3 Maciej Trzaskowski153 Daniel Umbricht154 Sandra van der Auwera155 Gerard van Grootheest43 Albert M. van Hemert156 Alexander Viktorin132 Henry Völzke149 Yunpeng Wang67,100,151 Bradley T. Webb157 Myrna M. Weissman158,159 Jürgen Wellmann74 Gonneke Willemsen64 Hualin S. Xi160 Bernhard T. Baune68 Douglas H. R. Blackwood65 Dorret I. Boomsma64 Anders D. Børglum61,62,67 Henriette N. Buttenschøn62,67,161 Sven Cichon12,162,163,164 Enrico Domenici165 Jonathan Flint50,166 Hans J. Grabe155 Steven P. Hamilton167 Kenneth S. Kendler71 Qingqin S. Li168 Susanne Lucae106 Patrik K. Magnusson132 Andrew M. McIntosh65,83 Ole Mors67,169 Preben Bo Mortensen62,8,67 Bertram Müller-Myhsok69,70,170 Brenda WJH Penninx43 Roy H. Perlis87,171 Martin Preisig76 Catherine Schaefer107 Jordan W. Smoller87,88 Kari Stephansson147 Henning Tiemeier24,56,57 Rudolf Uher172 Thomas Werge100,150,173 Ashley R. Winslow174,175 Gerome Breen77,176 Douglas F. Levinson177 Cathryn M. Lewis77,178 Naomi R. Wray5,153 Patrick F. Sullivan134,179,180 23MRC Human Genetics Unit, Institute for Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, EH4 2XU, UK. 24Department of Epidemiology, Erasmus Medical Centre, Rotterdam, Netherlands. 25Psychiatry, Dokuz Eylul University School Of Medicine, Izmir, TR, Turkey. 26Centre for Population Health Sciences, Institute for Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, EH8 9AG, UK. 27Internal Medicine, Erasmus MC, Rotterdam, NL, Netherlands. 28Institute of Behavioural Sciences, University of Helsinki, Helsinki, Finland. 29National Institute for Health and Welfare, Helsinki, Finland. 30Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland. 31Department of Medical Genetics, University of Helsinki and University Central Hospital, Helsinki, Finland. 32Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland. 33Helsinki University Central Hospital, Unit of General Practice, Helsinki, Finland. 34Folkhalsan Research Centre, Helsinki, Finland. 35Vasa Central Hospital, Vasa, Finland. 36Institute of Health Sciences and Biocenter Oulu, University of Oulu, Oulu, Finland. 37Department of Children and Yond People and Families, National Institute for Health and elfare, Oulu, Finland. 38Department of Epidemiology and Biostatistics, MRC-HPA Centre for Environment and Health, Imperial College London, London, UK. 39Unit of Primary Care, Oulu University Hospital, Oulu, Finland. 40MRC Centre for Causal Analyses in Translational Epidemiology, School of Social and Community Medicine, University of Bristol, Bristol, UK. 41School of Social and Community Medicine, University of Bristol, Bristol, UK. 42Longitudinal Studies Section, Clinical Research Branch, National Institute on Aging, Baltimore, MD, USA. 43Department of Psychiatry, VU University Medical Center/GGZ inGeest, Amsterdam, Netherlands. 44Geriatric Unit, ASF, Florence, Italy. 45University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, Netherlands. 46University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, Netherlands. 47Durrer Center for Cardiogenetic Research, ICIN-Netherlands Heart Institute, Utrecht, Netherlands. 48University of Groningen, University Medical Center Groningen, Interdisciplinary Center for Psychiatric Epidemiology, Groningen, Netherlands. 49University of Groningen, University Medical Center Groningen, Department of Internal Medicine, Groningen, Netherlands. 50Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK. 51Department of Medical Sciences, Uppsala University, Uppsala, Sweden. 52Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada. 53School of Women’s and Infant’s Health, The University of Western Australia, Crawley, Australia. 54Department of Physiology, University of Toronto, Toronto, Ontario, Canada. 55Center for Bone and Arthritis Research, Institute of Medicin, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 56Child and Adolescent Psychiatry, Erasmus MC, Rotterdam, Netherlands. 57Psychiatry, Erasmus MC, Rotterdam, Netherlands. 58Medical and Population Genetics, Broad Institute, Cambridge, USA. 59Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, USA. 60Department of Psychiatry and Psychotherapy, Universitätsmedizin Berlin Campus Charité Mitte, Berlin, Germany. 61Department of Biomedicine, Aarhus University, Aarhus, Denmark. 62iSEQ, Centre for Integrative Sequencing, Aarhus University, Aarhus, Denmark. 63iSPYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark. 64Dept of Biological Psychology, VU University Amsterdam, Amsterdam, Netherlands. 65Division of Psychiatry, University of Edinburgh, Edinburgh, UK. 66Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark. 67iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark. 68Discipline of Psychiatry, University of Adelaide, Adelaide, Australia. 69Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany. 70Munich Cluster for Systems Neurology (SyNergy), Munich, Germany. 71Department of Psychiatry, Virginia Commonwealth University, Richmond, USA. 72Center for Neonatal Screening, Department for Congenital Disorders, Statens Serum Institut, Copenhagen, Denmark. 73Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, USA. 74Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, UK. 75Human Genetics, Wellcome Trust Sanger Institute, Cambridge, UK. 76Department of Psychiatry, University Hospital of Lausanne, Prilly, Switzerland. 77MRC Social Genetic and Developmental Psychiatry Centre, King’s College London, London, UK. 78University of Oxford, Oxford, UK. 79Psychological Medicine, Cardiff University, Cardiff, UK. 80Department of Psychiatry, University of Marburg, Marburg, Germany. 81Department of Psychiatry, University of Münster, Münster, Germany. 82Avera Institute for Human Genetics, Sioux Falls, USA. 83Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK. 84EMGO+ Institute, VU University Medical Center, Amsterdam, Netherlands. 85Neurology, Brigham and Women’s Hospital, Boston, USA. 86Stanley Center for Psychiatric Research, Broad Institute, Cambridge, USA. 87Department of Psychiatry, Massachusetts General Hospital, Boston, USA. 88Psychiatric and Neurodevelopmental Genetics Unit (PNGU), Massachusetts General Hospital, Boston, USA. 89Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK. 90Division of Endocrinology, Children’s Hospital Boston, Boston, USA. 91Department of Genetics, Harvard Medical School, Boston, USA. 92Estonian Genome Center, University of Tartu, Tartu, Estonia. 93Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA. 94Department of Mathematics, Massachusetts Institute of Technology, Cambridge, USA. 95Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. 96Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Australia. 97Bioinformatics Research Centre (BiRC), Aarhus University, Aarhus, Denmark. 98Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK. 99Danish Headache Centre, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark. 100Institute of Biological Psychiatry, Mental Health Center Sct. Hans, Mental Health Services Capital Region of Denmark, Roskilde, Denmark. 101iPSYCH, The Lundbeck Foundation Initiative for Psychiatric Research, Copenhagen, Denmark. 102Department of Psychiatry, Washington University in Saint Louis School of Medicine, Saint Louis, USA. 103Interfaculty Institute for Genetics and Functional Genomics, Department of Functional Genomics, University Medicine and Ernst Moritz Arndt University Greifswald, Greifswald, Germany. 104Roche Pharmaceutical Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Basel, Switzerland. 105Department of Medicine, Harvard Medical School, Boston, USA. 106Max Planck Institute of Psychiatry, Munich, Germany. 107Division of Research, Kaiser Permanente Northern California, Oakland, USA. 108Centre for Addiction and Mental Health, Toronto, Canada. 109Department of Psychiatry, University of Toronto, Toronto, Canada. 110Psychiatry & The Behavioral Sciences, University of Southern California, Los Angeles, USA. 111Department of Endocrinology at Herlev University Hospital, University of Copenhagen, Copenhagen, Denmark. 112Swiss Institute of Bioinformatics, Lausanne, Switzerland. 113Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland. 114Division of Psychiatry, University College London, London, UK. 115Mental Health NHS 24, Glasgow, UK. 116Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. 117Statistics, University of Oxford, Oxford, UK. 118EMGO+ Institute for Health and Care Research, Amsterdam, Netherlands. 119School of Psychology and Counseling, Queensland University of Technology, Brisbane, Australia. 120Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia. 121Estonian Biocentre, Tartu, Estonia. 122Institute for Molecular Biology, University of Queensland, Brisbane, Australia. 123Medical Genetics, University of British Columbia, Vancouver, Canada. 124Statistics, University of British Columbia, Vancouver, Canada. 125DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, University Medicine, Matthias Nauck, Greifswald, Germany. 126Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany. 127Mental Health Centre Copenhagen, Copenhagen Universtity Hospital, Copenhagen, Denmark. 128Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia. 129MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, UK. 130Humus, Reykjavik, Iceland. 131Human Genetics and Computational Biomedicine, Pfizer Global Research and Development, Groton, USA. 132Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. 133Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA. 134Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. 135Medical Genetics Section, CGEM, IGMM, University of Edinburgh, Edinburgh, UK. 136Complex Trait Genetics, VU University Amsterdam, Amsterdam, Netherlands. 137Clinical Genetics, VU University Medical Center, Amsterdam, Netherlands. 138Psychiatry, University of Iowa, Iowa City, USA. 139Solid GT, Boston, USA. 140Department of Biochemistry and Molecular Biology II, Institute of Neurosciences, Center for Biomedical Research, University of Granada, Granada, Spain. 141Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA. 142Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, Netherlands. 143Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, USA. 144Faculty of Medicine, Department of Psychiatry, School of Health Sciences, University of Iceland, Reykjavik, Iceland. 145School of Medicine and Dentistry, James Cook University, Townsville, Australia. 146Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK. 147deCODE Genetics/Amgen, Reykjavik, Iceland. 148College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK. 149Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany. 150iPSYCH, The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Copenhagen, Denmark. 151KG Jebsen Centre for Psychosis Research, Norway Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway. 152Department of Psychiatry, University of California, San Diego, San Diego, USA. 153Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia. 154Roche Pharmaceutical Research and Early Development, Neuroscience, Ophthalmology and Rare Diseases Discovery & Translational Medicine Area, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Basel, Switzerland. 155Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany. 156Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands. 157Virginia Institute of Psychiatric & Behavioral Genetics, Virginia Commonwealth University, Richmond, USA. 158Psychiatry, Columbia University College of Physicians and Surgeons, New York, USA. 159Division of Epidemiology, New York State Psychiatric Institute, New York, USA. 160Computational Sciences Center of Emphasis, Pfizer Global Research and Development, Cambridge, USA. 161Department of Clinical Medicine, Translational Neuropsychiatry Unit, Aarhus University, Aarhus, Denmark. 162Institute of Neuroscience and Medicine (INM-1), Research Center Juelich, Juelich, Germany. 163Department of Biomedicine, University of Basel, Basel, CH, Switzerland. 164Division of Medical Genetics, University of Basel, Basel, CH, Switzerland. 165Centre for Integrative Biology, Università degli Studi di Trento, Trento, Italy. 166Psychiatry, University of California Los Angeles, Los Angeles, USA. 167Psychiatry, Kaiser Permanente Northern California, San Francisco, USA. 168Neuroscience Therapeutic Area, Janssen Research and Development, LLC, Titusville, USA. 169Psychosis Research Unit, Aarhus University Hospital, Risskov, Aarhus, Denmark. 170Institute of Translational Medicine, University of Liverpool, Liverpool, UK. 171Psychiatry, Harvard Medical School, Boston, USA. 172Psychiatry, Dalhousie University, Halifax, Canada. 173Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. 174Human Genetics and Computational Biomedicine, Pfizer Global Research and Development, Cambridge, USA. 175Orphan Disease Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA. 176NIHR BRC for Mental Health, King’s College London, London, UK. 177Psychiatry & Behavioral Sciences, Stanford University, Stanford, USA. 178Department of Medical & Molecular Genetics, King’s College London, London, UK. 179Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, USA. 180Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, USA.

CONTEXT: The mechanism of action of metformin remains unclear. Given regulation of the cortisol-regenerating enzyme 11βHSD1 by insulin, and limited efficacy of selective 11βHSD1 inhibitors to lower blood glucose when co-prescribed with metformin, we hypothesized that metformin reduces 11βHSD1 activity.OBJECTIVE: To determine whether metformin regulates 11βHSD1 activity in vivo in obese men with and without type 2 diabetes.DESIGN: Double blind randomised placebo controlled crossover study Setting: A hospital clinical research facility Participants: Eight obese non-diabeticmen (OND) and eight obesemenwith type 2 diabetes (ODM) Intervention: Participants received 28 days of metformin (1g twice daily), placebo, or (in the ODM group) gliclazide (80mg twice daily) in random order. A deuterated cortisol infusion at the end of each phase measured cortisol regeneration by 11βHSD1. Oral cortisone was given to measure hepatic 11βHSD1 activity in the ODM group. The effect of metformin on 11βHSD1 was also assessed in human hepatocytes and SGBS adipocytes.MAIN OUTCOME MEASURES: The effect of metformin on whole body and hepatic 11βHSD1 activity.RESULTS: Whole body 11βHSD1 activity was ~25% higher in the ODM than OND group. Metformin increased whole body cortisol regeneration by 11βHSD1 in both groups compared with placebo and gliclazide, and tended to increase hepatic 11βHSD1 activity. In vitro, metformin did not increase 11βHSD1 activity in hepatocytes or adipocytes.CONCLUSIONS: Metformin increases whole body cortisol generation by 11βHSD1 probably through an indirect mechanism, potentially offsetting other metabolic benefits of metformin. Co-prescription with metformin should provide a greater target for selective 11βHSD1 inhibitors.

This study, undertaken for the NSPCC, is the first comprehensive systematic search and review of research undertaken in all four nations of the United Kingdom on the subject of child protection. It covers the five year timespan January, 2010 through December, 2014 to produce a mapping review on the landscape of child protection.The research questions were:1) How can child protection research be classified?2) What child protection research has been published between January, 2010 and December, 2014?a. What proportion of the published research was undertaken within academia?b. Who undertakes child protection research in the UK?c. In which disciplines was the research undertaken?d. On what aspects of child protection has the research focused?e. What research designs have been used?f. What types of data have been used?g. Whose perspectives have been included?3) Who funded the research and how much money has been allocated to the research?

IntroductionBreakthrough pain is common in children and adults with cancer and other conditions, including those approaching end-of-life, although it is often poorly managed, possibly partly due to a lack of validated assessment tools. This review aims to (1) identify all available instruments measuring breakthrough pain in infants, children, adolescents or adults and (2) critically appraise, compare and summarise the quality of the psychometric properties of the identified instruments using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria.Methods and analysisTwo searches will be carried out between October 2019 and January 2020, one for each aim of the review. The Cochrane Library, International Prospective Register of Systematic Reviews, Embase, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online (MEDLINE), PsycINFO, Web of Science Core Collection, Google Scholar, the ProQuest Dissertations & Theses Database, Evidence Search and OpenGrey databases will be searched from database inception until the date the search is conducted. Reference lists of eligible articles will be screened and authors in the field contacted. For search 1, articles will be screened by two reviewers by abstract, and full-text where necessary, to identify if a breakthrough pain assessment was used. Search 2 will then be conducted to identify studies evaluating measurement properties of these assessments. Two reviewers will screen articles from search 2 by title and abstract. All potentially relevant studies will be screened by full text by both reviewers. For search 2, data will be extracted in parallel with the quality assessment process, as recommended by COSMIN. Two reviewers will assess methodological quality using the COSMIN Risk of Bias checklist and the COSMIN updated criteria for good measurement properties. Findings will be summarised and, if possible, data will be pooled using meta-analysis. The quality of the evidence will be graded and summarised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines.Ethics and disseminationResults of this review will be submitted for publication in a peer review journal and presented at conferences.PROSPERO registration numberCRD42019155583.