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Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.

OBJECTIVE: This study aimed to examine the association between performance of self-care activities and patient or disease factors as well as patient activation levels in patients with diabetes and chronic kidney disease (CKD) in Australia. METHODS: A cross-sectional study was conducted among adults with diabetes and CKD (eGFR <60 mL/min/1.73m2 ) who were recruited from renal and diabetes clinics of four tertiary hospitals in Australia. Demographic and clinical data were collected, as well as responses to the Patient Activation Measure (PAM) and the Summary of Diabetes Self-Care Activities (SDSCA) scale. Regression analyses were performed to determine the relationship between activation and performance of self-care activities. RESULTS: A total of 317 patients (70% men) with a mean age of 66.9 (SD=11.0) years participated. The mean (SD) PAM and composite SDSCA scores were 57.6 (15.5) % (range 0-100) and 37.3 (11.2) (range 0-70), respectively. Younger age, being male, advanced stages of CKD and shorter duration of diabetes were associated with lower scores in one or more self-care components. Patient activation was positively associated with the composite SDSCA score, and in particular the domains of general diet and blood sugar checking (P<.05), but not specific diet, exercising and foot checking. CONCLUSION: In people with diabetes and CKD, a high level of patient activation was positively associated with a higher overall level of self-care. Our results identify subgroups of people who may benefit from tailored interventions to further improve their health outcomes. Further prospective studies are warranted to confirm present findings.Copyright © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Introduction While a number of studies have reported increased risk of adverse pregnancy outcomes in polycystic ovary syndrome (PCOS), these have not been designed considering the impact of body mass index (BMI) as an important contributor to both PCOS severity and pregnancy outcomes. We therefore aimed to explore the impact of BMI on adverse pregnancy outcomes in PCOS. Methods A comprehensive search was conducted in Medline, Medline in-process and other non-indexed citations, EMBASE and all EBM reviews. Prospective studies reporting pregnancy outcomes including miscarriage, gestational diabetes, gestational hypertension, pre-eclampsia, preterm birth, small and large for gestational age birth in women with and without PCOS, until 4th April 2017, were identified as eligible for inclusion. Data were expressed as odds ratio (OR) with 95% confidence interval (CI) and analyzed using the random effect model for meta-analysis. Results Out of a total of 4292 identified articles, 24 prospective studies were included in the meta-analysis. Women with PCOS showed higher risk for miscarriage (OR 2.85, 95% CI 1.74-4.65), gestational diabetes (OR 3.04, 95% CI 2.26-4.10), gestational hypertension (OR 2.24, 95% CI 1.71-2.95), pre-eclampsia (OR 1.90, 95% CI 1.32-2.74), preterm birth (OR 1.51, 95% CI 1.09- 2.08) but similar risk for small for gestational age birth (OR 1.56, 95% CI 0.76-3.21) and large for gestational age birth (OR 1.19, 95% CI 0.90-1.58), compared to women without PCOS. On subgroup analysis by BMI-matched studies, this higher risk was maintained for miscarriage (OR: 4.00, 95% CI 2.59-6.18) and gestational diabetes (OR: 4.94, 95% CI 1.06-23.08), but not for gestational hypertension (OR: 2.50, 95% CI 0.69-9.05), preeclampsia (OR: 2.61, 95% CI 0.55-12.34) and preterm birth (OR: 1.64, 95% CI 0.61-4.41). The risks became significant for small for gestational age birth (OR: 4.52, 95% CI 1.92-10.61) and large for gestational age birth (OR: 1.99, 95% CI 1.05-3.77) in BMI-matc

Polycystic ovary syndrome (PCOS) is associated with worsened metabolic risk factors attributed to the interrelated effects of insulin resistance (IR), hyperandrogenism, sympathetic nervous system (SNS) dysfunction and chronic low grade inflammation. HMW-adiponectin is inversely associated with IR and metabolic disorders. Lower HMW-adiponectin levels are reported in PCOS however the regulatory mechanisms remain unclear. We explored the regulatory mechanisms for HMW-adiponectin in a cross sectional study of 46 PCOS (Rotterdam criteria) and 23 control women recruited from the community. Fasting lipids, total testosterone, sex hormone binding globulin (SHBG), highly sensitive C-reactive protein, HMW-adiponectin, muscle sympathetic nerve activity (as burst frequency (bursts/min) on microneurography) were measured and an oral glucose tolerance test was performed with IR determined on Homeostatic Model Assessment for Insulin Resistance (HOMA-IR). HMW-adiponectin was lower in PCOS after adjustment for age and BMI (2.2(2.3) mug/mL vs 3(2.5) mug/mL, adjusted P = .047). HMW-adiponectin correlated with SHBG, HOMA-IR, fasting insulin, triglycerides, high density lipoprotein cholesterol (HDL-C) and free androgen index (FAI) in all participants (r = .468 P < .001, r = -.429 P < .001, r = -.425 P < .001, r = -.324 P = .008, r = .347 P = .005 and r = -.456 P < .001 respectively) and in PCOS (r = .522 P < .001, r = -.476 P = .001, r = -.509 P < .0001, r = -.384 P = .01, r = .461 P = .002 and r = -.503 P < .001 respectively). Metabolic syndrome was significantly associated with lower HMW-adiponectin levels in all participants (odds ratio 0.033, 95% CI 0.002, 0.498 P = .014) and in PCOS (odds ratio 0.024, 95% CI 0.001, 0.652 P = .027). Burst frequency was significantly lower in PCOS (25.7(10.5) vs 21.6(13.7) bursts per minute, P = .037) and correlated significantly with HMW-adiponectin (r = -.326 P = .049). On multiple regression analysis burst frequency (B = -0.684 P = .011) and SHBG

Diabetes and chronic kidney disease (CKD) are two of the most prevalent co-morbid chronic diseases in Australia. The increasing complexity of multi-morbidity, and current gaps in health-care delivery for people with co-morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co-morbid diabetes and CKD have not been co-designed with stake-holders or formally evaluated. Particular components of health-care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self-management by the patient; and upskill primary health-care. Here we present an integrated patient-centred model of health-care delivery incorporating these components and co-designed with key stake-holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health-professionals; and semi-structured interviews of care-givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient-support through a phone advice line; and focused primary health-care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient-centred health-care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.Copyright © 2018 Asian Pacific Society of Nephrology

There is a growing realization that efforts to optimize the health of women and reduce the risk of adverse maternal, perinatal and neonatal outcomes during pregnancy should commence in the preconception period. The preconception period (priorto or between pregnancies) provides an opportune time to address reproductive intentions and promote and support wellbeing and healthy behavior change regardless of pregnancy intention. Research over the last 30 years has explored the influence of a range of preconception risk factors and determinants of health on pregnancy and maternal and neonatal outcomes including: pregnancy planning, diet and micronutrient supplementation, physical activity, weight smoking, recreational drug and alcohol use, mental health, oral hygiene, and chronic health and medical conditions. Preconception health messages, recommendations and guidelines originated in the USA and the preconception movement has gained momentum internationally with a variety of strategies developed and tested for improving preconception health, and related outcomes. The shift to integrate preconception health promotion into the continuum of women's healthcare requires a diverse multilevel and multistrategic approach involving a range of sectors and health professionals to address the determinants of health. This includes a system-wide effort to raise awareness of the importance of women's health priorto pregnancy, creating supportive environments as well as optimizing clinical practice, policy and programs informed by high quality research and longitudinal studies. While preconception health is relevant to both women and men globally, this review summarizes the predominant areas of preconception health for women in developed countries including the emergence of preconception health, the current health messages and evidence, the state of international guidelines and evidence-based interventions in preconception.

Background: Type 1 diabetes mellitus (T1DM) is associated with skeletal fragility. While previous meta-analyses have demonstrated an increased risk of fracture in individuals with T1DM, little is known about fracture risk in T1DM, in the absence of age-related confounders. Aim(s): To determine the risk of fracture in young and middle-aged adults with T1DM aged 18-50 years old. Design(s): Systematic review and meta-analysis. Data sources: Ovid MEDLINE, PubMed, EMBASE, EBM reviews and relevant conference abstracts. Study inclusion criteria: Studies of adults aged between 18-50 years with type 1 diabetes mellitus, with reported fracture outcomes. Primary outcomes: Incident or prevalent fracture. Result(s): Six studies were included in the meta-analysis. A total of 1724 fractures occurred in 35 925 patients with T1DM and 48 253 fractures occurred in 2 455 016 controls. RR for all fractures was 1.88 (95% CI 1.52-2.32, P <.001). Fifty-six hip fractures occurred among 34 707 patients with T1DM and 594 hip fractures occurred in 2 295 177 controls. The RR of hip fractures was 4.40 (95% CI 2.58-7.50, P <.001). Females and males with T1DM had a RR of 5.79 (95% CI 3.55-9.44, P <.001) and 3.67 (95% CI 2.10-6.41, P <.001), respectively. Conclusion(s): In the absence of age-related comorbidities, fracture risk remains significantly elevated in young and middle-aged adults with T1DM. Younger age does not mitigate against hip fracture risk in T1DM, and health professionals need to be aware of this risk. Further studies are needed to evaluate the mechanisms of fracture in T1DM.Copyright © 2018 John Wiley & Sons Ltd

To formulate clinical consensus recommendations on bone health assessment and management of women with oestrogen receptor-positive early breast cancer receiving endocrine therapy, representatives appointed by relevant Australian Medical Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing 5 key questions. Women receiving adjuvant aromatase inhibitors and the subset of premenopausal woman treated with tamoxifen have accelerated bone loss and increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven antifracture benefit. Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density (BMD) measurement, with monitoring based on risk factors. Weight-bearing exercise, vitamin D and calcium sufficiency are recommended routinely. Antiresorptive treatment should be considered in women with prevalent or incident clinical or morphometric fractures, a T-score (or Z-scores in women <50 years) of <-2.0 at any site, or if annual bone loss is >=5%, considering baseline BMD and other fracture risk factors. Duration of antiresorptive treatment can be individualized based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with antiresorptive treatments are low. Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimized by nonpharmacological intervention and where indicated antiresorptive treatment, in an individualized, multidisciplinary approach. Clinical trials are needed to better delineate long-term fracture risks of adjuvant endocrine therapy and to determine the efficacy of interventions designed to minimize these risks.Copyright © 2018 John Wiley & Sons Ltd

Aims. Back pain is the leading cause of disability worldwide. With minimal effective therapies and rising financial burden, identifying modifiable risk factors remains a key priority. Our objective was to determine the course and contributors to back pain in middle-aged women over a nine-year period. Methods. The Australian Longitudinal Study on Women's Health is a cohort study of community-based, middle-aged women who completed questionnaires every three years between 2004 and 2013. 10,530 completed the survey in 2004 (mean age 55.5 years), 9,020 completed follow-up nine years later. 7,562 (72%) women provided back pain data in all four surveys. Self-reported data on back pain in the last 12 months and other socio-demographic factors were collected at all four surveys. 'Frequent back pain' was defined as back pain reported at >= 3 surveys. Results. Back pain was common and persistent, with 48% having back pain in >= 3 out of four surveys, and 29% having back pain at every survey. Baseline obesity (RR 1.21, 95% CI 1.14-1.27), lack of vigorous physical activity (RR 1.21, 95% CI 1.13-1.30) and self-reported depression (RR 1.28, 95% CI 1.20-1.36), were independently associated with an increased risk of frequent back pain (all p<0.001). Overall, 22% of the risk of frequent back pain could be attributed to these factors, equating to one extra case of frequent back pain for every seven women with depression, for every 11 women who do not do vigorous physical activity, and for every 10 obese women, at baseline. Conclusions. Obesity, depression and lack of vigorous physical activity are associated with higher risk of frequent back pain over the following nine years among women in their mid-50s. Targeting these risk factors may lessen the burden of back pain.

Polycystic ovary syndrome (PCOS), the most common endocrinopathy of reproductive age women, is characterized by reproductive, metabolic and psychological features exacerbated by weight gain. Weight management in PCOS is challenged by greater propensity to weight gain and lack of sustainable dietary interventions. Metabolically active brown adipose tissue (BAT) has been described in humans. The sympathetic nervous system and sex hormones play role in modulating the thermogenic activity of BAT. Human studies confirmed the association of supraclavicular skin temperature, where most human BAT is located, with BAT activity. BAT activity and modulation has not been studied in PCOS. This observational study aimed to explore BAT thermogenesis and its associations in PCOS. Cutaneous wireless temperature probes (2 cm diameter, 0.5 depths) were taped to supraclavicular (BAT) and upper arm (muscle) regions of 49 premenopausal women with PCOS, over 96 hours, (mean age: 29.85 +/- 5.93, mean BMI: 29.02 +/- 5.43), recruited from community setting. Multiunit muscle SNS activity (MSNA by microneurography) and plasma noradrenaline were measured as markers of SNS activity. Fasting lipids and serum androgens were measured. An oral glucose tolerance test was performed to quantify insulin resistance (IR) using Homeostatic Model Assessment of Insulin Resistance (HOMA-IR). Recorded temperature data were available in 41 participants. Mean supraclavicular temperature was significantly higher than mean arm temperature (33.87 +/- 0.64 vs 32.28 +/- 0.76, P < .001). Supraclavicular temperature correlated with noradrenaline and triglyceride levels (r2 = -.435, P = .008 and r2 = -.392, P = .010 respectively) which remained significant after adjustment for BMI. Total testosterone significantly correlated with supraclavicular temperature after adjustment for BMI (r2 = -.598, P = .011). Arm temperature did not correlate with noradrenaline, triglyceride and androgens. This is the first study of BAT the

Study question: Is letrozole, used for ovulation induction (OI) or Assisted reproductive treatment (ART) associated with increased risk of major congenital malformations compared with other agents? Summary answer: Letrozole is associated with significantly lower risk of major congenital malformations compared with clomiphene and no significant difference when compared with natural conception or gonadotrophins. What is known already: OI agents such as clomiphene have been used in sub-fertile women with anovulatory cycles or unexplained infertility and in ART cycles. Letrozole, an aromatase inhibitor, has many advantages over clomi-phene, but has not been approved for OI. It is classified as a category 'x' drug, primarily due to a conference presentation in 2005, suggesting that, it is associated with higher risk of major congenital malformations when compared with low risk naturally conceived babies, despite the fact that this paper had meth-odological concerns, raising questions on its validity. Study design, size, duration: Systematic review and meta-analysis of randomised and non-randomised controlled trials that evaluated the risk of major congenital malformations in babies born with the use of Letrozole in infertile women. Participants/materials, setting, methods: We searched MEDLINE, EMBASE, Cochrane library, Register and Meta-register for RCTs, and WHO trials' search portal without any language restrictions. Studies that evaluated infertile women undergoing fertility treatment (OI or ART cycles) and compared letrozole with natural conception or other agents and reported on risk of major congenital malformations in the newborn were included. We pooled the results using fixed effects meta-analysis and reported the findings as relative risk (RR) with 95% confidence intervals (CI). Main results and the role of chance: We included seven studies which enrolled 2603 babies born from OI and 5 studies with 37,349 babies born from ART cycles. Comparison with Clomiphene

Objective: Insulin resistance, hyperandrogenism, sympathetic dysfunction and chronic low-grade inflammation may act together in a vicious cycle in the pathophysiology of PCOS. However, the inter-relationships of these components are not fully understood. We aimed to study these mechanisms in the pathophysiology of PCOS. Participants and methods: Premenopausal women with PCOS (Rotterdam diagnostic criteria) and without PCOS were recruited from a community setting into a cross-sectional substudy within a randomized control trial. Insulin resistance (fasting insulin and glucose), hyperandrogenism (testosterone, sex hormone-binding globulin [SHBG] and Free Androgen Index [FAI]), muscle sympathetic nerve activity (MSNA) and markers of chronic low-grade inflammation (high sensitivity C-reactive protein [hs-CRP] and high molecular weight adiponectin [HMW-adiponectin]) were measured. Result(s): Forty-nine women with PCOS (mean age 30 +/- 6 mean BMI 29 +/- 5) and 23 controls (mean age 29 +/- 8 mean BMI 33 +/- 7) with included in this analysis. MSNA and testosterone level were most significantly associated with PCOS status, after adjustment for age and BMI. In women with PCOS, markers of sympathetic activity correlated inversely with HMW-adiponectin and HMW-adiponectin correlated inversely with FAI. Testosterone and FAI both correlated positively with insulin resistance in women PCOS. Conclusion(s): Sympathetic dysfunction and hyperandrogenism are significantly associated with PCOS. Chronic low-grade inflammation potentially mediates the effect of sympathetic dysfunction on hyperandrogenism and insulin resistance.Copyright © 2018 John Wiley & Sons Ltd

Objective: To formulate clinical consensus recommendations for screening depression, anxiety, health-related quality of life (HRQoL), and disordered eating symptoms in women with polycystic ovary syndrome (PCOS) and review prevalence based on phenotypes and ethnicity, changes over time, etiology, and impact of treatment. Design(s): Systematic reviews and preparation of position statement. Setting(s): Not applicable. Patient(s): Women with PCOS and controls screened using validated tools. Intervention(s): None. Main Outcome Measure(s): Depressive symptoms, anxiety symptoms, disordered eating, and HRQoL scores. Result(s): Several studies demonstrate that women with PCOS have an increased prevalence of higher depression and anxiety scores and higher odds of moderate and severe depressive and anxiety symptoms compared with controls. Obesity, hyperandrogenism, and fertility have a weak association with these symptoms. HRQoL scores are consistently reduced in PCOS, with infertility and weight concerns having the most significant impact. Some studies suggest an increased prevalence of disordered eating in women with PCOS compared with controls. The few studies that have evaluated the impact of PCOS-related treatments (lifestyle interventions and pharmacotherapy) show no detrimental effect or some improvement in depressive and anxiety symptoms and HRQoL scores. Conclusion(s): In women with PCOS, screening for depressive and anxiety symptoms should be offered at the time of diagnosis and screening for disordered eating should be considered. Further research is required across PCOS phenotypes, in longitudinal cohorts and on impact of therapy on depressive and anxiety syptoms, HRQOL, and disordered eating.Copyright © 2018 American Society for Reproductive Medicine

Background People are increasingly seeking health information and managing their health through electronic technologies. We aimed to determine if women with polycystic ovary syndrome (PCOS) identified a need for PCOS-related mobile health apps and to evaluate related apps currently available. Design A national survey of women and a review of apps available on the iOS and Android platforms. Setting Community recruitment in Australia in 2016 and review of mobile apps available in 2017. Sample The survey received 264 responses. Sixteen apps related to PCOS were evaluated. Main Outcome Measures Survey: Women's likeliness to use mobile health apps, specifically a PCOS-related app and preferred features of apps. App review: Mapping of available apps and evaluation using the Mobile Application Rating Scale (MARS). Results Of 264 respondents, almost all women had a smartphone (98%), 72% had previously used an app to manage their health, and most (91%) would use a PCOS-specific app if available. The most important feature was the availability of current, evidence-based information. Current apps on PCOS lack provision of quality information. Conclusion Women with PCOS would use a PCOS-specific app of good quality that responds to their needs and facilitates self-care; however, currently available apps are unlikely to meet their information needs.Copyright © 2018 by Thieme Medical Publishers, Inc.

The association between type 1 diabetes mellitus (T1DM) and bone health has garnered interest over the years. Fracture risk is known to be increased in individuals with T1DM, although bone health assessment is not often performed in the clinical setting. We describe the case of a 21-year-old male with longstanding T1DM with multilevel vertebral fractures on imaging, after presenting with acute back pain without apparent trauma. Dual-energy X-ray absorptiometry (DXA) revealed significantly reduced bone mineral density at the lumbar spine and femoral neck. Extensive investigations for other secondary or genetic causes of osteoporosis were unremarkable, apart from moderate vitamin D deficiency. High-resolution peripheral quantitative computed tomography and bone biospy revealed significant alterations of trabecular bone microarchitecture. It later transpired that the patient had sustained vertebral fractures secondary to unrecognised nocturnal hypoglycaemic seizures. Intravenous zoledronic acid was administered for secondary fracture prevention. Despite anti-resorptive therapy, the patient sustained a new vertebral fracture after experiencing another hypoglycaemic seizure in his sleep. Bone health in T1DM is complex and not well understood. There are significant challenges in the assessment and management of osteoporosis in T1DM, particularly in young adults, where fracture prediction tools have not been validated. Clinicians should be aware of hypoglycaemia as a significant risk factor for fracture in patients with T1DM.Copyright © 2018 The authors.

Objective: To develop a question prompt list (QPL) for women with polycystic ovary syndrome (PCOS) and explore its acceptability and feasibility. Design(s): Nationwide online survey, interviews, and clinical pilot test. Setting(s): Australia. Patient(s): Two-hundred and forty-nine women online, 18 women in interviews, and 20 women in clinics. Intervention(s): A QPL for PCOS. Main Outcome Measure(s): From survey, women's likeliness to use a QPL and priority topics; from interview, QPL user-friendliness and associated feelings; from pilot, women's QPL use, perceived helpfulness, and intended future use. Result(s): Evidence-based guidelines and multidisciplinary experts informed the QPL development. Of 249 survey respondents, 66.7% to 68.7% reported difficulty communicating with health care providers about mood, weight management, and how PCOS affects daily life, and 85.8% indicated they were very likely to use a PCOS QPL. Women were interviewed to explore acceptability; the semistructured interviews (n = 18) revealed that the devised QPL was easy to understand, user-friendly, and encouraged information seeking and targeted question asking. The refined QPL was pilot-tested in a clinic setting to explore feasibility between 2016 and 2017: 60.0% of women asked 1 to 2 questions from the QPL, 20.0% asked several questions, and 10.0% reported the QPL helped them generate their own questions. Women agreed the QPL was helpful (95.0%) and that they would use the QPL again (90.0%). Conclusion(s): The PCOS QPL is acceptable and feasible, and may assist women in information seeking and targeted question asking.Copyright © 2018 American Society for Reproductive Medicine

Background: Knee pain is common with obesity and weight gain being important risk factors. Previous clinical trials have focused on overweight or obese adults with knee pain and osteoarthritis and demonstrated modest effects of intense weight loss programs on reducing knee pain despite very significant weight loss. There has been no lifestyle intervention that targets community-based adults to test its effect on prevention of knee pain. We aimed to determine the effect of a simple low-intensity self-management lifestyle intervention (HeLP-her), proven in randomised controlled trials to improve lifestyle and prevent weight gain, on knee pain in community-based young to middle-aged rural women. Method(s): A 1-year pragmatic, cluster randomised controlled trial was conducted in 649 community-based women (aged 18-50 years) to receive either the HeLP-her program (consisting of one group session, monthly SMS text messages, one phone coaching session, and a program manual) or one general women's health education session. Secondary analyses were performed in 390 women who had knee pain measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and 12-month follow-up. "Any knee pain" was defined as a WOMAC pain score >= 1. Knee pain worsening was defined as an increase in WOMAC pain score over 12 months. Result(s): Thirty-five percent of women had "any knee pain" at baseline. The risk of knee pain worsening did not differ between the intervention and control groups over 12 months. For women with any knee pain at baseline, those in the intervention arm had a lower risk of knee pain worsening compared with those in the control arm (OR 0.37, 95% CI 0.14-1.01, p = 0.05), with a stronger effect observed in women with body mass index >= 25 kg/m2 (OR 0.28, 95% CI 0.09-0.87, p = 0.03). Conclusion(s): In community-based young to middle-aged women, a simple low-intensity lifestyle program reduced the risk of knee pain worsening in those with

The benefits of lifestyle interventions for women who have survived gynaecological cancer (GC) remain unclear. This systematic review aimed to determine the effect of lifestyle interventions on cancer recurrence, overall survival and quality of life (QoL) in women with GC. We searched Medline, Embase, PsycINFO and EBM Reviews from June to July 2016 to identify relevant literature. We included randomized controlled trials in which a lifestyle intervention (diet, weight loss, physical activity and/or behavioural interventions) were compared with a control condition (usual care, placebo or other lifestyle interventions) in women who had survived endometrial or ovarian cancer. Primary outcomes included cancer recurrence and overall survival and the secondary outcome was QoL. Data extraction and risk-of-bias assessment were performed by two independent reviewers. A random-effects meta-analysis model was used to calculate mean differences (md) and 95% confidence intervals (CI). The literature search yielded 928 citations and three trials met the inclusion criteria. No randomized controlled trial assessed the effect of lifestyle interventions on cancer recurrence or survival. Meta-analysis of two randomized controlled trials on the effect of lifestyle interventions on total QoL at 3 or 6 months post-intervention showed no significant difference between intervention and control groups [(md; 1.60; 95% CI, -1.65 to 4.85) and (md; 2.07; 95% CI, -1.80 to 5.94), respectively]. That is, lifestyle intervention had no effect on overall QoL or individual QoL domains (physical, emotional, social wellbeing and fatigue) in GC survivors. Systematic review registration: PROSPERO CRD42016043719.Copyright © 2018 Elsevier B.V.

Background: Type 1 diabetes mellitus (T1DM) and coeliac disease (CD) have been independently associated with reduced bone mineral density (BMD) and increased fracture risk in adults1,2. Whilst poorer glycaemic control and increased microvascular complications3,4 have been described in patients with concomitant CD and T1DM (T1+CD), the literature examining bone health and its determinants in this cohort is limited. Objective(s): To evaluate associations of T1+CD with glycaemic control, microvascular disease and fractures, compared with T1DM alone. Method(s): We conducted a retrospective cross-sectional study of young adults with T1DM, who attended outpatient diabetes clinics at a tertiary referral centre between August 2016 to February 2017. Clinical information, radiological and biochemistry results were extracted from medical records. Patients with comorbid chronic kidney disease, glucocorticoid use, malignancy, hypogonadism and untreated hyperthyroidism were excluded. Result(s): 346 patients with T1DM only (median age 22 years) and 49 patients with T1+CD (median age 24 years) were included. Median age, gender distribution, BMI, glycated haemoglobin, total daily insulin dose, presence of microvascular complications and serum vitamin D levels were similar between groups. Subjects with T1+CD had a longer median duration of diabetes (14.0 vs 11.0 years; P = 0.01) and median duration of CD was 8 years. The adjusted risk of hypoglycaemia (>2 per week) was significantly greater for T1+CD (55.1% vs 27.7%, OR 3.28, P = .001, 95%CI 1.61-6.69). Vitamin D sufficiency was associated with a reduced risk of hypoglycaemia (OR 0.48, 95%CI 0.29-0.80; P = .005), but not fractures. Despite patients with T1+CD having a higher adjusted risk of fracture compared with T1DM alone(12.2% vs 3.5%; P < .05, OR 3.50, 95%CI 1.01-12.12), BMD was measured in only 6.1%. Conclusion(s): Young adults with T1+CD have significantly more hypoglycaemia and fractures. Recurrent hypoglycaemia may contribut

The role of the sympathetic nervous system (SNS) in polycystic ovary syndrome (PCOS) is emerging. Previous studies support increased SNS activity in PCOS, potentially contributing to metabolic features. Moxonidine is a second-generation imidazoline I1 agonist inhibiting sympathetic outflow at the level of rostral ventrolateral medulla with known beneficial effects on hypertension, insulin sensitivity, dyslipidemia and inflammation. This study aimed to explore modification of SNS activity for the first time in PCOS. We hypothesized moxonidine will modify elevated SNS activity and downstream metabolic abnormalities in PCOS. 51 premenopausal women with PCOS were recruited, from a community setting, in a double blind placebo controlled clinical trial. 48 women were weaned off any interacting medication for 3 months, then randomized to moxonidine (0.2 mg daily initially, up titrated to 0.4 mg daily in 2 weeks) (n = 23) or placebo (n = 25) for 3 months. Multiunit muscle SNS activity (by microneurography), heart rate variability (HRV) and endothelial function (ischaemic reactive hyperaemia index (RHI) using EndoPAT) were examined. Fasting lipids, serum androgens and inflammatory markers were measured and an oral glucose tolerance test was performed to quantify IR using HOMA-IR pre and post intervention. 43 women (mean age: 29.8 +/- 5.9 years, mean BMI: 29.0 +/- 5.4 kg/m2) completed the trial (19 moxonidine, 24 placebo). Mean percentage change from baseline in MSNA (-10 +/- 23% vs -10 +/- 29% bursts per minute, P = NS), HRV (14 +/- 26% vs 14 +/- 41%nu in low frequency component, P = NS) and endothelial function (7 +/- 44% vs 15 +/- 45% in RHI, P = NS) did not differ significantly between two groups. hs-CRP reduced in moxonidine group (-26 +/- 37% vs 26 +/- 82%, P = .012) and triglyceride reduced in placebo group (-4 +/- 29% vs 19 +/- 33%, P = .027) which remained significant after adjustment for change in BMI. Change in blood pressure, HOMA-IR, and androgens did not differ

Background: Polycystic ovary syndrome (PCOS) is common and characterised by reproductive and metabolic features. Women with PCOS have lower vitamin D levels compared to healthy controls. Vitamin D binding protein (DBP) is the main carrier of vitamin D and plays an important role in regulating vitamin D concentration and bioavailability. To our knowledge, no previous studies have examined DBP, bioavailable and free 25-hydroxyvitamin D (25(OH)D) in women with PCOS. Our aim was to (1) compare DBP, bioavailable and free 25(OH)D concentrations in women with PCOS and controls; (2) to investigate relationships between DBP, bioavailable and free 25(OH)D and metabolic features. Method(s): In a cross-sectional study using bio-banked samples, we measured 25(OH)D, DBP, albumin, and calculated bioavailable and free 25(OH)D. BMI, body composition(DXA), insulin resistance (HOMA-IR and glucose infusion rate from hyperinsulinaemic euglycaemic clamp) and serum lipids were also measured in 90 women with PCOS and 59 controls. Result(s): DBP concentrations were lower in PCOS compared to controls (median[IQR]:443.40[314.4] vs 482.4[156.8] mug/mL, P = .02). No significant differences were found in bioavailable or free 25(OH) D concentrations between groups. DBP was not associated with BMI, %body fat or insulin resistance. HDL cholesterol was the main determinant of DBP in the overall cohort (beta = -0.12, P = .02), after adjusting for covariates including PCOS/control status, age, BMI, total 25(OH)D and HOMA-IR. In PCOS, total and free 25(OH)D were related to markers of insulin resistance and lipids. Only the associations between total 25(OH)D and HDL (P = .001), free 25(OH)D and triglycerides (P = .02), and HDL (P < .001) remained significant after adjusting for age and BMI. Conclusion(s): Women with PCOS had lower DBP, but similar bioavailable or free 25(OH)D concentrations compared to controls, independent of BMI and age. DBP was not associated with insulin resistance or BMI in PCOS. F

Research indicates that there are worryingly low levels of physical activity among South Asians compared with Anglo-Australians with type 2 diabetes and/or cardiovascular disease (CVD). We compared perceptions, barriers, and enablers of physical activity in these groups. We used a qualitative design, conducting in-depth, semistructured iterative interviews in Victoria with 57 South Asian and Anglo-Australian participants with either type 2 diabetes or CVD. While both groups exhibited knowledge of the value of physical activity in health maintenance and disease management, they wished for more specific and culturally tailored advice from clinicians about the type, duration, and intensity of physical activity required. Physical activity identities were tied to ethnic identities, with members of each group aspiring to meet the norms of their culture regarding engagement with physical activity as specific exercise or as incidental exercise. Individual personal exercise was deemed important by Anglo-Australians whereas South Asians preferred family-based physical activity.

Background and aims: The extent to which patient-centred factors affect treatment target attainment in co-morbid diabetes and chronic kidney disease (CKD) is uncharacterised. Here, we explore the association between patient-reported barriers to health care, patient activation, quality of life (QOL), and diabetes self-care, with attainment of glycaemic and blood pressure (BP) targets. Material(s) and Method(s): This cross-sectional multi-centre study recruited adults with diabetes and CKD (eGFR between 20/2 and 60 mLmin/1. 73m). All completed a questionnaire explor-ing patient-reported barriers to care (elicited from focus groups), the Patient Activation Measure (PAM), 12-Item Short Form Survey (SF-12), the Summary of Diabetes Self-Care Activity (SDSCA) surveys, and had demographic and clinical data collected. Poor glycaemic and BP control were defined as an HbA1c > 8% and systolic BP > 140 mmHg respectively. Multivariable logistic regression was used to identify the most parsimonious models inclusive of age, gender and diabetes duration for poor control and dose response between the number of patient-reported barriers and poor control was analysed, using STATA v13.1. Result(s): 199 patients, mean age 68.7 (SD 9.6) were studied. Most were male (70.4%) and had type 2 diabetes (90.0%). There were no differences in the proportion of patients with poor glycaemic and BP control across age groups, gender, smoking status, eGFR, dia-betes duration and activation levels. Poor glycaemic control was associated with an increased odds of "poor family support" (OR 4.90; 95% CI 1.80 to 13.32, P< 0.002). Poor BP control was associated with an increased odds of "not having a good GP" (OR 6.01; 2.42 to 14.95, P< 0.001). Poor glycaemic or BP control was not associated with lower PAM, SDSCA and SF-12 scores (all P > 0.05). The total number of patient-reported barriers was not associated with an increased odds of poor control. Conclusion(s): Particular patient-reported barriers rather th

Introduction Healthcare service redesign and improvement has become an important activity that health system leaders and clinicians realise must be nurtured and mastered, if the capacity issues that constrain healthcare delivery are to be solved. However, little is known about the critical success factors that are essential for sustaining and scaling up improvement initiatives. This situation limits the impact of these initiatives and undermines the general standing of redesign and improvement activity within healthcare systems. The conduct of the doctoral research detailed in this study protocol will be nested within a broader parent study that seeks to address this problem by drawing on the theory of 'institutional entrepreneurship'. The doctoral research will apply this idea to understanding the capacities and capabilities required at the organisation level to bring about transformational change in healthcare services. Methods and analysis The parent study is predominantly qualitative, is multilevel in nature and has been codesigned with five partner healthcare organisations. The focus is a sector-wide attempt in an Australian state jurisdiction to transfer new redesign and improvement knowledge into the public healthcare system. The doctoral research will focus on the implementation of the sector-wide approach in one healthcare service in the jurisdiction. This research involves interviews with project team members and stakeholders involved in two improvement initiatives undertaken by the health service. It will involve interviews with redesign and improvement leaders and senior managers responsible for the overall health service improvement approach. The methods will also include immersive fieldwork, interviews and focus groups. Appropriate methods for coding and thematic extraction will be applied to the qualitative data. Ethics and dissemination Ethical approval has been granted by the health service and Monash University Human Research Ethics Committee. Diss

Background: Polycystic Ovary Syndrome (PCOS) is a common female reproductive disorder with multiple manifestations. Weight management is a key therapeutic goal. Acupuncture is a potential adjunctive weight loss treatment in non-PCOS populations. We aimed to engage patients in co-design and assess the feasibility and acceptability of methods for a randomised controlled trial (RCT) on acupuncture and telephone-based health coaching for weight management in overweight or obese women with PCOS using qualitative methods. Method(s): We recruited women who had PCOS and were aged 18-45 years and with a body mass index of 25 kg/m2 and over, using social media. Two face-to-face focus group meetings and three semi-structured telephone interviews were conducted (n = 10). We analysed data using thematic analysis and aimed to compare and contrast motivations for joining the trial between women who were actively trying to conceive (n = 7) and not trying to conceive (n = 3). Attitudes to, knowledge and experiences of acupuncture; perceptions and attitudes towards the interventions in the RCT (real acupuncture, sham acupuncture and telephone-based health coaching); the outcomes of importance; and barriers and facilitators to successful trial recruitment and retention were collected. Result(s): Women were both acupuncture-naive and acupuncture-experienced. Overall, attitudes towards acupuncture were positive, and the trial design was acceptable with appointment flexibility requested. Ideal enrolment time, if women were trying to conceive, was six months prior to conception. Women supported three-month intervention and the use of sham acupuncture as a control. Financial incentives were not believed to be necessary, and women spoke of altruistic intentions in enrolling for such a trial. Women who were trying to conceive voiced a need for support from their family, health coaches, and peers. The telephone-based health coaching offered welcome support and accountability, noted as possibl

To formulate clinical consensus recommendations on bone health assessment and management of women with oestrogen receptor-positive early breast cancer receiving endocrine therapy, representatives appointed by relevant Australian Medical Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing 5 key questions. Women receiving adjuvant aromatase inhibitors and the subset of premenopausal woman treated with tamoxifen have accelerated bone loss and increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven antifracture benefit. Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density (BMD) measurement, with monitoring based on risk factors. Weight-bearing exercise, vitamin D and calcium sufficiency are recommended routinely. Antiresorptive treatment should be considered in women with prevalent or incident clinical or morphometric fractures, a T-score (or Z-scores in women <50 years) of <-2.0 at any site, or if annual bone loss is ≥5%, considering baseline BMD and other fracture risk factors. Duration of antiresorptive treatment can be individualized based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with antiresorptive treatments are low. Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimized by nonpharmacological intervention and where indicated antiresorptive treatment, in an individualized, multidisciplinary approach. Clinical trials are needed to better delineate long-term fracture risks of adjuvant endocrine therapy and to determine the efficacy of interventions designed to minimize these risks.

BACKGROUND: Knee pain is common with obesity and weight gain being important risk factors. Previous clinical trials have focused on overweight or obese adults with knee pain and osteoarthritis and demonstrated modest effects of intense weight loss programs on reducing knee pain despite very significant weight loss. There has been no lifestyle intervention that targets community-based adults to test its effect on prevention of knee pain. We aimed to determine the effect of a simple low-intensity self-management lifestyle intervention (HeLP-her), proven in randomised controlled trials to improve lifestyle and prevent weight gain, on knee pain in community-based young to middle-aged rural women. METHODS: A 1-year pragmatic, cluster randomised controlled trial was conducted in 649 community-based women (aged 18-50 years) to receive either the HeLP-her program (consisting of one group session, monthly SMS text messages, one phone coaching session, and a program manual) or one general women's health education session. Secondary analyses were performed in 390 women who had knee pain measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and 12-month follow-up. "Any knee pain" was defined as a WOMAC pain score ≥ 1. Knee pain worsening was defined as an increase in WOMAC pain score over 12 months. RESULTS: Thirty-five percent of women had "any knee pain" at baseline. The risk of knee pain worsening did not differ between the intervention and control groups over 12 months. For women with any knee pain at baseline, those in the intervention arm had a lower risk of knee pain worsening compared with those in the control arm (OR 0.37, 95% CI 0.14-1.01, p = 0.05), with a stronger effect observed in women with body mass index ≥ 25 kg/m2 (OR 0.28, 95% CI 0.09-0.87, p = 0.03). CONCLUSIONS: In community-based young to middle-aged women, a simple low-intensity lifestyle program reduced the risk of knee pain worsening in those with any knee

BACKGROUND: Type 1 diabetes mellitus (T1DM) is associated with skeletal fragility. While previous meta-analyses have demonstrated an increased risk of fracture in individuals with T1DM, little is known about fracture risk in T1DM, in the absence of age-related confounders. AIMS: To determine the risk of fracture in young and middle-aged adults with T1DM aged 18-50 years old. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Ovid MEDLINE, PubMed, EMBASE, EBM reviews and relevant conference abstracts. STUDY INCLUSION CRITERIA: Studies of adults aged between 18-50 years with type 1 diabetes mellitus, with reported fracture outcomes. PRIMARY OUTCOMES: Incident or prevalent fracture. RESULTS: Six studies were included in the meta-analysis. A total of 1724 fractures occurred in 35 925 patients with T1DM and 48 253 fractures occurred in 2 455 016 controls. RR for all fractures was 1.88 (95% CI 1.52-2.32, P < .001). Fifty-six hip fractures occurred among 34 707 patients with T1DM and 594 hip fractures occurred in 2 295 177 controls. The RR of hip fractures was 4.40 (95% CI 2.58-7.50, P < .001). Females and males with T1DM had a RR of 5.79 (95% CI 3.55-9.44, P < .001) and 3.67 (95% CI 2.10-6.41, P < .001), respectively. CONCLUSIONS: In the absence of age-related comorbidities, fracture risk remains significantly elevated in young and middle-aged adults with T1DM. Younger age does not mitigate against hip fracture risk in T1DM, and health professionals need to be aware of this risk. Further studies are needed to evaluate the mechanisms of fracture in T1DM.

Study question: What is the recommended assessment and management of women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference? Summary answer: International evidence-based guidelines including 166 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of women with PCOS. What is known already: Previous guidelines either lacked rigorous evidence-based processes, did not engage consumer and international multidisciplinary perspectives, or were outdated. Diagnosis of PCOS remains controversial and assessment and management are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. Study design, size, duration: International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Appraisal of Guidelines for Research and Evaluation (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength. Participants/materials, setting, methods: Governance included a six continent international advisory and a project board, five guideline development groups, and consumer and translation committees. Extensive health professional and consumer engagement informed guideline scope and priorities. Engaged international society-nominated panels included pediatrics, endocrinology, gynecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, public health and other experts, alongside consumers, project management, evidence synthesis, and translation

Obesity is a growing epidemic both in Australia and worldwide. Being overweight or obese is known to be adversely associated with multiple cardiovascular risk factors, such as type 2 diabetes mellitus, lipid disorders and hypertension. Despite the adverse impact of overweight and obesity, recent observational studies have suggested that in some overweight and obese individuals with established chronic disease, there is a survival advantage that is paradoxically better than individuals of normal weight. A burgeoning area of interest is the existence of this paradox in chronic endocrine disorders, especially with respect to osteoporosis and type 2 diabetes mellitus, as well as the latter's chronic complications, chronic kidney disease and coronary artery disease. In this article, we review the postulated mechanisms and latest evidence concerning the obesity paradox, with a focus on endocrine-related diseases. We discuss confounders and biases that exist in observational studies from which the paradox has been described and highlight that, despite the observed paradox, substantial literature exists supporting the benefits of weight reduction in obesity.Copyright © 2017 Royal Australasian College of Physicians

Objective: To evaluate the knowledge and attitudes of Australian health professionals (HPs) including general practitioners (GPs), gynecologists and endocrinologists, to menopausal hormone therapy (MHT). Method(s): Participants were recruited from medical societies/colleges and a national GP conference. An online survey containing devised and previously published questions was used. Data analysis included frequencies, ANOVA, chi2 and regression analysis. Result(s): A total of 745/888 responses were analyzed. Fewer HPs (52%) reported being knowledgeable regarding non-hormonal therapies compared with menopause physiology or MHT (72%), with no significant knowledge differences between specialties. Most HPs (91%) would offer MHT to symptomatic menopausal women. The combined oral contraceptive pill (52%) was preferred for women with premature menopause. Transdermal MHT was preferred for women >50 years, although differences were observed between specialties (p = 0.005). HPs varied regarding duration of MHT for women with premature menopause (p = 0.009) and women over 50 years (p = 0.001). Menopause society members were more likely to prescribe MHT and for longer duration (p < 0.05). Consumer concern regarding breast cancer was considered the main barrier in prescribing MHT. Conclusion(s): Although most HPs will recommend MHT, when indicated, for symptomatic menopausal women, variations exist between specialties in prescribing practices. HPs' knowledge gaps and perceived consumer concerns are barriers to prescribing MHT.Copyright © 2017 International Menopause Society.

Background: Vitamin D supplementation has been proposed as a potential strategy to prevent type 2 diabetes. Existing clinical trials have been limited by short duration, low doses of Vitamin D, variability in participants' Vitamin D-deficiency status, and the use of surrogate measures of body composition, insulin sensitivity, and insulin secretion. Objective(s): To address existing knowledge gaps, we conducted a double-blind, randomized, placebo-controlled trial to investigate whether Vitamin D supplementation that is provided in a sufficient dose and duration to Vitamin D-deficient individuals would improve insulin sensitivity or secretion as measured with the use of goldstandard methods. We hypothesized that Vitamin D supplementation would improve insulin sensitivity and secretion compared with placebo. Design(s): Sixty-five overweight or obese, Vitamin D-deficient (25-hydroxyVitamin D [25(OH)D] concentration <=50 nmol/L) adults were randomly assigned to receive either a bolus oral dose of 100,000 IU cholecalciferol followed by 4000 IU cholecalciferol/d or a matching placebo for 16 wk. Before and after the intervention, participants received gold-standard assessments of body composition (via dual X-ray absorptiometry), insulin sensitivity (via hyperinsulinemic-euglycemic clamps), and insulin secretion [via intravenous-glucose-tolerance tests (IVGTTs)]. Result(s): Fifty-four participants completed the study [35 men and 19 women; mean +/- SD age: 31.9 +/- 8.5 y; body mass index (in kg/m2): 30.9 +/- 4.4]. 25(OH)D increased with Vitamin D supplementation compared with placebo (57.0 +/- 21.3 compared with 1.9 +/- 15.1 nmol/L, respectively; P = 0.02). Vitamin D and placebo groups did not differ in change in insulin sensitivity (0.02 +/- 2.0 compared with 20.03 +/- 2.8 mg * kg-1 * min-1, respectively; P = 0.9) or firstphase insulin secretion (-21 +/- 212 compared with 24 +/- 184 mU/L, respectively; P = 0.9). Results remained nonsignificant after adjustment for age, sex

Background: Patients with diabetes and chronic kidney disease (CKD) are a complex subset of the growing number of patients with diabetes, due to multi-morbidity. Gaps between recommended and received care for diabetes and chronic kidney disease (CKD) are evident despite promulgation of guidelines. Here, we document gaps in tertiary health-care, and the commonest patient-reported barriers to health-care, before exploring the association between these gaps and barriers. Method(s): This cross-sectional study recruited patients with diabetes and CKD (eGFR < 60 mL/min/1.73 m2) across 4 large hospitals. For each patient, questionnaires were completed examining clinical data, recommended care, and patient-reported barriers limiting health-care. Descriptive statistics, subgroup analyses by CKD stage and hospital, and analyses examining the relationship between health-care gaps and barriers were performed. Result(s): 308 patients, of mean age 66.9 (SD 11.0) years, and mostly male (69.5%) and having type 2 diabetes (88.0%), participated. 49.1% had stage 3, 24.7% stage 4 and 26.3% stage 5 CKD. Gaps between recommended versus received care were evident: 31.9% of patients had an HbA1c >= 8%, and 39.3% had a measured blood pressure >= 140/90 mmHg. The commonest barriers were poor continuity of care (49.3%), inadequate understanding/education about CKD (43.5%), and feeling unwell (42.6%). However, barriers associated with a failure to receive items of recommended care were inadequate support from family and friends, conflicting advice from and poor communication amongst specialists, the effect of co-morbidities on self-management and feeling unmotivated (all p < 0.05). Conclusion(s): Barriers to health-care varied across CKD stages and hospitals. Barriers associated with a deviation from recommended care were different for different items of care, suggesting that specific interventions targeting each item of care are required.Copyright © 2017 The Author(s).

Background: Benefits of lifestyle interventions in gynaecological cancer (GC) survivors remain unclear. This systematic review aimed to determine the effect of lifestyle interventions on cancer recurrence, overall survival and quality of life (QoL) in women with GC. Method(s): We searched Medline, Embase, CINAHL, PsycINFO and EBM Reviews in September 2016 to identify relevant literature. Studies involving a lifestyle intervention (including diet, weight loss, physical activity and behavioural interventions) were compared with a control group (usual care, placebo or other lifestyle interventions) in endometrial and ovarian cancer survivors. Primary outcomes were cancer recurrence and overall survival and secondary outcome was QoL. Data extraction and risk of bias assessment were performed by two independent reviewers. A random-effects meta-analysis model calculated mean difference (md)/95% Confidence Interval (CI). Result(s): Literature search yielded 928 citations and three trials met inclusion criteria. No studies assessed the effect of lifestyle interventions on cancer recurrence/survival. Meta-analysis of two randomized control trials on the effect of lifestyle interventions on total QoL at 3/6 months post-intervention showed no significant difference between intervention and control groups [(md; 1.60; 95% CI-1.65-4.85) and (md; 2.07; 95% CI-1.80-5.94) respectively]. Lifestyle intervention had no effect on individual QoL domains (eg. physical/emotional/social wellbeing) in GC survivors. Discussion(s): Lifestyle intervention had no effect on QoL of women with GC although findings are limited by the paucity of studies and no trials investigating GC recurrence/survival.

Background: Little is known about the relationship between patient activation, which is defined as an individual's level of knowledge, confidence and skills in managing their health care and the performance of self-care activities in people with diabetes and chronic kidney disease (CKD). Consequently, we examined the association between patient activation and performance of self-care activities in this population. Method(s): A cross sectional study was conducted among adults with diabetes and CKD (eGFR <60 mL/minute/1.73 m2). Participants were recruited from renal and diabetes clinics of four large tertiary referral hospitals in Australia. For each participant, demographic and clinical data were collected, as were their responses to the Patient Activation Measure, quantifying the level of patient engagement in self- care, and the Summary of Diabetes Self-Care Activity (SDSCA) scale, assessing self-care activities. Regression analyses were performed to determine the relationship between activation and performance of self-care activities. Result(s): 317 patients (70% men) with a mean age of 66.9 (SD=11.0) years participated. The mean+/-(SD) Patient Activation Measure and composite SDSCA scores were 57.6 (15.5) % (range 0-100) and 37.3 (11.2) (range 0-70) respectively. Patient activation was positively associated with the composite SDSCA score, and in particular the SDSCA domains of general diet and blood sugar checking (P<0.05), but not the SDSCA domains of specific diet, exercising and foot checking. Younger age, being male, advanced stages of CKD and shorter duration of diabetes were associated with lower scores in one or more self-care components. Conclusion(s): In people with diabetes and CKD, although a high level of patient activation in self-management is positively associated with a higher level of self-care in general, this was not necessarily the case across all diabetes self-care components. Additionally, younger age, male gender, advanced CKD and a shorter

Background: People living with diabetes and chronic kidney disease (CKD) experience compromised quality of life. Consequently, it is critical to identify and understand factors influencing their health-related quality of life (HRQoL). This study examined factors associated with HRQoL among patients with diabetes and CKD. Method(s): A cross sectional study among adults with comorbid diabetes and CKD (EGFR <60 mL/min/ 1.73m2) recruited from renal and diabetes clinics of four large tertiary referral hospitals in Australia was performed. Each participant completed the Kidney Disease Quality of Life (KDQoL TM -36) questionnaire, which is comprised of two composite measures of physical and mental health and 3 kidney disease specific subscales with possible scores ranging from 0 to 100 with higher values indicating better HRQoL. Demographic and clinical data were also collected. Regression analyses were performed to determine the relationship between HRQoL and potential predictor factors. Result(s): A total of 308 patients were studied with a mean age of 66.9 (SD = 11.0) years and 70% were males. Mean scores for the physical composite summary, mental composite summary, symptom/problem list, effects of kidney disease and burden of kidney disease scales were 35.2, 47.0, 73.8, 72.5 and 59.8 respectively. Younger age was associated with lower scores in all subscales except for the physical composite summary. Female gender, obese or normal weight rather than overweight, and smoking were all associated with lower scores in one or more subscales. Scores were progressively lower with more advanced stage of CKD (p<0.05) in all subscales except for the mental composite summary. Conclusion(s): In patients with diabetes and CKD, younger age was associated with lower scores in all HRQoL subscales except the physical composite summary and female gender, obese or normal weight and more advanced stages of CKD were associated with lower scores in one or more subscales. Identifying these fa