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Aims: This study examines prehospital Emergency Medical Service (EMS) utilisation and patterns of demand for hyperglycaemia management, including characteristics of individuals and factors related to hospital transport. Material(s) and Method(s): A state-wide, community-based observational study of all patients requiring prehospital EMS for hyperglycaemia during a 7 year study period (Jan 2009-Dec 2015) using electronic data from the Ambulance Victoria data warehouse was conducted. Pre-specified variables related to patient demographics, comorbidities, examination findings, paramedic treatment and transport outcomes were obtained. Logistic regression was used to assess factors associated with transport to hospital. Result(s): There were 11,417 cases of hyperglycaemia attended by paramedics during the study period, accounting for 0.3-0.4% of the total annual EMS caseload, and equating to 0.54 attendances per 100 people with diabetes in the state of Victoria, Australia, per year. There was a significant increase in annual utilisation, with a rate ratio of 1.62 between 2009 (2.42 cases per 10,000 population) and 2015 (3.91 cases per 10,000 population). Fifty-one percent of cases had type 2 diabetes, 37% had type 1 diabetes, 4% had diabetes with the type unspecified and 8% had no recorded history of diabetes. Ninety percent of cases were transported to hospital. Factors associated with increased odds of transport to hospital included no known history of diabetes, regional/rural locations, case time between 0600 and <1800 hours, increasing number of comorbidities and increasingly unstable vital sign observations. Conclusion(s): There is substantial utilisation of prehospital EMS for hyperglycaemia. With increased population prevalence of diabetes predicted, further research on opportunities for prevention, as well as optimal management in the prehospital environment is warranted.Copyright © 2017 Villani et al. This is an open access article distributed under the terms of

Background: Polycystic ovary syndrome (PCOS) is associated with features linked to metabolic syndrome including visceral obesity, dyslipidemia and impaired glucose homeostasis. Recent studies suggest that these metabolic effects are linked to a low-grade chronic inflammation with the triad of hyperinsulinemia, hyperandrogenism, and low-grade inflammation acting together in a vicious cycle. Adipose tissue produces immunomodulatory adipocytokines which contribute to regulation of insulin sensitivity, reproduction and cardiovascular function. Limited evidence is available on the role of adipocytokines in PCOS. Aim(s): This study investigated the relationships between PCOS status, adipocytokines and aetiological features of PCOS. Method(s): In an observational study of community recruited PCOS and controls, we measured serum HMW-adiponectin, omentin, resistin, interleukin-6 (IL-6), asymmetric dimethylarginine (ADMA), plasminogen activator inhibotir-1(PAI-1), high sensitivity CRP (hs-CRP), androgens, SHBG, fasting glucose and insulin levels. Result(s): Forty-nine women with PCOS (age 29.8 +/- 5.9 years, BMI: 29.0 +/- 5.4 kg/m2) and 25 healthy controls (age 37.6 +/- 7.8 years, BMI: 28.9 +/- 4.0 kg/m2) were recruited. Homeostatic model assessment for insulin resistance (HOMA-IR) (P = 0.006), free androgen index (FAI) (P = 0.01) and Ferriman-Galway score (P < 0.001) were higher in PCOS. For adipocytokines, women with PCOS had lower omentin [median (IQR): 68.76(67.17) vs 112.45(67.42)] (P = 0.01) and higher hs-CRP [median (IQR): 2.15 (3.4) vs 1.00 (2.1)] (P = 0.03) after adjustment for age and BMI. On assessment of non-obese and obese subgroups, HMWadiponectin and omentin were lower in obese women with PCOS compared to obese controls (P = 0.022 and P = 0.034 respectively) and nonobese PCOS (P = 0.028 and P = 0.016 respectively). Among women with PCOS, HMW-adiponectin was negatively correlated with HOMA-IR and FAI, however only the correlation between HMW-adiponectin and FAI

Introduction: Polycystic ovary syndrome (PCOS) is a common condition affecting up to 18% of reproductive-aged women. It is associated with reproductive, metabolic and psychological dysfunction. While the genetics of PCOS are as yet not fully understood, it is recognised as a familial condition. Limited research suggests that offspring of women with PCOS have altered insulin resistance, glucose intolerance, lipids and leptin, however other markers of cardio-metabolic function have not been characterised. Method(s): A cross-sectional comparison of cord blood parameters in the offspring of women with (n = 55) and without (n = 55) PCOS. Women were further categorised into those with (n = 82) and without (n = 28) gestational diabetes, and subgrouped by treatment status (metformin n = 33, insulin n = 43 or unknown n = 6). Outcomes included cord rather than core blood insulin, glucose, leptin, lipids and inflammatory cytokines. Result(s): Offspring of women with and without PCOS had similar cord blood markers on unadjusted analysis. On models adjusting for GDM, maternal race, maternal age, birth weight, gestational age, infant gender, method of delivery and smoking status, offspring of women with PCOS had elevated leptin (P = 0.040) and granulocyte-macrophage-colony-stimulating factor (GMCSF; P = 0.043). GDM, irrespective of PCOS status, was associated with increased glucose (P < 0.001) and high density lipoproteins (P < 0.001), and decreased CRP (P < 0.001). Treatment of GDM with metformin decreased glucose levels compared to insulin (P = 0.024), while the other measures were unaffected by treatment. Conclusion(s): The elevation in cord blood GMCSF and leptin with PCOS indicates potential programming of cardiometabolic systems in-utero, independent of GDM or treatment status. These programming effects may become exacerbated in combination with the increased glucose and high density lipoprotein concentrations that occurs with gestational diabetes. This research contributes

Polycystic ovary syndrome (PCOS) is a common condition with serious physiological and psychological health consequences. It affects women across their reproductive lifespan and is associated with pregnancy complications, including gestational diabetes, preeclampsia, and large gestational-age babies. PCOS is associated with excess weight gain, which, in turn, exacerbates the health burden of PCOS. Therefore, weight management, including a modest weight loss, maintenance of weight loss, prevention of weight gain, and prevention of excess gestational weight gain, is a first-line treatment for women with PCOS during and independent of pregnancy. Despite evidence-based guidelines, international position statements, and Cochrane reviews promoting lifestyle interventions for PCOS, the optimal complexity, intensity, and behavioral components of lifestyle interventions for women with PCOS are not well understood. The focus of this narrative review is the evidence supporting the use of behavioral strategies in weight management interventions for reproductive-aged women to apply to PCOS. Behavioral theories, behavior change strategies, and psychological correlates of weight management have been thoroughly explored in weight loss interventions in the general population, reproductive-aged women, and peri-natal women. This article uses this parallel body of research to inform suggestions regarding lifestyle interventions in women with PCOS. Outcomes of weight management programs in women with PCOS are likely to be improved with the inclusion of behavioral and psychological strategies, including goal setting, self-monitoring, cognitive restructuring, problem solving, and relapse prevention. Strategies targeting improved motivation, social support, and psychological well-being are also important. These can be applied to the clinical management of women with PCOS at different reproductive life stages.Copyright © 2017, Mary Ann Liebert, Inc.

Introduction There is conflicting evidence regarding the efficacy of high dose salicylates in improving cardiometabolic risk in healthy and type 2 diabetes patients. We aimed to determine whether treatment with salicylates at an anti-inflammatory dose (>= 1 g daily) would improve cardiometabolic risk in healthy individuals and type 2 diabetes patients, compared to placebo. Methods Medline, Medline-in-process, Embase, and all EBM databases were searched for studies published up to December 2016. Twenty-eight articles from 24 studies comprising 1591 participants were included. Two reviewers independently assessed the risk of bias and extracted data from included studies. Meta-analyses using random-effects model were used to analyze the data. Results High dose salicylates (>= 3 g/d) decreased fasting glucose (MD -0.4 mmol/l, 95% CI - 0.54, - 0.27) and glucose area under the curve (MD -0.41 mmol/l, 95% CI - 0.81, - 0.01). Salicylates (>= 3 g/d) also increased fasting insulin (MD 2.4 muU/ml, 95% CI 0.3, 4.4), 2-h insulin (MD 25.4 muU/ml, 95% CI 8.2, 42.6), insulin secretion (MD 79.2, 95% CI 35, 123) but decreased fasting C-peptide (MD -0.11 nmol/l, 95% CI - 0.2, - 0.04), insulin clearance (MD -0.26 l/min, 95% CI - 0.36, - 0.16) and triglycerides (MD -0.36 mmol/l, 95% CI - 0.51, - 0.21) and increased total adiponectin (MD 1.97 mug/ml, 95% CI 0.99, 2.95). A lower salicylate dose (1-2.9 g) did not change any cardiometabolic parameters (p > 0.1). No significant difference was observed between those receiving salicylates and placebo following withdrawal due to adverse events. Conclusions High dose salicylates appear to improve cardiometabolic risk factors in healthy individuals and type 2 diabetes patients. PROSPERO registration number CRD42015029826.Copyright © 2017 Elsevier Inc.

South Asians are a growing migrant population, both globally and in Australia. This group are at higher risk for both cardiovascular disease and type 2 diabetes. The aim of this qualitative study was to compare dietary practices of South Asians, n = 41 (Indian, n = 25; Sri Lankan, n = 16) and Anglo-Australians, n = 16, with these conditions, using semi-structured in-depth interviews. Findings suggest that both groups had a high level of awareness of dietary practices necessary for optimum disease management, both prior to and post diagnosis. Bi-directional effects of migration were noted in the dietary practices of both groups suggesting hybrid diets are evident in Australia. A key barrier to implementing dietary changes highlighted by both groups of participants was a lack of specific, timely and detailed dietary advice from clinicians. Both groups expressed that advice should be repeated and reinforced throughout the course of their disease. In addition, South Asian participants wanted more culturally relevant advice. Clinicians providing dietary advice need to recognise that preferences for staple food items are resistant to change and may affect adherence. Acculturation was evident in the dietary practices of the South Asian participants. Nevertheless, many maintained traditional food practices which were tied to their cultural identity. It is recommended that clinicians consider these factors when offering advice.Copyright © 2017

Polycystic ovary syndrome (PCOS) is a common and complex endocrinopathy with reproductive, metabolic, and psychological features and significantly increased cardiometabolic risks. PCOS is underpinned by inherent insulin resistance and hyperandrogenism. Obesity, more common in PCOS, plays an important role in the pathophysiology, exacerbating hyperinsulinaemia and hyperandrogenism, leading to recommended first-line lifestyle intervention. Significant traditional and non-traditional risk factors are implicated in PCOS in addition to obesity-exacerbated cardiometabolic risks and are explored in this review to promote the understanding of this common metabolic and reproductive condition.Copyright © 2016 S. Karger AG, Basel.

Introduction: Polycystic ovary syndrome (PCOS) is a common condition affecting up to 18% of reproductive-aged women. In addition to reproductive complications, women with PCOS have elevated risk factors for cardiovascular disease including insulin resistance and dyslipidaemia. Lipidomics identifies specific molecular lipid species and classes and subclasses with important implications for lipid profiling for disease classification, risk assessment and lipid metabolism associated with specific disease states. There is no research examining lipidomics in PCOS and the pathphysiological features of hyperandrogenism and insulin resistance in PCOS. Method(s): In biobanked samples, we examined the lipidomic profile in 156 pre-menopausal overweight women (n = 92 with PCOS and 64 without PCOS), specifically 24 lipid classes comprising 325 species using liquid chromatography mass spectrometry. Result(s): There were no differences in lipid classes or species between women with or without PCOS. There were no association of lipid classes with total testosterone on unadjusted or adjusted models. There was a significant negative association of SHBG with diacylglycerol and triacylglyercol on adjusted models. There was a significant positive association of FAI with ceramide, phosphatidylcholine, lysophosphatidylcholine, phosphatidylethanolamine, lysophosphatidylethanolamine, phosphatidylinositol, diacylglycerol and triacylglyercol on adjusted models. Conclusion(s): While PCOS status was not associated with differences in lipid classes or species, SHBG and FAI (as key pathophysiological aspects in PCOS and correlates of obesity) were associated with differences in a number of lipid classes. This highlights the interaction between reproductive hormones in women and cardiovascular risk, independent of PCOS status.

The aim of this study was to systematically review and meta-analyse the associations between parity, pre-pregnancy body mass index (BMI), gestational weight gain (GWG) and, when included, postpartum weight retention (PPWR). Papers reporting associations between parity and BMI and/or GWG in adult women were eligible: 2,195 papers were identified, and 41 longitudinal studies were included in the narrative synthesis; 17 studies were included in a meta-analysis. Findings indicated that parity was associated positively with pre-pregnancy BMI. In contrast, the role of parity in GWG was less clear; both positive and negative relationships were reported across studies. Parity was not associated directly with PPWR. This pattern of results was supported by our meta-analysis with the only significant association between parity and pre-pregnancy BMI. Overall, parity was associated with higher pre-pregnancy BMI; however, the role of parity in GWG and PPWR remains unclear, and it is likely that its influence is indirect and complex. Further research to better understand the contribution of parity to maternal obesity is warranted.Copyright © 2017 World Obesity Federation

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. Methods: 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. Results: 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). Conclusions: 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.

OBJECTIVE: Back pain causes greater disability worldwide than any other condition, with women more likely to experience back pain than men. Our aim was to identify modifiable risk factors for back pain in middle-aged women. METHODS: Women born between 1946 and 1951 were randomly selected from the national health insurance scheme database to participate in The Australian Longitudinal Study on Women's Health. Self-reported data on back pain in the last 12 months, and on weight, physical activity, and other sociodemographic factors, were collected in 1998, 2001, 2004, 2007, 2010, and 2013. In 1998, a total of 12,338 women completed the survey and 10,011 (74%) completed the 2013 survey. RESULTS: At baseline, median (range) age was 49.5 years (44.6-53.5 years), and 54% reported back pain. In multivariate analysis, baseline weight and depression were positive predictors of back pain over each 3-year survey interval and over the following 15 years, whereas participation in vigorous physical activity was protective. The effects of weight on back pain were most marked in women with a body mass index of ≥25 kg/m2 . CONCLUSION: Back pain is common in middle-aged women. Increased weight, weight gain, and depression were independent predictors of back pain over 15 years, whereas participation in vigorous physical activity was protective. Targeting these lifestyle factors is an important area for future research on reducing the burden of back pain in middle-aged women.

Background: Health-care for co-morbid diabetes and chronic kidney disease (CKD) is often sub-optimal. To improve health-care, we explored the perspectives of general practitioners (GPS) and tertiary health-care professionals concerning key factors influencing health-care of diabetes and CKD. Methods: A total of 65 health professionals were purposively sampled from Australia's 2 largest cities to participate in focus groups and semi-structured interviews. Four focus groups were conducted with GPS who referred to 4 tertiary health services in Australia's 2 largest cities, with 6 focus groups conducted with tertiary health-care professionals from the 4 tertiary health services. An additional 8 semi-structured interviews were performed with specialist physicians who were heads of diabetes and renal units. All discussions were facilitated by the same researcher, with discussions digitally recorded and transcribed verbatim. All qualitative data was thematically analysed independently by 2 researchers. Results: Both GPS and tertiary health-care professionals emphasised the importance of primary care and that optimal health-care was an inter-play between patient self-management and primary health-care, with specialist tertiary health-care support. Patient self-management, access to specialty care, coordination of care and a preventive approach were identified as key factors that influence healthcare and require improvement. Both groups suggested that an integrated specialist diabetes-kidney service could improve care. Unit heads emphasised the importance of quality improvement activities. Conclusions: GPS and tertiary health-care professionals emphasised the importance of patient self-management and primary care involvement in the health-care of diabetes and CKD. Supporting GPS with an accessible, multidisciplinary diabetes-renal health service underpinned by strong communication pathways, a preventive approach and quality improvement activities, may improve health-care and

Back pain causes enormous financial and disability burden worldwide, which could potentially be reduced by understanding its determinants to develop effective prevention strategies. Our aim was to identify whether modifiable risk factors, weight and physical activity, are predictive of back pain in young adult women. Women born between 1973 and 1978 were randomly selected from the national health insurance scheme database to participate in The Australian Longitudinal Study of Women's Health. Self-reported data on back pain in the last 12 months, weight, height, age, education status, physical activity, and depression were collected in 2000, 2003, 2006, 2009, and 2012. In 2000, 9688 women completed the questionnaire and 83% completed follow-up 12 years later. At baseline, median age was 24.6 years and 41% had self-reported back pain. For every 5 kg higher weight at baseline, there was a 5% (95% confidence interval [CI] 4%-6%) increased risk of back pain over the next 12 years. Higher weight at each survey also predicted back pain risk 3 years later (P<0.001). The effects of weight on back pain were most significant in those with BMI >=25 kg/m2 and were observed at all levels of physical activity. Inadequate physical activity and depression were independent predictors of back pain over the following 12 years (both P<0.001), after adjusting for age, weight, height, and education status. Back pain is common in community-based young adult women. Higher weight, inadequate levels of physical activity, and depression were all independent predictors of back pain over the following decade. Furthermore, the adverse effects of weight on back pain were not mitigated by physical activity. Our findings highlight the role of both higher weight and physical inactivity in back pain among young women and suggest potential opportunities for future prevention.Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Aims Diabetes is associated with several acute, life-threatening complications yet there are limited data on the utilisation of prehospital services for their management. This study aimed to examine the utilisation of emergency medical services (EMS) for prehospital hypoglycaemia, including patient characteristics and factors related to hospital transportation. Methods An observational study of patients requiring EMS for hypoglycaemia across Victoria, Australia over three years was conducted. Pre-specified data including patient demographics, comorbidities, examination findings and transport outcomes were obtained. Logistic regression was used to assess factors associated with transportation. Results During the study period, 12,411 hypoglycaemia events were attended by paramedics for people with diabetes. The majority were individuals with type 1 diabetes (58.8%), followed by type 2 diabetes (35.2%) and unspecified diabetes type (5.9%). Thirty-eight percent of patients were transported to hospital by EMS following hypoglycaemia. Factors associated with transport by EMS included extremes of age (< 15 and > 75 years), female gender, type 2 diabetes, event at a nursing home or hospital/community clinic, presence of comorbidities and time of day. Conclusions Examination of the utilisation of EMS for hypoglycaemia has identified a previously unquantified need for emergency care for people with diabetes as well as factors related to hospital transportation.Copyright © 2016 Elsevier Inc.

Objective Polycystic ovary syndrome (PCOS) is a common endocrine condition underpinned by insulin resistance and associated with increased risk of obesity, type 2 diabetes and adverse cardiovascular risk profile. Previous data suggest autonomic imbalance [elevated sympathetic nervous system (SNS) activity and decreased heart rate variability (HRV)] as well as endothelial dysfunction in PCOS. However, it is not clear whether these abnormalities are driven by obesity and metabolic disturbance or whether they are independently related to PCOS. Participants and methods We examined multiunit and single-unit muscle SNS activity (by microneurography), HRV (time and frequency domain analysis) and endothelial function [ischaemic reactive hyperaemia index (RHI) using the EndoPAT device] in 19 overweight/obese women with PCOS (BMI: 31.3 +/- 1.5 kg/m2, age: 31.3 +/- 1.6 years) and compared them with 21 control overweight/obese women (BMI: 33.0 +/- 1.4 kg/m2, age: 28.2 +/- 1.6 years) presenting a similar metabolic profile (fasting total, HDL and LDL cholesterol, glucose, triglycerides, insulin sensitivity and blood pressure). Results Women with PCOS had elevated multiunit muscle SNS activity (41 +/- 2 vs 33 +/- 3 bursts per 100 heartbeats, P < 0.05). Single-unit analysis showed that vasoconstrictor neurons were characterized by elevated firing rate and probability and incidence of multiple spikes (P < 0.01 for all parameters). Women with PCOS also had impaired endothelial function (RHI: 1.77 +/- 0.14 vs 2.18 +/- 0.14, P < 0.05). HRV did not differ between the groups. Conclusion Women with PCOS have increased sympathetic drive and impaired endothelial function independent of obesity and metabolic disturbances. Sympathetic activation and endothelial dysfunction may confer greater cardiovascular risk in women with PCOS.Copyright © 2015 John Wiley & Sons Ltd.

Young clinicians and clinical and research scientists in endocrinology will be the future lifeblood of our society and field over the next several decades. We have seen major changes in the key focus areas in clinical endocrinology with an aging population, challenges obtaining public hospital positions, a shift in the gender of the workforce, increased engagement in research training (~7000 PhD's in Australia annually) and falling research funding. In this context the role of recruitment, retention, career opportunity and development and empowerment of young clinicians and researchers in endocrinology are important. In this session past and current US Endocrine Society and ESA President's will explore these themes in the US and Australian context. We will also discuss career challenges for young women and men trying to balance career and family. The session will be interactive and include a panel discussion with younger ESA members and will assist the society in strategic planning, lobbying and progressing the future of this field.

With increasingly adverse lifestyles, young women in many countries have rapid weight gain and rising obesity. In keeping with this, most pregnant women exceed recommended gestational weight gain (GWG) and then retain weight postpartum. The consequences of excess GWG include maternal risks during pregnancy, neonatal risks and maternal obesity and chronic disease longer term, presenting a significant public health and economic burden worldwide. This article discusses the adverse maternal and infant risks with excess GWG apparent from observational studies, summarizes the existing guidelines for optimal GWG and highlights the need for further research to identify optimal GWG recommendations across the different ethnicities and weight ranges. We also review the evidence for lifestyle interventions in pregnancy to prevent excess GWG and highlighting the work underway to integrate large scale meta-analyses of individual patient data from lifestyle intervention studies to inform clinical practice beyond current observational data. Finally, we address the need to implement lifestyle interventions into routine pregnancy care to improve short and long term maternal health outcomes.Copyright © 2016 by Thieme Medical Publishers, Inc.

Objective: There is insufficient evidence for treatment targets in Gestational Diabetes Mellitus (GDM). We aimed to explore the impact of different treatment targets on pregnancy outcomes. Method(s): An observational study was conducted of singleton births >20 weeks at Monash Health (MH) and Royal Women's Hospital (RWH) from 2009-2013. Data (pregnancy details, maternal and neonatal outcomes) were obtained from each hospital's pregnancy database. Outcomes for women with GDM at MH (n = 2891) and RWH (n = 1930) were compared [diagnosis: 2 h 75 g OGTT at 24-28 weeks with fasting glucose >=5.5 mmol/L and/or 2 h >= 8.0 mmol/L]. Each hospital follows a similar GDM management protocol but applies different treatment targets: MH fasting <5.5 mmol/L, 2 h post-prandial <7.0 mmol/L; RWH fasting <5.0 mmol/L, 2 h < 6.7 mmol/L. Descriptive statistics are presented. Multivariable regression analysis will be used to examine associations between GDM treatment and adverse outcomes. Result(s): The prevalence of GDM and requirement for insulin at MH were 7.9% and 31%, and at RWH with stricter treatment targets were 6.3% and 47% respectively. Over half of women with GDM were overweight or obese. The rate of special care nursery admission (29.6% vs 17.0%) was higher at MH compared to RWH, but rates of induction of labour (30.6% vs 56.6%) and caesarean section (33.8% vs 39.5%) were lower (all p < 0.001), partly reflecting hospital protocols. Babies of women with GDM were born later (mean gestation 39 +/- 2 vs 38 +/- 2 wk, p < 0.001) at MH compared to RWH, and had higher rates of respiratory distress (3.6% vs 1.2%, p < 0.001), hypoglycaemia (9.9% vs 2.2%, p < 0.001) and macrosomia (11.3% vs 9.5%, p = 0.035), but lower rates of pre-term birth (8.5% vs 11.3%, p = 0.001) and stillbirth (0.3% vs 0.7%, p = 0.024). Rates of shoulder dystocia and jaundice were comparable. Conclusion(s): Stricter treatment targets for GDM appear to reduce macrosomia, without increasing neonatal hypoglycaemia or spe

Study question: Do young women with polycystic ovary syndrome (PCOS) or endometriosis report more psychological distress than their peers without a history of these conditions? summaryanswer: Youngwomen(aged 18-23 years) withPCOSor endometriosis had a greater risk ofmoderate to severe psychological distress than women without a history of these conditions. what is known already: Psychological distress appears common among women with PCOS and endometriosis. However, population- based studies that examine the psychological outcomes for adolescents and young women are generally absent from the literature. study design, size, duration: This is a secondary analysis of data collected from 17 015 young, Australian women participating in a national, longitudinal cohort study.Womenwere first surveyed in 2012-2013 when they were aged 18-23 years. In 2014,womencompleted the second survey when they were aged 19-24 years and 11324 (67%) women responded. participants/materials, setting, methods:We analysed data from11 238 women who participated in both Surveys 1 and 2 and who responded to questions about PCOS and endometriosis. Using logistic regression, we compared the odds of moderate to severe psychological distress at Surveys 1 and 2 for women reporting a recent diagnosis (within the last 12 months) of PCOS or endometriosis and women with a pre-existing diagnosis, with that for women without a history of these conditions. main results and the role of chance: At Survey 2, around 60% of women reporting a diagnosis of PCOSor endometriosis had moderate to severe levels of psychological distress. Compared to women without a history of these conditions, the odds of moderate to severe psychological distress at Survey 2 were significantly higher for women recently diagnosed with PCOS [Adjusted Odds Ratio (AOR) = 1.62, 95% CI = 1.21-2.18] or endometriosis (AOR= 1.77; 95% CI = 1.20-2.63) and for women with a pre-existing diagnosis of PCOS (AOR = 1.57, 95% CI = 1.30-1.89) or endometrios

Background Multi-morbidity due to diabetes and chronic kidney disease (CKD) remains challenging for current health-systems, which focus on single diseases. As a first step toward health-care improvement, we explored the perspectives of patients and their carers on factors influencing the health-care of those with co-morbid diabetes and CKD. Methods In this qualitative study participants with co-morbid diabetes and CKD were purposively recruited using maximal variation sampling from 4 major tertiary health-services from 2 of Australia's largest cities. Separate focus groups were conducted for patients with CKD stages 3, 4 and 5. Findings were triangulated with semi-structured interviews of carers of patients. Discussions were transcribed verbatim and thematically analysed. Results Twelve focus groups with 58 participants and 8 semi-structured interviews of carers were conducted. Factors influencing health-care of co-morbid diabetes and CKD grouped into patient and health service level factors. Key patient level factors identified were patient selfmanagement, socio-economic situation, and adverse experiences related to co-morbid diabetes and CKD and its treatment. Key health service level factors were prevention and awareness of co-morbid diabetes and CKD, poor continuity and coordination of care, patient and carer empowerment, access and poor recognition of psychological co-morbidity. Health-service level factors varied according to CKD stage with poor continuity and coordination of care and patient and carer empowerment emphasized by participants with CKD stage 4 and 5, and access and poor recognition of psychological co-morbidity emphasised by participants with CKD stage 5 and carers. Conclusions According to patients and their carers the health-care of co-morbid diabetes and CKD may be improved via a preventive, patient-centred health-care model which promotes self-management and that has good access, continuity and coordination of care and identifies and manages

Background: Health-care for co-morbid diabetes and chronic kidney disease (CKD) is often sub-optimal. To improve health-care, we explored the perspectives of general practitioners (GPS) and tertiary health-care professionals concerning key factors influencing health-care of diabetes and CKD. Method(s): A total of 65 health professionals were purposively sampled from Australia's 2 largest cities to participate in focus groups and semi-structured interviews. Four focus groups were conducted with GPS who referred to 4 tertiary health services in Australia's 2 largest cities, with 6 focus groups conducted with tertiary health-care professionals from the 4 tertiary health services. An additional 8 semi-structured interviews were performed with specialist physicians who were heads of diabetes and renal units. All discussions were facilitated by the same researcher, with discussions digitally recorded and transcribed verbatim. All qualitative data was thematically analysed independently by 2 researchers. Result(s): Both GPS and tertiary health-care professionals emphasised the importance of primary care and that optimal health-care was an inter-play between patient self-management and primary health-care, with specialist tertiary health-care support. Patient self-management, access to specialty care, coordination of care and a preventive approach were identified as key factors that influence healthcare and require improvement. Both groups suggested that an integrated specialist diabetes-kidney service could improve care. Unit heads emphasised the importance of quality improvement activities. Conclusion(s): GPS and tertiary health-care professionals emphasised the importance of patient self-management and primary care involvement in the health-care of diabetes and CKD. Supporting GPS with an accessible, multidisciplinary diabetes-renal health service underpinned by strong communication pathways, a preventive approach and quality improvement activities, may improve health-ca

Introduction: The extraskeletal role of Vitamin D is being increasingly recognised. This has important clinical implications, as Vitamin D deficiency has reached epidemic proportions worldwide. Vitamin D has proposed anti-inflammatory properties, yet the role of Vitamin D supplementation in reducing inflammation remains largely unknown. The purpose of this review is to investigate the impact of Vitamin D supplementation on inflammation, and to identify relevant knowledge gaps in the field. Methods and analysis: Medline, CINAHL, EMBASE and All EBM will be systematically searched for randomised controlled trials (RCTs) and systematic reviews of RCTs, comparing Vitamin D supplementation with placebo, usual care or other pharmacological or non-pharmacological interventions. One reviewer will assess articles for eligibility according to prespecified selection criteria, after which 2 independent reviewers will perform data extraction and quality appraisal. Meta-analyses will be conducted where appropriate. Ethics and dissemination: Formal ethical approval is not required as no primary data is collected. This systematic review will identify potential clinical implications of Vitamin D deficiency and supplementation, and will be disseminated through a peer-reviewed publication and at conference meetings, to inform future research on the efficacy of Vitamin D supplementation for inflammation and inflammatory diseases.

BACKGROUND: Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS). OBJECTIVE AND RATIONALE: The aim of this paper was to present an evidence base for the management of anovulatory PCOS. SEARCH METHOD(S): The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus. OUTCOME(S): Evidence was synthesized and we made recommendations across the definition of PCOS including hyperandrogenism, menstrual cycle regulation and ovarian assessment. Metabolic features and the impact of ethnicity were covered. Management includes lifestyle changes, bariatric surgery, pharmacotherapy (including clomiphene citrate (CC), aromatase inhibitors, metformin and gonadotropins), as well as laparoscopic surgery. In-vitro fertilization (IVF) was considered as were the risks of ovulation induction and of pregnancy in PCOS. Approximately 80% of women who suffer from anovulatory infertility have PCOS. Lifestyle intervention is recommended first in women who are obese largely on the basis of general health benefits. Bariatric surgery can be considered where the body mass index (BMI) is >= 35 kg/m2 and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good

The development of immunotherapy has provided patients with metastatic melanoma with improved tumour response and overall survival rates1. However, these medications are associated with unique adverse event profiles, unlike other chemotherapeutic agents. A 61 year male presented in diabetic ketoacidosis (DKA) following sequential therapy with ipilimumab and pembrolizumab for the treatment of metastatic melanoma. He had completed four cycles of ipilimumab and had commenced pembrolizumab following disease progression six weeks prior to his presentation. There was no past history or family history of Type 1 diabetes or other autoimmune conditions. He was managed according to a standard DKA protocol and subsequently changed to a basal bolus insulin regimen. Antibodies to GAD or IA-2 were negative and C-peptide was 57 pmol/L (300-2350 pmmol/L). There was biochemical evidence of mild hyperthyroidism (TSH 0.01, T4 26.4) with negative thyroid antibodies. He had normal pituitary function. He was commenced on high doses of glucocorticosteroids (GCS), conventional immunosuppressive therapy for pembrolizumab induced autoimmune adverse effects, in an attempt to salvage beta cell function. His insulin requirements significantly declined with weaning of GCS doses suggesting potential recovery. Ipilimumab is a monoclonal antibody against CTLA-4 and pembrolizumab, against the Programmed death-1 (PD-1) receptor. They amplify the host cell response against tumoural antigens and have shown superior response rates and overall survival in patients with metastatic melanoma. They are associated with unique immune related adverse effects (IRAE) from non-specific stimulation of the immune system. The IRAE's are typically managed with high doses of GCS and are mostly reversible. There are only a handful of case reports of pembrolizumab induced T1DM. Beta cell recovery following administration of GCS has not previously been described. Here we describe a case of DKA in a patient receiving novel

Low vitamin D and insulin resistance are common in polycystic ovary syndrome (PCOS) and associated with higher inter- and intra-muscular adipose tissue (IMAT). We investigated associations between vitamin D, IMAT and insulin resistance in a cross-sectional study of 40 women with PCOS and 30 women without PCOS, and pre- and post-exercise in a 12-week intervention in 16 overweight participants (10 with PCOS and six without PCOS). A non-classical body mass index (BMI) threshold was used to differentiate lean and overweight women (BMI >= 27 kg/m2). Measurements included plasma 25-hydroxyvitamin D (25OHD), insulin resistance (glucose infusion rate (GIR; mg/m2/min), fasting glucose and insulin, and glycated haemoglobin), visceral fat, mid-thigh IMAT (computed tomography) and total body fat (dual-energy X-ray absorptiometry). Women with both PCOS and low 25OHD levels had the lowest GIR (all p < 0.05). Higher IMAT was associated with lower 25OHD (B = -3.95; 95% CI -6.86, -1.05) and GIR (B = -21.3; 95% CI -37.16, -5.44) in women with PCOS. Overweight women with pre-exercise 25OHD >=30 nmol/L had significant increases in GIR, and decreases in total and visceral fat (all p < 0.044), but no associations were observed when stratified by PCOS status. Women with PCOS and low 25OHD levels have increased insulin resistance which may be partly explained by higher IMAT. Higher pre-training 25OHD levels may enhance exercise-induced changes in body composition and insulin resistance in overweight women.Copyright © 2016 by the authors; licensee MDPI, Basel, Switzerland.

Background: Obesity is reaching epidemic proportions in both developed and developing countries. Even modest weight gain increases the risk for chronic illness, yet evidence-based interventions to prevent weight gain are rare. This trial will determine if a simple low-intensity intervention can prevent weight gain in women compared to general health information. Methods and Findings: We conducted a 1-yr pragmatic, cluster randomised controlled trial in 41 Australian towns (clusters) randomised using a computer-generated randomisation list for intervention (n = 21) or control (n = 20). Women aged 18 to 50 yr were recruited from the general population to receive a 1-yr self-management lifestyle intervention (HeLP-her) consisting of one group session, monthly SMS text messages, one phone coaching session, and a program manual, or to a control group receiving one general women's health education session. From October 2012 to April 2014 we studied 649 women, mean age 39.6 yr (+/- SD 6.7) and BMI of 28.8 kg/m2 (+/- SD 6.9) with the primary outcome weight change between groups at 1 yr. The mean change in the control was +0.44 kg (95% CI -0.09 to 0.97) and in the intervention group -0.48kg (95% CI -0.99 to 0.03) with an unadjusted between group difference of -0.92 kg (95% CI -1.67 to -0.16) or -0.87 kg (95% CI -1.62 to -0.13) adjusted for baseline values and clustering. Secondary outcomes included improved diet quality and greater self-management behaviours. The intervention appeared to be equally efficacious across all age, BMI, income, and education subgroups. Loss to follow-up included 23.8% in the intervention group and 21.8% in the control group and was within the anticipated range. Limitations include lack of sensitive tools to measure the small changes to energy intake and physical activity. Those who gained weight may have been less inclined to return for 1 yr weight measures. Conclusion(s): A low intensity lifestyle program can prevent the persistent weight gain ob

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. Methods: 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 ™ -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. Results: 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: 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 factors wi

Background Multi-morbidity due to diabetes and chronic kidney disease (CKD) remains challenging for current health-systems, which focus on single diseases. As a first step toward health-care improvement, we explored the perspectives of patients and their carers on factors influencing the health-care of those with co-morbid diabetes and CKD. Methods In this qualitative study participants with co-morbid diabetes and CKD were purposively recruited using maximal variation sampling from 4 major tertiary health-services from 2 of Australia's largest cities. Separate focus groups were conducted for patients with CKD stages 3, 4 and 5. Findings were triangulated with semi-structured interviews of carers of patients. Discussions were transcribed verbatim and thematically analysed. Results Twelve focus groups with 58 participants and 8 semi-structured interviews of carers were conducted. Factors influencing health-care of co-morbid diabetes and CKD grouped into patient and health service level factors. Key patient level factors identified were patient selfmanagement, socio-economic situation, and adverse experiences related to co-morbid diabetes and CKD and its treatment. Key health service level factors were prevention and awareness of co-morbid diabetes and CKD, poor continuity and coordination of care, patient and carer empowerment, access and poor recognition of psychological co-morbidity. Health-service level factors varied according to CKD stage with poor continuity and coordination of care and patient and carer empowerment emphasized by participants with CKD stage 4 and 5, and access and poor recognition of psychological co-morbidity emphasised by participants with CKD stage 5 and carers. Conclusions According to patients and their carers the health-care of co-morbid diabetes and CKD may be improved via a preventive, patient-centred health-care model which promotes self-management and that has good access, continuity and coordination of care and identifies and manages

Background.: Co-morbid diabetes and chronic kidney disease (CKD) are common in primary care but health care can be suboptimal. Objective.: In this multi-centre mixed-methods study, we investigated GPs' perspectives on health service barriers in managing diabetes and CKD as an initial step towards health care improvement. Methods.: Four focus groups were conducted among GPs in Australia's two largest cities. Transcripts underwent content analysis to inform development of a survey exploring health service barriers. This survey was then emailed/mailed to 840 GPs. Statistical analyses were performed using STATA v2.1. Results.: Responses were received from 13.7% of GPs (n = 115), mean (+/-SD) age 55.3 (10.1) years and mean duration of practice 26.6 (10.6). The majority (88.4%) reported wanting to manage diabetes and CKD in primary care with specialist assistance. However, 34.8% were unclear about the definition of CKD with 73.2% wanting more education. Access to specialist services was problematic with 39.3% and 28.2% reporting the process of referring patients to diabetes or CKD services, respectively, as hard. Coordination of care was also a problem with 35.6% unclear about each health care provider's role, 50.5% believing patients faced difficulties due to poor coordination across providers and 51.6% reporting duplication of tests. Conclusions.: GPs expressed a clear interest in being the principal health care providers for patients with co-morbid diabetes and CKD. Supporting GPs and health care improvement focusing on overcoming reported barriers such as inadequate knowledge about CKD, access to specialist services and coordination of care may improve outcomes for people with co-morbid diabetes and CKD.Copyright © The Author 2016. Published by Oxford University Press. All rights reserved.

Low vitamin D and insulin resistance are common in polycystic ovary syndrome (PCOS) and associated with higher inter- and intra-muscular adipose tissue (IMAT). We investigated associations between vitamin D, IMAT and insulin resistance in a cross-sectional study of 40 women with PCOS and 30 women without PCOS, and pre- and post-exercise in a 12-week intervention in 16 overweight participants (10 with PCOS and six without PCOS). A non-classical body mass index (BMI) threshold was used to differentiate lean and overweight women (BMI ≥ 27 kg/m2). Measurements included plasma 25-hydroxyvitamin D (25OHD), insulin resistance (glucose infusion rate (GIR; mg/m2/min), fasting glucose and insulin, and glycated haemoglobin), visceral fat, mid-thigh IMAT (computed tomography) and total body fat (dual-energy X-ray absorptiometry). Women with both PCOS and low 25OHD levels had the lowest GIR (all p < 0.05). Higher IMAT was associated with lower 25OHD (B = -3.95; 95% CI -6.86, -1.05) and GIR (B = -21.3; 95% CI -37.16, -5.44) in women with PCOS. Overweight women with pre-exercise 25OHD ≥30 nmol/L had significant increases in GIR, and decreases in total and visceral fat (all p < 0.044), but no associations were observed when stratified by PCOS status. Women with PCOS and low 25OHD levels have increased insulin resistance which may be partly explained by higher IMAT. Higher pre-training 25OHD levels may enhance exercise-induced changes in body composition and insulin resistance in overweight women.

Back pain causes enormous financial and disability burden worldwide, which could potentially be reduced by understanding its determinants to develop effective prevention strategies. Our aim was to identify whether modifiable risk factors, weight and physical activity, are predictive of back pain in young adult women.Women born between 1973 and 1978 were randomly selected from the national health insurance scheme database to participate in The Australian Longitudinal Study of Women's Health. Self-reported data on back pain in the last 12 months, weight, height, age, education status, physical activity, and depression were collected in 2000, 2003, 2006, 2009, and 2012. In 2000, 9688 women completed the questionnaire and 83% completed follow-up 12 years later.At baseline, median age was 24.6 years and 41% had self-reported back pain. For every 5 kg higher weight at baseline, there was a 5% (95% confidence interval [CI] 4%-6%) increased risk of back pain over the next 12 years. Higher weight at each survey also predicted back pain risk 3 years later (P < 0.001). The effects of weight on back pain were most significant in those with BMI ≥25 kg/m and were observed at all levels of physical activity. Inadequate physical activity and depression were independent predictors of back pain over the following 12 years (both P < 0.001), after adjusting for age, weight, height, and education status.Back pain is common in community-based young adult women. Higher weight, inadequate levels of physical activity, and depression were all independent predictors of back pain over the following decade. Furthermore, the adverse effects of weight on back pain were not mitigated by physical activity. Our findings highlight the role of both higher weight and physical inactivity in back pain among young women and suggest potential opportunities for future prevention.

Objective: To develop maternal, fetal, and neonatal composite outcomes relevant to the evaluation of diet and lifestyle interventions in pregnancy by individual patient data (IPD) meta-analysis. Design: Delphi survey. Setting: The International Weight Management in Pregnancy (i-WIP) collaborative network. Sample Twenty-six researchers from the i-WIP collaborative network from 11 countries. Methods: A two-generational Delphi survey involving members of the i-WIP collaborative network (26 members in 11 countries) was undertaken to prioritise the individual outcomes for their importance in clinical care. The final components of the composite outcomes were identified using pre-specified criteria. Main outcome measures: Composite outcomes considered to be important for the evaluation of the effect of diet and lifestyle in pregnancy. Results Of the 36 maternal outcomes, nine were prioritised and the following were included in the final composite: pre-eclampsia or pregnancy-induced hypertension, gestational diabetes mellitus (GDM), elective or emergency caesarean section, and preterm delivery. Of the 27 fetal and neonatal outcomes, nine were further evaluated, with the final composite consisting of intrauterine death, small for gestational age, large for gestational age, and admission to a neonatal intensive care unit (NICU). Conclusions: Our work has identified the components of maternal, fetal, and neonatal composite outcomes required for the assessment of diet and lifestyle interventions in pregnancy by IPD meta-analysis. Tweetable abstract: Composite outcomes in IPD meta-analysis on diet and lifestyle in pregnancy. This article includes Author Insights, a video abstract available at https://vimeo.com/148890226