Tumor-induced osteomalacia (TIO) can be challenging due to underlying tumors being either unresectable or unidentifiable. Burosumab, an anti-FGF23 monoclonal antibody, has been proven to be effective in treating TIO but is currently not subsidized for this indication in Australia. Our experience suggests that burosumab should be considered a first-line treatment.

Background:Aboriginal and Torres Strait Islander women experience a disproportionate burden of hyperglycaemia in pregnancy. A multi-component health systems intervention aiming to improve antenatal and postpartum care was implemented across Australia's Northern Territory (NT) and Far North Queensland (FNQ) between 2016 and 2019. Components included clinician education, improving recall systems, enhancing policies and guidelines, and embedding Diabetes in Pregnancy (DIP) Clinical Registers in systems of care. This program was evaluated to determine impacts on clinical practice and maternal health. Methods:Data for women with hyperglycaemia in pregnancy from primary care clinical records and the DIP Clinical Registers were analysed to assess changes in: antenatal and postpartum diabetes testing; HbA1c/glucose levels; medication use; weight checks performed, weight and body mass index; and postpartum contraception, smoking and breastfeeding. Findings:Clinical practice in the NT improved, including increased uptake of the recommended first trimester 75 g oral glucose tolerance test among women with hyperglycaemia risk factors (Aboriginal and Torres Strait Islander women 11.7% to 26.5%, p < 0.001; non-Indigenous women 6.2% to 19.3%, p < 0.001). In the NT, postpartum diabetes monitoring (56% to 68%, p = 0.039) and contraceptive use (41% to 60%, p = 0.001) increased among Aboriginal and Torres Strait Islander women. In FNQ, postpartum glucose monitoring increased among women with T2D (26% to 68% Aboriginal and Torres Strait Islander, p = 0.002; 50% to 100% non-Indigenous, p = 0.008), although there were no improvements in antenatal care indicators. Interpretation:Aspects of care for women with hyperglycaemia in pregnancy improved in the NT and FNQ following a multi-component health systems intervention. Funding:This study is funded by the Australian National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Diseases Grant 1092968.

McCune-Albright syndrome (MAS) is a rare mosaic disorder characterized by the classic triad of fibrous dysplasia of bone (FD), café-au-lait skin macules, and hyperfunctioning endocrinopathies. MAS is caused by a postzygotic mutation in the G-protein alpha subunit (GNAS) gene resulting in G-protein α-subunit somatic activation. There is no approved treatment for MAS. We present the case of a 43-yr-old male carpenter with severe polyostotic FD and adult-onset growth hormone (GH) excess who was treated with denosumab and somatostatin analog, complicated with a diagnosis of chronic myeloid leukemia (CML). The patient had multiple skeletal lesions, resulting in pain on movement and neurovascular compromise of the left arm. A forequarter amputation was considered to treat a large clavicular lesion, however, involvement of his thoracic cage resulted in significant cardiopulmonary impairment, including restrictive lung disease, and the surgery was deemed too risky. Denosumab was commenced after failed intravenous bisphosphonate for pain management, resulting in alleviation of pain. Screening of endocrinopathy revealed GH excess with an elevated Insulin-like Growth Factor-1 (IGF-1) level and 7 mm pituitary adenoma. Lanreotide was commenced as a medical therapy, resulting in a reduction in IGF-1 levels. Over 9 mo into the denosumab treatment, the patient was diagnosed with CML in the context of routine full blood examination. The patient achieved a hematological remission with imatinib. Polyostotic FD can lead to serious complications from deformities of the skeleton, including cardiopulmonary complications. This case represents a patient with a severe spectrum of MAS/FD with a diagnosis of CML. We postulate that CML is unlikely due to the MAS, as the two have different pathogenic pathways. Denosumab is effective in pain management, however, it should be used with caution, and there are no large studies to guide long-term management. Evaluation and management of MAS should also include detailed endocrinopathy assessment and screening, even in adulthood.

Flash glucose monitoring (FGM) can improve diabetes management, but no randomised controlled trials (RCTs) of FGM have been undertaken in Indigenous Australian populations. This study aimed to assess the feasibility of performing a RCT of FGM in Indigenous Australians with type 2 diabetes. In this open-labelled pilot RCT, Indigenous adults with type 2 diabetes were randomised to FGM or standard care for 6 months. Eligible participants were being treated with injectable diabetes medications and had a glycosylated haemoglobin (HbA1c) ≥ 7.0

Summary:Intravascular large B-cell lymphoma is an uncommon haematological condition that may present with a variety of non-specific symptoms and signs. In this report, we discuss the case of a man in his 70s who presented with subacute cognitive and functional decline. Subsequent investigation revealed hyponatraemia secondary to syndrome of inappropriate antidiuresis (SIAD), as well as hypopituitarism. The underlying aetiology for his condition was not discovered until postmortem examination following his death from respiratory failure, which demonstrated intravascular lymphoma involving multiple organs, including the brain, dura and pituitary. As such, this case represents the challenging diagnosis of a rare cause of multiple endocrinopathies. Learning points:Intravascular lymphoma is a rare diagnosis, often presenting with non-specific symptoms and biochemical derangements. This condition should be considered as a differential diagnosis for hypopituitarism, presenting in isolation or in combination with the syndrome of inappropriate antidiuresis. A broad and multisystem differential diagnosis should be considered for any patient presenting with endocrinopathy.

Background:Traditional markers modestly predict chronic kidney disease progression in Aboriginal and Torres Strait Islander people. Therefore, we assessed associations of cardiometabolic and inflammatory clinical biomarkers with kidney disease progression among Aboriginal and Torres Strait Islander people with and without diabetes. Objectives:To identify cardiometabolic and inflammatory clinical biomarkers that predict kidney disease progression in Aboriginal and Torres Strait Islander people. Design:Prospective observational cohort study. Setting:Northern Territory, Australia. Participants:Aboriginal and Torres Strait Islander participants of the estimated glomerular filtration rate (eGFR) study with (n = 218) and without diabetes (n = 278). Measurements:Baseline biomarkers (expressed as 1 standard deviation increase in logarithmic scale), plasma kidney injury molecule-1 (pKIM-1) (pg/ml), high-sensitivity troponin-T (hs-TnT) (ng/L), troponin-I (hs-TnI) (ng/L), and soluble tumor necrosis factor receptor-1 (sTNFR-1) (pg/ml) were assessed in 496 adults. Annual change in eGFR (ml/min/1.73 m2) and a composite kidney outcome (first of ≥30% eGFR decline with follow-up eGFR <60 ml/min/1.73 m2, initiation of kidney replacement therapy or kidney disease-related death) over a median of 3 years. Methods:Linear regression estimated annual change in eGFR (ml/min/1.73 m2). Cox proportional hazards regression estimated hazard ratio (HR) and 95% CI for developing a combined kidney health outcome. Results:In individuals with diabetes, but not those without diabetes, higher baseline hs-TnT (-2.1 [-4.1 to -0.2], P = .033) and sTNFR-1 (-1.8 [-3.5 to -0.1], P = .039) predicted mean (95% CI) eGFR change, after adjusting for age, gender, baseline eGFR, and urinary albumin-to-creatinine ratio. Baseline variables explained 11% of eGFR decline variance; increasing to 27% (P < .001) with biomarkers. In diabetes, hs-TnT and hs-TnI were significantly associated with increased risk of kidney health outcomes. Limitations:Limitations included potential chronic kidney disease misclassification from single creatinine and albumin measurements, limited adjustment for covariates due to a small sample size, and short follow-up restricting long-term outcome assessment. Conclusions:Cardiovascular, kidney, and inflammatory biomarkers are likely associated with kidney function loss in diabetes, with particularly prominent associations for cardiac injury markers.

The Northern Territory (NT) and Far North Queensland (FNQ) have a high proportion of Aboriginal and Torres Strait Islander women birthing who experience hyperglycaemia in pregnancy. A multi-component health systems intervention to improve antenatal and postpartum care in these regions for women with hyperglycaemia in pregnancy was implemented between 2016 and 2019. We explored health professional perspectives on the impact of the intervention on healthcare. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) underpinned this mixed-methods evaluation. Clinicians were surveyed before (n = 183) and following (n = 137) implementation. The constructs explored included usual practice and satisfaction with care pathways and communication between services. Clinicians, policymakers and the implementation team were interviewed (n = 36), exploring the impact of the health systems intervention on practice and systems of care. Survey and interview participants reported improvements in clinical practice and systems of care. Self-reported glucose screening practices improved, including the use of recommended tests (72.0% using recommended first-trimester screening test at baseline, 94.8% post-intervention, p < 0.001) and the timing of postpartum diabetes screening (28.3% screening at appropriate interval after gestational diabetes at baseline, 66.7% post-intervention, p < 0.001). Health professionals reported multiple improvements to care for women with hyperglycaemia in pregnancy following the health systems intervention.

Aims:To assess morbidity among young people with diabetes presenting to a regional hospital in Northern Australia and compare the risk of complications among those living with type 2 diabetes (T2D) versus type 1 diabetes (T1D). Materials and Methods:A cross-sectional study of young people with T1D or T2D (diagnosed age 1-25 years) presenting to a regional Northern Australian hospital with any condition from 2015 to 2019. Demographics, cardiometabolic comorbidities, and diabetes-related complications were collected from individual medical records and compared between those with T1D and T2D. Results:Among 357 young people (192 had T2D, 165 T1D), the mean age was 22 years, the mean duration of diabetes was 6.7 years, 52% were Aboriginal or Torres Strait Islander, and 28% lived remotely. Cardiometabolic comorbidities (obesity, hypertension, and dyslipidaemia) and diabetes-related complications (microalbuminuria, amputation, and elevated non-alcoholic fatty liver disease score) were more prevalent in those with T2D compared to T1D, despite shorter disease duration and lower median HbA1c. When adjusted for age, sex, and BMI, the odds ratio (95% CI) for microalbuminuria was 4.8 (1.83-12.8) with T2D compared to T1D. Conclusion:In a cohort of young people with diabetes in Northern Australia, the prevalence of diabetes-related complications was higher among those with T2D than T1D.

Chronic kidney disease (CKD) and diabetes have significant health and well-being impacts on Australian Aboriginal and Torres Strait Islander populations. Although routine clinical tests modestly predict CKD progression, assessment of other biomarkers is warranted as there is an increasing appreciation that myocardial and renal microvascular disease driven by subclinical inflammation may be the link that explains the tight relation between dysfunction in the heart and kidney. Few studies have assessed novel biomarkers concurrently in populations with and without diabetes, which is vital to determining risk factor correlations.

Introduction Premature onset of type 2 diabetes and excess mortality are critical issues internationally, particularly in Indigenous populations. There is an urgent need for developmentally appropriate and culturally safe models of care. We describe the methods for the codesign, implementation and evaluation of enhanced models of care with Aboriginal and Torres Strait Islander youth living with type 2 diabetes across Northern Australia.Methods and analysis Our mixed-methods approach is informed by the principles of codesign. Across eight sites in four regions, the project brings together the lived experience of Aboriginal and Torres Strait Islander young people (aged 10-25) with type 2 diabetes, their families and communities, and health professionals providing diabetes care through a structured yet flexible codesign process. Participants will help identify and collaborate in the development of a range of multifaceted improvements to current models of care. These may include addressing needs identified in our formative work such as the development of screening and management guidelines, referral pathways, peer support networks, diabetes information resources and training for health professionals in youth type 2 diabetes management. The codesign process will adopt a range of methods including qualitative interviews, focus group discussions, art-based methods and healthcare systems assessments. A developmental evaluation approach will be used to create and refine the components and principles of enhanced models of care. We anticipate that this codesign study will produce new theoretical insights and practice frameworks, resources and approaches for age-appropriate, culturally safe models of care.Ethics and dissemination The study design was developed in collaboration with Aboriginal and Torres Strait Islander and non-Indigenous researchers, health professionals and health service managers and has received ethical approval across all sites. A range of outputs will be produced to disseminate findings to participants, other stakeholders and the scholarly community using creative and traditional formats.

First Nations Australians experience health disparity in comparison to non-Indigenous Australians. This inequality in health outcomes is driven predominantly by an increase in metabolic and cardiovascular disease. Metabolic syndrome affects up to 50% of First Nations Australians and has significant implications for the risk of cardiovascular disease, type two diabetes mellitus (T2DM) and chronic kidney disease. The striking differences in youth-onset T2DM and rates of T2DM in pregnancy between First Nations Australians and non-Indigenous Australians are particularly concerning and represent key time points for intervention. Management of metabolic syndrome and its complications in First Nations Australians requires a multidisciplinary approach and involvement of Aboiginal healthcare practitioners is essential.

Aboriginal and Torres Strait Islander peoples are disproportionately impacted by type 2 diabetes. Continuous glucose monitoring (CGM) technology (such as Abbott Freestyle Libre 2, previously referred to as Flash Glucose Monitoring) offers real-time glucose monitoring that is convenient and easy to use compared to self-monitoring of blood glucose (SMBG). However, this technology’s use is neither widespread nor subsidised for Aboriginal and Torres Strait Islander peoples with type 2 diabetes. Building on existing collaborations with a national network of Aboriginal and Torres Strait Islander communities, this randomised controlled trial aims to assess the effect of CGM compared to SMBG on (i) haemoglobin A1c (HbA1c), (ii) achieving blood glucose targets, (iii) reducing hypoglycaemic episodes and (iv) cost-effective healthcare in an Aboriginal and Torres Strait Islander people health setting. This is a non-masked, parallel-group, two-arm, individually randomised, controlled trial (ACTRN12621000753853). Aboriginal and Torres Strait Islander adults with type 2 diabetes on injectable therapy and HbA1c ≥ 7.5

Background Type 2 diabetes mellitus (T2DM) is highly prevalent within the Indigenous Australian community. Novel glucose monitoring technology offers an accurate approach to glycaemic management, providing real-time information on glucose levels and trends. The acceptability and feasibilility of this technology in Indigenous Australians with T2DM has not been investigated. Objective This feasibility phenomenological study aims to understand the experiences of Indigenous Australians with T2DM using flash glucose monitoring (FGM). Methods Indigenous Australians with T2DM receiving injectable therapy ( n = 8) who used FGM (Abbott Freestyle Libre) for 6-months, as part of a clinical trial, participated in semi-structured interviews. Thematic analysis of the interviews was performed using NVivo12 Plus qualitative data analysis software (QSR International). Results Six major themes emerged: 1) FGM was highly acceptable to the individual; 2) FGM’s convenience was its biggest benefit; 3) data from FGM was a tool to modify lifestyle choices; 4) FGM needed to be complemented with health professional support; 5) FGM can be a tool to engage communities in diabetes management; and 6) cost of the device is a barrier to future use. Conclusions Indigenous Australians with T2DM had positive experiences with FGM. This study highlights future steps to ensure likelihood of FGM is acceptable and effective within the wider Indigenous Australian community.

The global epidemic of type 2 diabetes (T2DM) in young people has contributed to an increase in pregestational diabetes in pregnancy.1-3 Maternal glycemia is a key modifiable risk factor to optimize pregnancy outcomes, with new diabetes technology potentially contributing to improved glycemic levels and neonatal outcomes.4 There are limited data regarding intermittently scanned continuous glucose monitoring (iscCGM) in pregnancy for women with T2DM. We conducted a prospective pilot to assess the feasibility and acceptability of iscCGM in pregnancy among women with pre-existing T2DM. During the intervention period (2019-2021), 78 women were referred to a regional diabetes in pregnancy service in northern Australia. Eighteen (23%) women were excluded due to late referral (>30 weeks gestation) and three women declined. Fifty-seven women enrolled and were given a FreeStyle Libre glucose monitor and sensors for the pregnancy duration. Thirty-four (75%) women were Aboriginal and/or Torres Strait Islander, 14 (31%) lived >100 km from the city, and 40 (91%) used insulin. Fifty (88%) completed the satisfaction questionnaire and 45 (79%) used iscCGM for ≥2 weeks. Mean sensor use was 12 (range = 0-32, SD = 9.2) weeks, with 40% commencing in first trimester. In the final two weeks of use, mean sensor activity time was 60% (range = 12%-98%, SD = 22%), mean number of scans per day was 4.3 (SD 3.3), and the proportion of women with sensor activity >75% was 12 (27%). Most participants found iscCGM was worthwhile and easy to use (Figure 1); 47 (94%) would recommend iscCGM to others. Self-reported frequency of glucose testing four times per day increased from 36% to 68% (P = .001), compared with prior finger-stick measurements. Participants reported that Diabetes Educators gave the most useful device education, of all health professionals encountered. Reasons for discontinuation included rash, sensors falling off early, and distrust of accuracy. Women who discontinued use had similar demographic characteristics, but less insulin prescribed than those who continued use (67% vs 91%, P = .04). Half the women reported thinking about diabetes “more than I wanted to” indicating the amount of information may have been excessive for some, in particular those using less complex insulin regimes. Feasibility assessment revealed that nearly all eligible women agreed to participate and were able to use the technology. Ethnicity and remoteness were not necessarily barriers to use. However, in this real-world setting, late referrals (23%), discontinuation (21%), and variability of use meant that few patients used iscCGM for the entire pregnancy. This differs considerably to studies investigating continuous glucose monitoring for women with type 1 diabetes in pregnancy, where all patients commenced in the first trimester and >70% had sensor activity >75%.4 Improving referral pathways,6 culturally appropriate health systems,3,6 and ensuring access to diabetes educator time and expertise are essential to support optimal use of this technology. This study suggests that iscCGM could be a useful and well-received tool for improving glycemic control in women with T2DM in pregnancy. Further rigorous study by way of randomized controlled testing is needed to confirm this impression. 1124956 DSTXXX10.1177/19322968221124956Journal of Diabetes Science and TechnologyMcLean et al research-article2022

Melioidosis has a highly variable presentation. Almost any organ can be involved, although an antemortem diagnosis of acute suppurative thyroiditis (AST) has not, to our knowledge, been described previously. A 68-year-old Australian male with poorly controlled type 2 diabetes mellitus presented with fever, odynophagia, and thyroid function tests that were consistent with hyperthyroidism. Imaging demonstrated a lung abscess and an enlarged thyroid gland with three nodules. Blood cultures and fine-needle aspiration of the thyroid nodules grew Burkholderia pseudomallei. He received intravenous ceftazidime with concurrent oral trimethoprim/sulfamethoxazole (TMP/SMX) for 4 weeks followed by high-dose oral TMP/SMX for a further 3 months and made a complete recovery. Acute suppurative thyroiditis is an uncommon cause of hyperthyroidism and thyroid aspirates are not commonly sent for bacterial culture. The case highlights the need to consider AST in patients presenting with a hyperthyroid state and disseminated infection. It also demonstrates that in a case of disseminated melioidosis any symptom may be a clue to underlying metastatic infection.

ObjectiveThe objective of this report is to present 2 cases of cardiac paragangliomas (PGLs), and to outline the presentation, management, and associated genetic mutations.MethodsCase 1, a 38-year-old female, presented with a 12-month history of paroxysmal palpitations, headaches, and weight loss. Her investigations included plasma free metanephrines and urinary metanephrines, 68-gallium DOTATATE positron emission tomography/computed tomography, and cardiac imaging. Case 2, a 28-year-old male, presented with a hypertensive crisis and abdominal pain on a background of hypertension. Given his abdominal pain, he was investigated with an abdominal computed tomography (CT) scan, followed by plasma free meta-nephrines and urinary metanephrines, echocardiogram, and 123-iodine meta-iodobenzylguanidine single-photon emission CT.ResultsCase 1 had an elevated plasma normetadrenaline of 6,750 pmol/L (reference range is <900 pmol/L) and 3-methoxytyramine of 1,845 pmol/L (reference range is <110 pmol/L). 68-gallium DOTATATE positron emission tomography/computed tomography showed an avid cardiac lesion. The lesion was resected, and histopathology confirmed PGL. Genetic studies revealed an SDHC gene mutation. For case 2, abdominal CT revealed a para-spinal mass. Workup for this lesion revealed elevated normetadrenaline of 56,000 pmol/L (reference range is <900 pmol/L). An echocardiogram, arranged for investigation of hypertension, showed an additional cardiac mass. A 123-iodine meta-iodobenzylguanidine single-photon emission CT scan confirmed that both masses were functioning. The lesions were successfully excised. He was found to have an SDHB gene mutation.ConclusionBoth patients had long-standing symptoms secondary to catecholamine excess, thus it is important to promptly screen patients with unexplained hypertension or paroxysmal symptoms of palpitations, headaches, and diaphoresis with plasma free metanephrines or urinary metanephrines. All patients with PGLs should be offered genetic testing due to the high incidence of genetic mutations.

ObjectiveImmunotherapy is a novel treatment that can cause autoimmune diabetes in rare cases. More cases occur following use of the inhibitor to the protein programmed cell death-1 rather than the inhibitor to programmed cell death-ligand 1.MethodsWe report a unique case of autoimmune diabetes following atezolizumab use.ResultsA 55-year-old, Aboriginal Australian female with no prior history of diabetes was commenced on atezolizumab for recurrent squamous cell lung carcinoma. Two months following its commencement, there was the onset of fatigue, polyuria, polydipsia, and new hyperglycemia. Subsequently she was found to have a borderline-low C peptide level of 0.6 nmol/L (reference range is 0.5 to 1.0 nmol/L), and positive zinc transporter-8 antibodies. Following the diagnosis of autoimmune diabetes, 5 units of glargine insulin was commenced which maintained euglycemia and resolved her symptoms of hyperglycemia.ConclusionThere are few case reports of atezolizumab-induced autoimmune diabetes. We present the first case associated with zinc transporter-8 antibodies, and a unique case of autoimmune diabetes in a patient of Aboriginal Australian background.

Objective Adult nesidioblastosis is characterized by endogenous hyperinsulinemia typically causing post-prandial hypoglycemia, and most commonly occurs post-Roux-en-Y gastric bypass. Methods We report a unique case of nesidioblastosis occurring in a 67-year-old female. Results A 5-year history of symptomatic hypoglycemia occurred in a patient with short bowel syndrome and type 2 diabetes mellitus (T2DM) managed previously with a glucagon-like peptide 1 (GLP-1) agonist, which achieved significant weight loss. Continuous glucose monitoring captured 42 hypoglycemia episodes in a 2-week period, and following an oral glucose tolerance test there was the suggestion of a hyperinsulinemia state. She was managed with an open distal pancreatectomy, and subsequently required medical therapy to maintain euglycemia. Conclusion We present the first case of nesidioblastosis occurring in a patient with short bowel syndrome, pre-existing T2DM managed with a GLP-1 agonist which achieved significant weight loss, all of which we speculate could have predisposed to hypoglycemia and development of nesidioblastosis.

Background Glomerular hyperfiltration is not able to be detected in clinical practice. We assessed whether hyperfiltration is associated with albuminuria progression among Indigenous Australians at high risk of diabetes and kidney disease to determine its role in kidney disease progression. Methods Longitudinal observational study of Indigenous Australians aged ≥18 years recruited from >20 sites, across diabetes and/or kidney function strata. At baseline, iohexol clearance was used to measure glomerular filtration rate (mGFR) and hyperfiltration was defined as (i) a mGFR of ≥125 mL/min/1.73 m2, and (ii) an age-adjusted definition, with the top 10% of the mGFR for each 10 year age group at baseline. Baseline and follow-up urine albumin-to-creatinine ratio (uACR) was collected, and linear regression was used to assess the associations of hyperfiltration and uACR at follow up. Results 407 individuals (33% men, mean age 47 years) were followed-up for a median of 3 years. At baseline, 234 had normoalbuminuria and 173 had albuminuria. Among participants with normoalbuminuria, those with mGFR ≥125 mL/min/1.73 m2 had 32% higher uACR at follow-up (p = 0.08), and those with age-adjusted hyperfiltration had 60% higher uACR (p = 0.037) compared to those who had normofiltration. These associations were independent of uACR at baseline, but attenuated by HbA1c. Associations were stronger among those without than those with albuminuria at baseline. Conclusions Although not available for assessment in current clinical practice, hyperfiltration may represent a marker of subsequent albuminuria progression among individuals who have not yet developed albuminuria.

Aims: To map health practitioners' experiences and describe knowledge regarding screening and management of Diabetes in Pregnancy (DIP) in Far North Queensland, Australia. Methods: Mixed methods including a cross-sectional survey (101 respondents) and 8 focus groups with 61 health practitioners. All participants provided clinical care for women with DIP. Results: A wide range of healthcare professionals participated; 96% worked with Indigenous women, and 63% were from regional or remote work settings. Universal screening for gestational diabetes at 24-28 weeks gestation was reported as routine with 87% using a 75 g Oral Glucose Tolerance Test. Early screening for DIP was reported by 61% although there was large variation in screening methods and who should be screened <24 weeks. Health practitioners were confident providing lifestyle advice (88%), dietary, and blood glucose monitoring education (67%, 81%) but only 50% were confident giving insulin education. Electronic medical records were used by 80% but 55% also used paper records. Dissatisfaction with information from hospitals was reported by 40%. In the focus groups improving communication and information technology systems were identified as key areas. Other barriers described were difficulties in care coordination and access for remote women. Conclusions: Communication, information technology systems, coordination of care, and education for health professionals are key areas that will be addressed by a complex health systems intervention being undertaken by the DIP Partnership in North Queensland.