Factors associated with empowerment after participating in a supported osteoarthritis self-management program: An explorative study.

Objective: To explore factors associated with change in empowerment in patients that have participated in a 3-month Supported Osteoarthritis Self-Management Program (SOASP). Further, to evaluate empowerment in the longer term. Design: An explorative analysis including patients from a cohort study conducted in primary healthcare in Sweden was performed. Univariable linear regression models were performed to assess associations between demographics and patient-reported outcome measures (explanatory factors), respectively, and change in empowerment from baseline to 3-month follow-up (outcome variable). Long-term follow-up of empowerment was at 9 months. Results: Self-reported increase in enablement at the 3-month follow-up was associated with a greater improvement in empowerment (B â€‹= â€‹0.041, 95% CI (0.011, 0.07), p â€‹= â€‹0.008). Living alone was associated with less improvement in empowerment (B â€‹= â€‹-0.278, 95% CI (-0.469, -0.086), p â€‹= â€‹0.005) compared to living together. Physical exercise >120 â€‹min per week at baseline was associated with less improvement in empowerment (B â€‹= â€‹-0.293, 95% CI (-0.583, -0.004), p â€‹= â€‹0.047) compared to reporting no exercise at baseline. No other associations were observed (p â€‹> â€‹0.05). Empowerment improved from baseline to the 3-month follow-up (mean 0.20 (SD 0.5), p â€‹< â€‹0.001) but there was no change from baseline to the 9-month follow-up (mean 0.02 (SD 0.6), p â€‹= â€‹0.641). Conclusions: Self-reported increased enablement may lead to greater improvement in empowerment after SOASP. Greater efforts may be needed to support those that live alone, are physically active, and to sustain empowerment in the longer term after SOASP. More research is needed on empowerment to provide personalized support for patients with OA after SOASP.

Antibiotic Use in Late Preterm and Full-Term Newborns.

Importance: Antibiotic treatment saves lives in newborns with early-onset sepsis (EOS), but unwarranted antibiotic use is associated with resistant bacteria and adverse outcomes later in life. Surveillance is needed to optimize treatment strategies. Objective: To describe antibiotic use in association with the incidence and mortality from EOS among late-preterm and full-term newborns. Design, Setting, and Participants: The Sweden Neonatal Antibiotic Use study was a nationwide observational study that included all late-preterm and full-term neonates born from January 1, 2012, to December 31, 2020, in neonatal units of all levels. All hospital live births from 34 weeks' gestation during the study period were included in the study. Data were collected from the Swedish Neonatal Quality Register and the Swedish Medical Birth Register. Data were analyzed from August 2022 to May 2023. Exposure: Admission for neonatal intensive care during the first week of life. Main Outcomes and Measures: The main outcomes were the usage of intravenous antibiotics during the first week of life, the duration of antibiotic therapy, the rate of culture-proven EOS, and mortality associated with EOS. Results: A total of 1 025 515 newborns were included in the study; 19 286 neonates (1.88%; 7686 girls [39.9%]; median [IQR] gestational age, 40 [38-41] weeks; median [IQR] birth weight, 3610 [3140-4030] g) received antibiotics during the first week of life, of whom 647 (3.4%) had EOS. The median (IQR) duration of antibiotic treatment in newborns without EOS was 5 (3-7) days, and there were 113 antibiotic-days per 1000 live births. During the study period there was no significant change in the exposure to neonatal antibiotics or antibiotic-days per 1000 live births. The incidence of EOS was 0.63 per 1000 live births, with a significant decrease from 0.74 in 2012 to 0.34 in 2020. Mortality associated with EOS was 1.39% (9 of 647 newborns) and did not change significantly over time. For each newborn with EOS, antibiotic treatment was initiated in 29 newborns and 173 antibiotic-days were dispensed. Conclusions and Relevance: This large nationwide study found that a relatively low exposure to antibiotics is not associated with an increased risk of EOS or associated mortality. Still, future efforts to reduce unwarranted neonatal antibiotic use are needed.

Assisting the implementation of screening for type 1 diabetes by using artificial intelligence on publicly available data.

The type 1 diabetes community is coalescing around the benefits and advantages of early screening for disease risk. To be accepted by healthcare providers, regulatory authorities and payers, screening programmes need to show that the testing variables allow accurate risk prediction and that individualised risk-informed monitoring plans are established, as well as operational feasibility, cost-effectiveness and acceptance at population level. Artificial intelligence (AI) has the potential to contribute to solving these issues, starting with the identification and stratification of at-risk individuals. ASSET (AI for Sustainable Prevention of Autoimmunity in the Society; www.asset.healthcare ) is a public/private consortium that was established to contribute to research around screening for type 1 diabetes and particularly to how AI can drive the implementation of a precision medicine approach to disease prevention. ASSET will additionally focus on issues pertaining to operational implementation of screening. The authors of this article, researchers and clinicians active in the field of type 1 diabetes, met in an open forum to independently debate key issues around screening for type 1 diabetes and to advise ASSET. The potential use of AI in the analysis of longitudinal data from observational cohort studies to inform the design of improved, more individualised screening programmes was also discussed. A key issue was whether AI would allow the research community and industry to capitalise on large publicly available data repositories to design screening programmes that allow the early detection of individuals at high risk and enable clinical evaluation of preventive therapies. Overall, AI has the potential to revolutionise type 1 diabetes screening, in particular to help identify individuals who are at increased risk of disease and aid in the design of appropriate follow-up plans. We hope that this initiative will stimulate further research on this very timely topic.

Prevalence and Predictive Factors for Celiac Disease in Children With Type 1 Diabetes: Whom and When to Screen? A Nationwide Longitudinal Cohort Study of Swedish Children.

OBJECTIVE: To examine the prevalence and predictive factors for celiac disease (CD) after a diagnosis of type 1 diabetes (T1D) in children and adolescents, to improve the current screening guidelines. RESEARCH DESIGN AND METHODS: The association between sex, age at T1D diagnosis, HLA, and diabetes autoantibodies, and a diagnosis of CD was examined in 5,295 children with T1D from the Better Diabetes Diagnosis study in Sweden. RESULTS: The prevalence of biopsy-proven CD was 9.8%, of which 58.2% already had a CD diagnosis before or at T1D onset. Almost all, 95.9%, were diagnosed with CD within 5 years after the T1D diagnosis. Younger age at the T1D diagnosis and being homozygote for DQ2 increased the risk of CD after T1D, but neither sex nor diabetes-related autoantibodies were associated with the risk. CONCLUSIONS: Age at and time after diabetes diagnosis should be considered in screening guidelines for CD in children with T1D.

Lower left atrial function in young individuals with type 1 diabetes mellitus compared to healthy controls: an echocardiographic study.

In adulthood, individuals with type 1 diabetes mellitus may develop a condition of heart failure with preserved ejection fraction. However, subclinical changes to the heart in diabetes are likely to occur prior to the clinical presentation. This cross-sectional study aimed to compare left atrial function by echocardiography between 43 individuals with type 1 diabetes and 43 healthy controls, aged 10-30 years. All participants underwent echocardiography and 2D speckle tracking measurements for left atrial phase function parameters. Physical capacity was assessed by exercise test on a bicycle. Results showed that participants with type 1 diabetes had significantly lower left atrial function parameters than healthy controls (p < 0.05). There was a significant negative correlation between HbA1c means and reservoir and conduit strain (p < 0.05) and individuals with BMI < 30 showed a lower left atrial stiffness (p < 0.05). Individuals with type 1 diabetes and a higher physical capacity did not differ from their healthy peers. Results indicate that lower HbA1c levels, BMI < 30 and a higher physical capacity are favourable in terms of left atrial function in children and young adults with type 1 diabetes mellitus. Left atrial strain by echocardiography might become a new important tool in assessing heart function in T1DM.

Autoimmune comorbidity in type 1 diabetes and its association with metabolic control and mortality risk in young people: a population-based study.

AIMS/HYPOTHESIS: This register-based study aimed to describe autoimmune comorbidity in children and young adults from type 1 diabetes onset, and to investigate whether such comorbidity was associated with a difference in HbA1c or mortality risk compared with children/young adults with type 1 diabetes without autoimmune comorbidity. METHODS: A total of 15,188 individuals from the Swedish National Diabetes Register, registered with type 1 diabetes before 18 years of age between 2000 and 2019, were included. Five randomly selected control individuals from the Swedish population (Statistics Sweden) were matched to each individual with type 1 diabetes (n=74,210 [346 individuals with type 1 diabetes were not found in the Statistics Sweden register at the date of type 1 diabetes diagnosis, so could not be matched to control individuals]). The National Patient Register was used to attain ICD-10 codes on autoimmune diseases and the Cause of Death Register was used to identify deceased individuals. RESULTS: In the total type 1 diabetes cohort, mean±SD age at onset of type 1 diabetes was 9.5±4.4 years and mean disease duration at end of follow-up was 8.8±5.7 years. Of the individuals with type 1 diabetes, 19.2% were diagnosed with at least one autoimmune disease vs 4.0% of the control group. The HRs for comorbidities within 19 years from onset of type 1 diabetes were 11.6 (95% CI 10.6, 12.6) for coeliac disease, 10.6 (95% CI 9.6, 11.8) for thyroid disease, 1.3 (95% CI 1.1, 1.6) for psoriasis, 4.1 (95% CI 3.2, 5.3) for vitiligo, 1.7 (95% CI 1.4, 2.2) for rheumatic joint disease, 1.0 (95% CI 0.8, 1.3) for inflammatory bowel disease, 1.0 (95% CI 0.7, 1.2) for systemic connective tissue disorder, 1.4 (95% CI 1.1, 1.9) for uveitis, 18.3 (95% CI 8.4, 40.0) for Addison's disease, 1.8 (95% CI 0.9, 3.6) for multiple sclerosis, 3.7 (95% CI 1.6, 8.7) for inflammatory liver disease and 19.6 (95% CI 4.2, 92.3) for atrophic gastritis. Autoimmune disease in addition to type 1 diabetes had no statistically significant effect on HbA1c or mortality risk. CONCLUSIONS/INTERPRETATION: To our knowledge, this is the first comprehensive study where young individuals with type 1 diabetes were followed regarding development of a wide spectrum of autoimmune diseases, from onset of type 1 diabetes. In this nationwide and population-based study, there was already a high prevalence of autoimmune diseases in childhood, especially coeliac and thyroid disease. The presence of autoimmune comorbidity did not have a statistically significant effect on metabolic control or mortality risk.

Relative poverty is associated with increased risk of diabetic ketoacidosis at onset of type 1 diabetes in children. A Swedish national population-based study in 2014-2019.

AIMS: The aim of the study was to estimate the effect of household relative poverty on the risk of diabetic ketoacidosis at diagnosis of children with type 1 diabetes using an international standard measurement of relative poverty. METHODS: A national population-based retrospective study was conducted. The Swedish National Diabetes Register (NDR) was linked with data from Sweden's public statistical agency (Statistics Sweden). Children who were diagnosed with new-onset type 1 diabetes in the period of 2014-2019 were common identifiers. The definition of diabetic ketoacidosis was venous pH <7.30 or a serum bicarbonate level <18 mmol/L. The exposure variable was defined according to the standard definition of the persistent at-risk-of-poverty rate used by the statistical office of the European Union (Eurostat) and several other European public statistical agencies. Univariate and multi-variable analyses were used to calculate the effect of relative poverty on the risk of diabetic ketoacidosis. RESULTS: Children from households with relative poverty had a 41% higher risk of diabetic ketoacidosis (1.41, CI 1.12-1.77, p = 0.004) and more than double the risk of severe diabetic ketoacidosis (pH <7.10) (RR 2.10, CI 1.35-3.25, p = 0.001), as compared to children from households without relative poverty. CONCLUSIONS: Relative poverty significantly increases the risk of diabetic ketoacidosis at onset of type 1 diabetes in children, even in a high-income country with publicly reimbursed health care.

Empowerment and enablement and their associations with change in health-related quality of life after a supported osteoarthritis self-management programme - a prospective observational study.

BACKGROUND: Osteoarthritis is a leading cause of disability worldwide. Current treatment supports coping strategies to improve health-related quality of life (HRQoL). The need to predict response to treatment has been raised to personalise care. This study aims to examine change in HRQoL from baseline to three and nine months follow-up after participating in a Supported Osteoarthritis Self-Management Programme (SOASP) and to examine if empowerment and/or enablement were associated with change in HRQoL after a SOASP. METHODS: Patients participating in a SOASP were recruited consecutively between April 2016 and June 2018. The EQ-5D was used to measure HRQoL, the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23) (score range 1-5) to measure empowerment and the Patient Enablement Instrument (PEI) (score range 0-12) to measure enablement. The instruments were answered before (EQ-5D, SWE-RES-23) and after (EQ-5D, SWE-RES-23, PEI) the SOASP. A patient partner was involved in the research process to enhance the patient perspective. Changes in outcome were examined with paired sample t-test and standardized effect sizes (Cohen´s d). Multiple linear regression analysis was performed to assess potential associations. RESULTS: One hundred forty-three patients participated in baseline measurement. Mean EQ-5D-5 L index score increased significantly from baseline to three months corresponding to a standardised effect size (Cohen´s d) of d = 0.43, 95% CI [0.24, 0.63] (n = 109), and from baseline to nine months d = 0.19, 95% CI [0.01, 0.37] (n = 119). The average EQ VAS score increased significantly from baseline to three months corresponding to a standardised effect size of d = 0.26, 95% CI [0.07, 0.45] (n = 109), and from baseline to nine months d = 0.18, 95% CI [0.00, 0.36] (n = 119). Neither SWE-RES-23 nor PEI at three months follow-up nor the change in the SWE-RES-23 score from baseline to three months follow-up were associated with change in either EQ-5D-5 L index (p > 0.05) or the EQ VAS (p > 0.05). CONCLUSIONS: Health-related quality of life increased after participating in a SOASP. Empowerment and enablement as measured with the SWE-RES-23 and the PEI were not associated with change in HRQoL among patients participating in a SOASP. TRIAL REGISTRATION: ClinicalTrials.gov. Identification number: NCT02974036. First registration 28/11/2016, retrospectively registered.

No association between incidence of type 1 diabetes and rotavirus vaccination in Swedish children.

Background: Rotavirus infection is a potential trigger of type 1 diabetes (T1D) and rotavirus vaccination is hypothesized to decrease the incidence of T1D. In Sweden, rotavirus vaccination was introduced in 2014 in two regions and from 2019, nationwide. This study aims to investigate the association between rotavirus vaccination and incidence of T1D in Swedish children and whether rotavirus vaccination is associated with a change in clinical manifestation at diabetes onset. Methods: A nationwide register-based study with all Swedish children <15 years of age, diagnosed with T1D 2009-2019 was conducted. 7893 children were retrieved. Nationwide vaccine coverage was collected from Child Health Services. Three vaccine groups were created: I: Vaccination start 2014; II: Gradual vaccination start 2016-2018; III: No vaccination. Incidence rates of T1D before (2009-2014) and after (2014-2019) introduction of rotavirus vaccine were compared. Findings: The mean incidence of T1D in children <15 years was 42·61 per 100 000 during the observed period. When comparing the years before and after 2014 the incidence rate ratio (IRR) for children <5 years was 0·86 in group I (p=0·10), 0·85 (p=0·05) in group II and 0·87 (p=0·06) in group III. A similar IRR reduction was also seen among older children who received no vaccine. Children developing or not developing T1D were vaccinated to the same extent. No differences regarding clinical manifestation at onset associated with rotavirus vaccination were seen. Interpretation: There is no association between rotavirus vaccination in children and incidence or clinical manifestation of T1D.

Enablement and empowerment among patients participating in a supported osteoarthritis self-management programme - a prospective observational study.

BACKGROUND: In Sweden, core treatment for osteoarthritis is offered through a Supported Osteoarthritis Self-Management Programme (SOASP), combining education and exercise to provide patients with coping strategies in self-managing the disease. The aim was to study enablement and empowerment among patients with osteoarthritis in the hip and/or knee participating in a SOASP. An additional aim was to study the relation between the Swedish version of the Patient Enablement Instrument (PEI) and the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23). METHODS: Patients with osteoarthritis participating in a SOASP in primary health care were recruited consecutively from 2016 to 2018. The PEI (score range 0-12) was used to measure enablement and the SWE-RES-23 (score range 1-5) to measure empowerment. The instruments were answered before (SWE-RES-23) and after the SOASP (PEI, SWE-RES-23). A patient partner was incorporated in the study. Descriptive statistics, the Wilcoxon's signed rank test, effect size (r), and the Spearman's rho (rs) were used in the analysis. RESULTS: In total, 143 patients were included in the study, 111 (78%) were women (mean age 66, SD 9.3 years). At baseline the reported median value for the SWE-RES-23 (n = 142) was 3.6 (IQR 3.3-4.0). After the educational part of the SOASP, the reported median value was 6 (IQR 3-6.5) for the PEI (n = 109) and 3.8 (IQR 3.6-4.1) for the SWE-RES-23 (n = 108). At three months follow-up (n = 116), the reported median value was 6 (IQR 4-7) for the PEI and 3.9 (IQR 3.6-4.2) for the SWE-RES-23. The SWE-RES-23 score increased between baseline and three months (p ≤ 0.000). The analysis showed a positive correlation between PEI and SWE-RES-23 after the educational part of the SOASP (rs = 0.493, p < 0.00, n = 108) and at follow-up at three months (rs = 0.507, p < 0.00, n = 116). CONCLUSIONS: Patients reported moderate to high enablement and empowerment and an increase in empowerment after participating in a SOASP, which might indicate that the SOASP is useful to enable and empower patients at least in the short term. Since our results showed that the PEI and the SWE-RES-23 are only partly related both instruments can be of use in evaluating interventions such as the SOASP. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02974036 . First registration 28/11/2016, retrospectively registered.

A collaborative comparison of international pediatric diabetes registries.

BACKGROUND: An estimated 1.1 million children and adolescents aged under 20 years have type 1 diabetes worldwide. Principal investigators from seven well-established longitudinal pediatric diabetes registries and the SWEET initiative have come together to provide an international collaborative perspective and comparison of the registries. WORK FLOW: Information and data including registry characteristics, pediatric participant clinical characteristics, data availability and data completeness from the Australasian Diabetes Data Network (ADDN), Danish Registry of Childhood and Adolescent Diabetes (DanDiabKids), Diabetes prospective follow-up registry (DPV), Norwegian Childhood Diabetes Registry (NCDR), National Paediatric Diabetes Audit (NPDA), Swedish Childhood Diabetes Registry (Swediabkids), T1D Exchange Quality Improvement Collaborative (T1DX-QI), and the SWEET initiative was extracted up until 31 December 2020. REGISTRY OBJECTIVES AND OUTCOMES: The seven diabetes registries and the SWEET initiative collectively show data of more than 900 centers and around 100,000 pediatric patients, the majority with type 1 diabetes. All share the common objectives of monitoring treatment and longitudinal outcomes, promoting quality improvement and equality in diabetes care and enabling clinical research. All generate regular benchmark reports. Main differences were observed in the definition of the pediatric population, the inclusion of adults, documentation of CGM metrics and collection of raw data files as well as linkage to other data sources. The open benchmarking and access to regularly updated data may prove to be the most important contribution from registries. This study describes aspects of the registries to enable future collaborations and to encourage the development of new registries where they do not exist.

Changes in HbA1c Between 2011 and 2017 in Germany/Austria, Sweden, and the United States: A Lifespan Perspective.

Aims: This study assessed hemoglobin A1c (HbA1c) across the lifespan in people with type 1 diabetes (T1D) in Germany/Austria, Sweden, and the United States between 2011 and 2017 to ascertain temporal and age-related trends. Methods: Data from the Diabetes-Patienten-Verlaufsdokumentation (DPV) (n = 25,651 in 2011, n = 29,442 in 2017); Swedish Pediatric Diabetes Quality Registry (SWEDIABKIDS)/National Diabetes Register (NDR), (n = 44,474 in 2011, n = 53,690 in 2017); and T1D Exchange (n = 16,198 in 2011, n = 17,087 in 2017) registries were analyzed by linear regression to compare mean HbA1c overall and by age group. Results: Controlling for age, sex, and T1D duration, HbA1c increased in the United States between 2011 and 2017, decreased in Sweden, and did not change in Germany/Austria. Controlling for sex and T1D duration, mean HbA1c decreased between 2011 and 2017 in all age cohorts in Sweden (P < 0.001). In the United States, HbA1c stayed the same for participants <6 years and 45 to <65 years and increased in all other age groups (P < 0.05). In Germany/Austria, HbA1c stayed the same for participants <6 to <13 years and 18 to <25 years; decreased for participants ages 13 to <18 years (P < 0.01); and increased for participants ≥25 years (P < 0.05). Conclusions: The comparison of international trends in HbA1c makes it possible to identify differences, explore underlying causes, and share quality improvement processes. National quality improvement initiatives are well accepted in Europe but have yet to be implemented systematically in the United States. However, disparities created by the lack of universal access to health care coverage, unequal access to diabetes technologies (e.g., continuous glucose monitoring) regardless of insurance status, and high out-of-pocket cost for the underinsured ultimately limit the potential of quality improvement initiatives.

Physical activity and health-related quality of life in men and women with hip and/or knee osteoarthritis before and after a supported self-management programme - a prospective observational study.

PURPOSE: To study differences between men and women in physical activity (PA) and health-related quality of life (HRQoL) before and after participating in a supported osteoarthritis (OA) self-management programme. MATERIALS AND METHODS: A prospective observational study using data from a Swedish National Quality Register. Patients recorded between 2008 and 2013 with hip and/or knee OA with data at baseline, at 3 and 12 months follow-up (n = 7628) were included. Outcome measures were patient-reported PA and HRQoL (EQ-5D-3L). RESULTS: A greater proportion of men (p = 0.002) changed to being physically active ≥150 min/week at 3 months follow-up. The proportion of women being physically active ≥150 min/week was larger than for men at baseline (p = 0.003) and at follow-up at 12 months (p = 0.035). Women reported lower HRQoL than men at baseline (p < 0.001), at follow-up at 3 (p < 0.001) and 12 months (p = 0.010). There were no differences between men and women in change in HRQoL at 3 (p = 0.629) and 12 months (p = 0.577) follow-up. CONCLUSIONS: This study showed differences between men and women in PA and HRQoL before and after participating in a supported OA self-management programme. These differences should be considered when supporting PA and HRQoL.Implications for rehabilitationMen with hip and/or knee osteoarthritis (OA) might need more support during rehabilitation in order to maintain or even increase physical activity (PA) in the long run.Women with hip and/or knee OA might need more support during rehabilitation in order to maintain or even increase health-related quality of life (HRQoL) in the long run.Booster sessions might be suggested in order to enable both men and women with hip and/or knee OA to sustain improvements in PA and HRQoL after participating in a supported OA self-management programme.

Physiotherapists' experiences of osteoarthritis guidelines in primary health care - an interview study.

BACKGROUND: Osteoarthritis is a common joint disease, globally. Guidelines recommend information, exercise and, if needed, weight reduction as core treatment. There is a gap between evidence-based recommended care for osteoarthritis and clinical practice. To increase compliance to guidelines, implementation was conducted. The aim of the study was to explore physiotherapists' experiences of osteoarthritis guidelines and their experiences of implementation of the guidelines in primary health care in a region in southern Sweden. METHODS: Eighteen individual, semi-structured interviews with physiotherapists in primary health care were analysed with inductive qualitative content analysis. RESULTS: The analysis resulted in two categories and four subcategories. The physiotherapists were confident in their role as primary assessors for patients with osteoarthritis and the guidelines were aligned with their professional beliefs. The Supported Osteoarthritis Self-Management Programme, that is part of the guidelines, was found to be efficient for the patients. Even though the physiotherapists followed the guidelines they saw room for improvement since all patients with hip and/or knee osteoarthritis did not receive treatment according to the guidelines. Furthermore, the physiotherapists emphasised the need for management's support and that guidelines should be easy to follow. CONCLUSION: The physiotherapists believed in the guidelines and were confident in providing first line treatment to patients with osteoarthritis. However, information about the guidelines probably needs to be repeated to all health care providers and management. Data from a national quality register on osteoarthritis could be used to a greater extent in daily clinical work in primary health care to improve quality of care for patients with osteoarthritis.

A decade of improved glycemic control in young children with type 1 diabetes: A population-based cohort study.

BACKGROUND: Early-onset type 1 diabetes (T1D) is associated with high risk of early cardiovascular complications and premature death. The strongest modifiable risk factor is HbA1c. Other modifiable factors, such as overweight, also increase the risk of complications. During the last decade, the introduction of continuous glucose monitoring (CGM) has offered new options in the treatment of T1D. OBJECTIVE: To compare treatment outcomes in children younger than 7 years with T1D in Sweden in two separate cohorts: one in 2008 and one in 2018. METHODS: All children in the national pediatric diabetes registry (SWEDIABKIDS) younger than 7 years with T1D were included. Data from 2008 and 2018 were analyzed. RESULTS: Data were available on 666 children (45% girls) in 2008 and 779 children (45% girls) in 2018. Mean age was 5.6 (1.4) versus 5.5 (1.4) years and mean diabetes duration 2.3 (1.4) versus 2.2 (1.4) years. The use of CGM increased from 0% to 98% and the use of an insulin pump from 40% in 2008 to 82% (p < 0.01)in 2018.Mean HbA1c was 58 mmol/mol (7.4%) in 2008 and 50 mmol/mol (6.7%) in 2018 (p < 0.01). The frequency of overweight and obesity was the same in 2008 and 2018(26% vs. 29%). CONCLUSION: During this decade, usage of CGM and insulin pump increased and HbA1c decreased. However, HbA1c remained higher than the physiological level and thus continued to represent a cardiovascular risk, especially in combination with overweight or obesity. The frequency of overweight and obesity remained unchanged.

The importance of low HbA1c during childhood on glycaemic control in adulthood and the risk of late complications.

AIM: To evaluate whether a very low glycated haemoglobin A (HbA1c) (<48 mmol/mol, 6.5%) during childhood compared to higher HbA1c values further decreases the risk for microvascular complications. METHODS: Data were included from the 5116 patients with type 1 diabetes transferred from the Swedish paediatric diabetes quality registry to the Swedish National Diabetes Register (NDR), until 2014. All HbA1c values ever registered in the paediatric registry were used to divide patients into six groups based on the mean HbA1c. Values were compared with HbA1c registered in 2013 and 2014 in NDR, together with data on retinopathy, micro- and macroalbuminuria, age at onset and duration of diabetes. RESULTS: The group with lowest mean-HbA1c during childhood had also the lowest mean as young adults during 2013 and 2014. The most common complication as young adults was retinopathy. The proportion with macroalbuminuria was 3% in the lowest HbA1c group during childhood and 3.9% in the highest group, and lower in the groups in between. Microalbuminuria had the same pattern. Retinopathy increased with each HbA1c group. CONCLUSION: Children with the lowest HbA1c values had the lowest HbA1c values as adults. HbA1c was associated with retinopathy but the relationship with albuminuria was not obvious.

Celiac disease can be predicted by high levels of tissue transglutaminase antibodies in children and adolescents with type 1 diabetes.

OBJECTIVES: Children with type 1 diabetes (T1D) are not included in guidelines regarding diagnosis criteria for celiac disease (CD) without a diagnostic biopsy, due to lack of data. We explored whether tissue transglutaminase antibodies (anti-tTG) that were ≥ 10 times the upper limit of normal (10× ULN) predicted CD in T1D. METHODS: Data from the Swedish prospective Better Diabetes Diagnosis study was used, and 2035 children and adolescents with T1D diagnosed between 2005-2010 were included. Of these, 32 had been diagnosed with CD before T1D. The children without CD were repeatedly screened for CD using anti-tTG antibodies of immunoglobulin type A. In addition, their human leukocyte antigen (HLA) were genotyped. All children with positive anti-tTG were advised to undergo biopsy. Biopsies were performed on 119 children and graded using the Marsh-Oberhüber classification. RESULTS: All of the 60 children with anti-tTG ≥10x ULN had CD verified by biopsies. The degree of mucosal damage correlated with anti-tTG levels. Among 2003 screened children, 6.9% had positive anti-tTG and 5.6% were confirmed CD. The overall CD prevalence, when including the 32 children with CD before T1D, was 7.0% (145/2035). All but one of the children diagnosed with CD had HLA-DQ2 and/or DQ8. CONCLUSIONS: As all screened children and adolescents with T1D with tissue transglutaminase antibodies above 10 times the positive value 10x ULN had CD, we propose that the guidelines for diagnosing CD in screened children, when biopsies can be omitted, should also apply to children and adolescents with T1D as a noninvasive method.

Assessing heart rate variability in type 1 diabetes mellitus-Psychosocial stress a possible confounder.

BACKGROUND: Autonomic neuropathy (AN) commonly arises as a long-term complication in diabetes mellitus and can be diagnosed from heart rate variability (HRV), calculated from electrocardiogram recordings. Psychosocial stress also affects HRV and could be one of several confounders for cardiac AN. The present work investigated the impact of psychosocial stress on HRV in individuals with type 1 diabetes mellitus (T1DM) and assessed the use of salivary cortisol as a biomarker for psychosocial stress in this context. METHODS: A total of 167 individuals 6-60 years old (113 with T1DM and 54 healthy controls) underwent 24-hr ECG recordings with HRV analysis. Salivary cortisol was sampled thrice during the registration day. Perceived psychosocial stress along with other factors of possible importance for the interpretation of HRV was documented in a diary. RESULTS: Heart rate variability (high-frequency power during sleep) was reduced (p < .05) with older age, longer diabetes duration, higher mean glucose levels, physical inactivity, and perceived psychosocial stress. Salivary cortisol levels in the evening were increased (p < .05) in women in ovulation phase, in individuals with preceding hypoglycemia or with hyperglycemia. The amplitude of salivary cortisol was reduced (p < .05) with the presence of perceived psychosocial stress, but only in adult healthy controls, not in individuals with diabetes. CONCLUSION: Psychosocial stress might be a confounder for reduced HRV when diagnosing cardiac AN in T1DM. Salivary cortisol is, however, not a useful biomarker for psychosocial stress in diabetes since the physiological stress of both hypoglycemia and hyperglycemia seems to overrule the effect of psychosocial stress on cortisol.

Temporal trends in diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes between 2006 and 2016: results from 13 countries in three continents.

AIMS/HYPOTHESIS: The aim of this work was to evaluate geographical variability and trends in the prevalence of diabetic ketoacidosis (DKA), between 2006 and 2016, at the diagnosis of childhood-onset type 1 diabetes in 13 countries over three continents. METHODS: An international retrospective study on DKA at diagnosis of diabetes was conducted. Data on age, sex, date of diabetes diagnosis, ethnic minority status and presence of DKA at diabetes onset were obtained from Australia, Austria, Czechia, Denmark, Germany, Italy, Luxembourg, New Zealand, Norway, Slovenia, Sweden, USA and the UK (Wales). Mean prevalence was estimated for the entire period, both overall and by country, adjusted for sex and age group. Temporal trends in annual prevalence of DKA were estimated using logistic regression analysis for each country, before and after adjustment for sex, age group and ethnic minority status. RESULTS: During the study period, new-onset type 1 diabetes was diagnosed in 59,000 children (median age [interquartile range], 9.0 years [5.5-11.7]; male sex, 52.9%). The overall adjusted DKA prevalence was 29.9%, with the lowest prevalence in Sweden and Denmark and the highest in Luxembourg and Italy. The adjusted DKA prevalence significantly increased over time in Australia, Germany and the USA while it decreased in Italy. Preschool children, adolescents and children from ethnic minority groups were at highest risk of DKA at diabetes diagnosis in most countries. A significantly higher risk was also found for females in Denmark, Germany and Slovenia. CONCLUSIONS/INTERPRETATION: DKA prevalence at type 1 diabetes diagnosis varied considerably across countries, albeit it was generally high and showed a slight increase between 2006 and 2016. Increased awareness of symptoms to prevent delay in diagnosis is warranted, especially in preschool children, adolescents and children from ethnic minority groups.