Göran Hermansson

Declining incidence of nephropathy in insulin-dependent diabetes mellitus.

BACKGROUND The high relative mortality among patients with insulin-dependent diabetes mellitus results mainly from diabetic nephropathy. The cumulative incidence of nephropathy of 25 to 30 percent among patients who had had diabetes for 25 years remained stable from 1950 to the early 1980s. In a population study, we assessed recent trends in the incidence of diabetic nephropathy. METHODS We studied all 213 patients in whom insulin-dependent diabetes mellitus was diagnosed before the age of 15 years between 1961 and 1980 in a district in southeastern Sweden. Ninety-two percent of the patients were followed from the onset of diabetes to 1991 or to death. Patients with persistent albuminuria (positive Albustix test) were considered to have diabetic nephropathy. Glycosylated hemoglobin was measured periodically in all patients, beginning in 1980. RESULTS The cumulative incidence of persistent albuminuria after 25 years of diabetes decreased from 30.0 percent among the patients in whom diabetes developed in the period 1961 to 1965 to 8.9 percent among those in whom it developed from 1966 to 1970 (P = 0.01). After 20 years of diabetes, the cumulative incidence decreased from 28.0 percent among the patients in whom diabetes developed from 1961 to 1965 to 5.8 percent among those in whom it developed from 1971 to 1975 (P = 0.01). Persistent albuminuria has not yet developed in any patient in whom diabetes was diagnosed in the period 1976 to 1980. The average glycosylated hemoglobin value decreased from 7.4 percent in the period 1980 to 1985 to 7.0 percent from 1986 to 1991 (P < 0.001). The mean glycosylated hemoglobin value was higher in the patients with persistent albuminuria than the patients with no albuminuria (8.1 percent vs. 7.1 percent, P < 0.001). CONCLUSIONS During the past decade the cumulative incidence of diabetic nephropathy, as manifested by persistent albuminuria, among patients who have had diabetes for 25 years has decreased substantially, probably as a result of improved glycemic control.

Parents' reported reasons for avoiding MMR vaccination : A telephone survey

Objective. During the second half of the 1990s and the first years of the 2000s a declining coverage for MMR vaccination in two-year-olds was observed in Sweden. The aim was to assess reasons for postponement or non-vaccination. Design. A telephone survey using a structured questionnaire on parents’ attitudes regarding their choice to postpone or abstain from vaccinating their child. Setting. The County of Östergötland in Sweden. Subjects. A total of 203 parents of children who had no registered date for MMR vaccination at a Child Health Centre. Main outcome measures. Parental reasons for non-vaccination. Results. In all, 26 of the 203 children had received MMR vaccination but this had not been registered. Of those not vaccinated, 40% of the parents had decided to abstain and 60% to postpone vaccination. Fear of side effects was the most common reason for non-vaccination in both groups. The main source of information was the media followed by the Child Health Centre. Parents with a single child more often postponed vaccination and those who abstained were more likely to have had a discussion with a doctor or nurse about MMR vaccine. Conclusion. Postponers and abstainers may have different reasons for their decision. The role of well-trained healthcare staff in giving advice and an opportunity to discuss MMR vaccination with concerned parents is very important.

Home Blood Glucose Monitoring in Diabetic Children and Adolescents.: A 3-year Feasibility Study

ABSTRACT. In order to elucidate the question whether blood glucose monitoring should replace glucosuria testing in childhood diabetes 160 diabetic children and adolescents were invited to participate in a feasibility study on home blood glucose testing. Seventeen girls and 15 boys with an age of 4–21 years and duration of diabetes for 0.3‐18.7 years accepted, thus a selection of motivated patients. They performed 20–22 diurnal blood glucose profiles, each consisting of 7 blood samples, during a 3 month period. Thereafter, all patients were encouraged to continue blood glucose self‐control and the actual performance of the 32 patients was evaluated 3 years later. Daily glucosuria tests were also made and HbA1 was analysed. Patients’attitudes were evaluated through 2 questionnaires. The study shows that blood glucose monitoring is feasible in the actual age groups. Most patients were positive towards blood tests, particularly because it gave an immediate answer to an actual problem, but its introduction did not change the metabolic control. However, pain restricted its daily use and only 6.4% of the patients preferred blood testing to urinalysis for long term use. Furthermore, the correlation between home glucosuria and HbA1 was as good as between home blood glucose and HbA1. It is concluded, that blood glucose self‐monitoring is a valuable tool in the management of childhood diabetes, but that it should be regarded as a complement to and not a substitute for daily home urinalysis.

A High-Precision Protocol for Identification of Preschool Children at Risk for Persisting Obesity

Background Recent studies suggest that adolescent adiposity is established already in preadolescence. Earlier studies have confirmed a strong tracking of obesity from adolescence to adulthood. Our aim was to examine the diagnostic accuracy of a population-derived protocol for identification of preschool children at risk for obesity in preadolescence. Methodology/Principal Findings We analysed data obtained for child health surveillance up to age 5 from 5778 children born in a Swedish county in 1991. The basic data set included age, sex, and weight and height measurements from the regular checkups between ages 1.5 and 5. Data not routinely collected in the child health centre setting were disregarded. The children were at age 10 randomly assigned to protocol derivation and validation cohorts and assessed for obesity according to IOTF criteria. The accuracy of predicting obesity in the validation cohort was measured using decision precision, specificity, and sensitivity. The decision protocol selected 1.4% of preschool children as being at obesity risk. The precision of the protocol at age 10 was 82% for girls and 80% for boys, and the specificity was 100% for both boys and girls. The sensitivity was higher for girls (41%) than for boys (21%). The relative risk for obesity at age 10 estimated by the odds ratio for individuals selected by the protocol compared to non-selected peers was 212.6 (95% confidence interval 56.6 to 798.4) for girls and 120.3 (95% CI 24.5 to 589.9) for boys. Conclusion/Significance A simple and inexpensive decision protocol based on BMI values proved to have high precision and specificity for identification of preschool children at risk for obesity persisting into adolescence, while the sensitivity was low especially for boys. Implementation and further evaluations of the protocol in child health centre settings are warranted.

Child health nurses' roles and attitudes in reducing children's tobacco smoke exposure

AIM To investigate and analyse the attitudes to tobacco prevention among child healthcare nurses, to study how tobacco preventive work is carried out at child healthcare centres today. To evaluate how the tobacco preventive work had changed in child health care since the Swedish National Board of Health and Welfares national evaluation in 1997. BACKGROUND Exposure to environmental tobacco smoke has adverse health effects. Interventions aiming at minimising environmental tobacco smoke have been developed and implemented at child healthcare centres in Sweden but the long-term effects of the interventions have not been studied. DESIGN Survey. METHODS In 2004, a postal questionnaire was sent to all nurses (n = 196) working at 92 child healthcare centres in two counties in south-eastern Sweden. The questionnaire was based on questions used by the National Board of Health and Welfare in their national evaluation in 1997 and individual semi-structured interviews performed for this study. RESULTS Almost all the nurses considered it very important to ask parents about their smoking habits (median 9.5, range 5.1-10.0). Collaboration with antenatal care had decreased since 1997. Nearly all the nurses mentioned difficulties in reaching fathers (70%), groups such as immigrant families (87%) and socially vulnerable families (94%) with the tobacco preventive programme. No nurses reported having special strategies to reach these groups. CONCLUSIONS Improvement of methods for tobacco prevention at child healthcare centres is called for, especially for vulnerable groups in society. However, the positive attitude among nurses found in this study forms a promising basis for successful interventions. RELEVANCE TO CLINICAL PRACTICE This study shows that launching national programmes for tobacco prevention is not sufficient to achieve sustainable work. Nurses working in child healthcare centres have an overall positive attitude to tobacco prevention but need continuous education and training in communication skills especially to reach social vulnerable groups. Regular feedback from systematic follow-ups might increase motivation for this work.

RENAL FUNCTION AND BLOOD‐PRESSURE REACTION DURING EXERCISE IN DIABETIC AND NON‐DIABETIC CHILDREN AND ADOLESCENTS: A Pilot Study

Abstract. Hermansson, G. and Ludvigsson, J. (Department of Pediatrics, University Hospital, Linköping, Sweden). Renal function and blood‐pressure reaction during exercise in diabetic and non‐diabetic children and adolescents. A pilot study. Acta Paediatr Scand, Suppl. 283: 86, 1980.—In order to analyse whether protein excretion during exercise is an earlier sign of nephropathy in children and adolescents with juvenile diabetes than protein excretion during basal conditions, urinary excretion of albumin and beta‐2‐micro‐globulin was studied, during a basal 24‐hour period and during exercise, in 55 patients with insulin‐dependent diabetes (age 8–20 years; duration of disease 9 months‐17.5 years). Similar determinations were made in 55 non‐diabetics matched to the patients according to age, sex and weight. Mean glomerular filtration rate was lower in diabetics than in non‐diabetics (109, compared to 131 ml/min/1.73; p <0.001) partly due to errors in urine collection in the diabetics. Urinary albumin excretion during basal period and exercise was the same in patients and controls, but in the age group of 16–20 years the increase in albumin excretion during exercise was greater in the diabetics. There was no increase in albumin excretion during exercise in children below 10 years of age or with a duration of diabetes of 2 years or less. Methodological problems such as degree of hydration, choice of work loads and laboratory method for determining urinary albumin are discussed, and may contribute to the absence of significant differences in albumin excretion between diabetics and non‐diabetics. Beta‐2‐microglobulin excretion was greater in diabetics compared with controls both during basal conditions and during exercise (p<0.001 and p<0.05 respectively). Exercise test did not give any further information on beta‐2‐microglobulin excretion than basal excretion. The reason for elevated beta‐2‐microglobulin excretion in diabetics is not clear but the degree of metabolic control may be one factor of importance. Systolic blood pressure during exercise increases with increasing age but this goes parallel to increasing duration of diabetes making it difficult to analyse what is most important for protein excretion. Further studies are necessary in order to evaluate exercise test as a provocation for albumin excretion in diabetic children and adolescents, and to find out the significance of elevated beta‐2‐microglobulin in diabetics compared with controls.

Tobacco Exposure and Diabetes-Related Autoantibodies in Children Results from the ABIS Study

Passive smoking has decreased in recent years (“increased hygiene”). Less environmental tobacco smoke (ETS) gives increased hygiene that, if the hygiene hypothesis is true, in turn might give more autoimmune diseases. The presence of auto antibodies is considered to be an early indicator of type 1 diabetes (T1D). Because tobacco exposure may influence the immune system, we analyzed the relation between passive smoking and development of autoantibodies. A subsample (n= 8794) of the children in the ABIS study was used for this analysis. The parents answered questionnaires on smoking from pregnancy and onwards, and blood samples from the children aged 2.5–3 years were analyzed for GADA and IA‐2A. Results showed that there was no significant difference in the prevalence of GADA or IA‐2A (>95 percentile) between tobacco‐exposed and nonexposed children. It was concluded that passive smoking does not seem to influence development of diabetes‐related autoantibodies early in life.

Parents’ attitudes to smoking and passive smoking and their experience of the tobacco preventive work in child health care

The purpose of this study was to describe parents’ attitudes to smoking and their experience of the tobacco preventive work in antenatal care and in Child Health Care (CHC) in Sweden. A population based survey in which 62 percent of 3000 randomly selected parents with 1- and 3-year-old children answered a questionnaire. Fifty-six percent stated that smoking was registered in the health record of the child yet no further discussion regarding passive smoking took place. The parents’ educational level and smoking status was related to the attitudes and experiences of the tobacco preventive work. The results indicated that the dialogue with parents regarding children and environmental tobacco smoke (ETS) exposure has to be redesigned and intensified in order to meet the needs of parents with different backgrounds.

When does exposure of children to tobacco smoke become child abuse

We report an instance of a child aged 2.5 years, who is exposed to tobacco smoke in the home. The child is a participant in a prospective cohort study (ABIS; all babies in southeast Sweden) we are undertaking, on environmental factors affecting development of immune-mediated diseases in children.1Exposure to environmental tobacco smoke, known to affect present and future health of children,2 is one of the environmental factors being studied. Parents are asked, in questionnaires, if and how much they smoke. A subsample of smoking parents of 2–3 year-old children has been asked about their smoking behaviour at home—ie, what precautions they use to protect their child from tobacco smoke. To validate this questionnaire, we have analysed urine cotinine concentrations (the major urinary metabolite of nicotine) in specimens provided by children of this age. We recorded that the smoking behaviour of parents at home was significantly associated with cotinine concentrations of their child. Cotinine concentrations were adjusted for creatinine.3The child we report here had a cotinine/creatinine ratio of 800 μg cotinine/1 g creatinine, corresponding to active smoking of 3–5 cigarettes a day.4 The parents reported a joint consumption of 41–60 cigarettes a day. They said they smoke in the kitchen and living room, whereas bedrooms were reported to be smoke-free. The parents reported smoking at the dinner table once a day and in front of the television set several times a day. They also said they smoke near the kitchen fan several times a day and near an open door at least once a week. These comments from the parents indicate that, in their opinion, their child was well protected from exposure to environmental tobacco smoke, since they did not smoke in bedrooms and the windows were almost always open.Though nicotine and cotinine metabolism is independent probably due to genetic differences,5 the cotinine concentration of this child is remarkably high. If active smoking in adults causes lung cancer and other serious diseases, passive smoking from the age of 2.5 years (and probably younger) must be even more deleterious. Since a child at this age cannot, by his or her own will, avoid a smoky environment, we ask ourselves when exposure to tobacco smoke should be regarded as child abuse?We want to stress the fact that, although most parents are aware of the importance of protecting their children from tobacco smoke, and try in different ways, children can still be massively exposed to this toxic drug. Since to just forbid smoking might be ineffective, nurses and doctors should pay attention to smoking behaviour of smoking parents they meet. Until we know more about effective measures of protection, the recommendation should be never to smoke indoors in homes with children.

A Chromatographic Method for Measuring Haemoglobin A1: Comparison with Two Commercial Kits

A modified chromatographic method for the separation of haemoglobin A1 is described. Its use for the estimation of the concentrations of the fractions is compared with those of two commercial kits.