Ragnar Bjarnason

Asthma and allergy patterns over 18 years after severe RSV bronchiolitis in the first year of life

Background An increased prevalence of asthma/recurrent wheeze (RW), clinical allergy and allergic sensitisation up to age 13 years has previously been reported in subjects hospitalised with respiratory syncytial virus (RSV) bronchiolitis in their first year of life compared with matched controls. A study was undertaken to examine whether these features persist into early adulthood, to report longitudinal wheeze and allergy patterns, and to see how large and small airway function relates to RSV infection and asthma. Methods Follow-up at age 18 years was performed in 46 of 47 subjects with RSV and 92 of 93 controls. Assessments included questionnaire, clinical examination, skin prick tests, serum IgE antibodies to inhaled allergens, blood eosinophils, fraction of exhaled nitric oxide (FeNO), spirometry, multiple breath washout (lung clearance index, LCI) and dry air hyperventilation challenge. Results Increased prevalence of asthma/RW (39% vs 9%), clinical allergy (43% vs 17%) and sensitisation to perennial allergens (41% vs 14%) were present at age 18 in the RSV cohort compared with controls. Persistent/relapsing wheeze associated with early allergic sensitisation predominated in the RSV cohort compared with controls (30% vs 1%). Spirometric function was reduced in subjects with RSV with or without current asthma, but not in asthmatic controls. LCI was linked only to current asthma, airway hyperresponsiveness and FeNO. Conclusions Severe early RSV bronchiolitis is associated with an increased prevalence of allergic asthma persisting into early adulthood. Small airway dysfunction (LCI) is related to current asthma and airway inflammation but not to RSV bronchiolitis. Reduced spirometry after RSV may reflect airway remodelling.

Eosinophil cationic protein in nasal secretion and in serum and myeloperoxidase in serum in respiratory syncytial virus bronchiolitis: relation to asthma and atopy

Eosinophil cationic protein (ECP) in nasal secretions was determined in 34 infants with respiratory syncytial virus (RSV) bronchiolitis during the acute infection stage and one and six months later. ECP in serum was determined in 19 of these children at the same time. Myeloperoxidase (MPO) was determined in the same 19 children at the acute infection stage and after one month. All children were followed prospectively for two years after the infection with regard to the development of bronchial obstructive symptoms. Asthma, defined as three or more episodes of bronchial obstruction verified by a physician, developed in 18% of children and less severe obstructive symptoms in 29%. A screening test for food IgE antibodies in serum was performed six months and a skin prick test two years after the acute infection. Nasal ECP/albumin ratios after six months were significantly higher than during the acute RSV infection. MPO, but not ECP, levels in serum were significantly elevated at the time of acute infection compared with levels after one month. Nasal ECP/albumin ratios at the acute infection were compared to a control group of 27 infants with non‐RSV upper respiratory tract infections and did not differ. It was not possible to predict, either from ECP/albumin ratios in nasal secretion or from ECP and MPO in serum, which children would develop asthma, other bronchial obstructive symptoms or positive IgE tests.

The role of parental motivation in family-based treatment for childhood obesity.

This study investigated the role of parental motivation (importance, confidence and readiness) for predicting dropout and outcome from family‐based behavioral treatment for childhood obesity. Parent and child demographics, adherence to treatment, and weight loss parameters were also explored as potential predictors. Eighty‐four obese children (BMI‐standard deviation scores (SDS) >2.14) and a participating parent with each child started treatment consisting of 12 weeks of group and individual treatment sessions (24 sessions total) delivered over a period of 18 weeks. Sixty‐one families (73%) completed treatment and attended follow‐up at 1 year after treatment. Child session attendance and completion of self‐monitoring records served as measures of adherence. In regression analyses, parent reports (pretreatment) of confidence for doing well in treatment was the strongest predictor of treatment completion (P = 0.003) as well as early treatment response (weight loss at week 5) (P = 0.003). This variable remained a significant predictor of child weight loss at post‐treatment (P = 0.014), but was not associated with child outcome at 1‐year follow‐up (P > 0.05). The only significant predictor of child weight loss at that point was child baseline weight (P = 0.001). However, pretreatment parent ratings of importance of and readiness for treatment did not predict dropout or weight loss at any point. The results underscore the importance of addressing parental motivation, specifically parental confidence for changing lifestyle related behaviors, early in the treatment process. Doing so may reduce treatment dropout and enhance treatment outcome.

Childhood obesity and co-morbid problems: effects of Epstein's family-based behavioural treatment in an Icelandic sample.

OBJECTIVE This study assessed the effects of Epsteins family-based behavioural treatment in a clinical sample of obese children in Iceland. Also, it explored whether co-morbid concerns affect treatment outcome. METHODS Eighty-four obese children [mean body-mass-index standard-deviation-scores (BMI-SDS) = 3.11, aged 7.5-13.6 years] and a participating parent initiated treatment in response to a school-based screening. Sixty-one families completed treatment and were followed for 1 year post treatment. Measurements included height, weight, reports of psychological well-being (Strengths and Difficulties Questionnaire, Multidimensional Anxiety Scale for Children, Childrens Depression Inventory, Piers-Harris Self Concept Scale, Social Skills Rating System) and academic competencies. RESULTS Among treatment completers a large effect size was obtained for change in BMI-SDS during treatment (mean difference = -0.40, SD = 0.29). Psychological well-being improved and treatment effects were maintained at 1-year follow-up. At baseline, 69% of the children presented with one or more co-morbid concerns. Children who scored above cut-off for concern on parent-reported hyperactivity (Strengths and Difficulties Questionnaire subscale T-score ≥ 65) reduced their BMI-SDS less during treatment than children with lower hyperactivity scores whereas children who scored in the clinical range for social anxiety (Multidimensional Anxiety Scale for Children subscale T-score ≥ 65) reduced their BMI-SDS significantly more than children with lower social anxiety scores. The social anxiety effect was still present at 1-year follow-up, but not the hyperactivity effect (P > 0.05). No differential response was shown for children with higher depression scores, lower self-concept or low academic competencies. CONCLUSIONS Epsteins family-based behavioural treatment produced promising effects in both the short and the longer term in a clinical sample of Icelandic children with substantial rates of co-morbid concerns. Co-morbid problems affect outcome and tailoring treatment to address co-morbid concerns might improve outcomes for certain subgroups.

Childhood diabetes in the Nordic countries: a comparison of quality registries.

Background: In 2008 a Nordic collaboration was established between the quality registries in Denmark, Iceland, Norway, and Sweden to improve quality of care for children with diabetes. This study aimed to describe those registries and confirm that the registry variables are comparable. Selected variables were used to demonstrate outcome measurements. Methods: The organization of the registries and methodology are described. Cross-sectional data for patients between birth and 14.9 years with type 1 diabetes mellitus in 2009 (n = 6523) from 89 centers were analyzed. Variables were age, gender, and diabetic ketoacidosis at onset, together with age, gender, HbA1c, insulin regimen, and severe hypoglycemia at follow-up in 2009. Results: All 4 registries use a standardized registration at the onset of diabetes and at follow-up, conducted at the local pediatric diabetes centers. Methods for measuring HbA1c varied as did methods of registration for factors such as hypoglycemia. No differences were found between the outcomes of the clinical variables at onset. Significant variations were found at follow-up for mean HbA1c, the proportion of children with HbA1c < 57 mmol/mol (NGSP/DCCT 7.4%), (range 15-31%), the proportion with insulin pumps (range 34-55%), and the numbers with severe hypoglycemia (range 5.6-8.3/100 patient years). Conclusions: In this large unselected population from 4 Nordic countries, a high proportion did not reach their treatment target, indicating a need to improve the quality of pediatric diabetes care. International collaboration is needed to develop and harmonize quality indicators and offers possibilities to study large geographic populations, identify problems, and share knowledge.

Equal access to health care may diminish the differences in outcome between native and immigrant patients with type 1 diabetes.

Previous studies have found that ethnicity influences glycemic control. We hypothesized that differences between Nordic and non‐Nordic patients are less pronounced for children with type 1 diabetes in high incidence countries in Northern Europe.

A randomized-controlled pilot study of Epstein's family-based behavioural treatment for childhood obesity in a clinical setting in Iceland

Objective: To assess the acceptability and effectiveness of Epstein’s family-based behavioural treatment (FBBT) for childhood obesity in a medical setting in Iceland. Methods: Participants were 16 obese children (BMI > 2.4 SDS), aged 8-12 years, and a parent participating with each child. Families were randomly assigned to 4 months of treatment at two different times. One group started treatment right away, and the other group had a delayed treatment onset of 12 months during which the participants received standard care. Weight, height and BMI were assessed at baseline, 4 months, 12 months and 16 months. The main outcomes were ratings of treatment acceptability (measured post treatment) and child changes in body mass index standard deviation scores (BMI-SDS). Results: For the eight children in the standard care group, BMI-SDS remained constant from baseline until starting treatment at 12 months. Thirteen families completed treatment, during which the children lowered their BMI-SDS. The children first receiving treatment (n = 7) maintained their BMI-SDS from post-treatment to the 1-year follow-up. Conclusions: Treatment was found acceptable and effects were promising. These results provide substantiation for a larger study of treatment effects.

Incidence of severe hypoglycemia in children with type 1 diabetes in the Nordic countries in the period 2008–2012: association with hemoglobin A1c and treatment modality

Objective Treatment of type 1 diabetes has been intensified aiming at normalizing blood glucose, which may increase the risk of severe hypoglycemia (SH). We aimed to compare the incidence of SH events in the four Nordic countries Denmark, Iceland, Norway and Sweden, and to assess the influence of hemoglobin A1c (HbA1c) and treatment modalities on the frequency of SH; particularly, to explore if a HbA1c target ≤6.7% (50 mmol/mol) is feasible. Research design and methods Data on children below 15 years with a diabetes duration more than 1 year, registered in the national childhood diabetes databases in the four Nordic countries from 2008 to 2012, were compiled. Data completeness was more than 95%. Results Totally 8806 (48% females) patients with 29 715 person years were included, mean age and diabetes duration were 11 years and 5.1 years, respectively. The overall rate of SH was 6.0 per 100 patient-years, and did not change during the study period. The Swedish population constantly had the lowest SH incidence while it decreased significantly in the Danish population. HbA1c decreased significantly over time (p<0.01), while the number of pump users increased (p<0.01). Stratifying for HbA1c levels showed the lowest risk of SH in patients with HbA1c ≤6.7% (≤50 mmol/mol), but in the statistical models adjusting for possible confounders the difference between the HbA1c groups disappeared. Pump users had the lowest SH risk, also after adjusting for possible confounders. Conclusions Risk of SH differs between the Nordic countries with the lowest risk in Sweden. Pump therapy was associated with decreased risk of SH. The low HbA1c group had the same or a lower risk of SH compared with the highest HbA1c groups. A target HbA1c ≤6.7% (≤50 mmol/mol) seems achievable without increasing the risk of SH.

Effect of sequence variants on variance in glucose levels predicts type 2 diabetes risk and accounts for heritability

Sequence variants that affect mean fasting glucose levels do not necessarily affect risk for type 2 diabetes (T2D). We assessed the effects of 36 reported glucose-associated sequence variants on between- and within-subject variance in fasting glucose levels in 69,142 Icelanders. The variant in TCF7L2 that increases fasting glucose levels increases between-subject variance (5.7% per allele, P = 4.2 × 10−10), whereas variants in GCK and G6PC2 that increase fasting glucose levels decrease between-subject variance (7.5% per allele, P = 4.9 × 10−11 and 7.3% per allele, P = 7.5 × 10−18, respectively). Variants that increase mean and between-subject variance in fasting glucose levels tend to increase T2D risk, whereas those that increase the mean but reduce variance do not (r2 = 0.61). The variants that increase between-subject variance increase fasting glucose heritability estimates. Intuitively, our results show that increasing the mean and variance of glucose levels is more likely to cause pathologically high glucose levels than increase in the mean offset by a decrease in variance.

Cross-sectional study of randomly selected 18-year-old students showed that body mass index was only associated with sleep duration in girls

This study investigated the associations, by sex, between sleep and adiposity, dietary habits, cardiorespiratory fitness and metabolic risk in 18‐year‐old students.