A Long-term Follow-up of a Late Diagnosed Patient with Temple Syndrome - a Case Report.

Temple syndrome (TS) is a rare imprinting disorder, caused by alterations in the critical imprinted region 14q32 of chromosome 14. It is characterized by pre- and postnatal growth retardation, truncal hypotonia and facial dysmorphism in the neonatal period. We report a 18-year-old girl with a late diagnosis presenting all typical signs and symptoms of Temple syndrome - small for gestational age at birth, feeding difficulties, muscle hypotonia and delayed developmental milestones, central precocious puberty, truncal obesity and reduced growth. The patient is the second reported in the literature with signs of clinical and biochemical hyperandrogenism and the first treated with Dehydrocortisone®, with a good response. The clinical diagnosis of this patient was achieved after a long-term follow up at a single center of rare endocrine diseases, and a molecular genetics diagnosis of complete hypomethylation of 14q32 chromosome imprinting center (DLK/GTL2) was recently established. Growth hormone (GH) treatment was not given and although precocious puberty was treated in line with standard protocols, patient's final height remained below the target range. Increased awareness of Temple syndrome and timely molecular diagnosis enables improvement of clinical care of these patients as well as prevention of inherent metabolic consequences.

A critical evaluation of the EU-virtual consultation platform (CPMS) within the European Reference Network on Rare Endocrine Conditions.

In 2017, the European Commission installed 24 European Reference Networks (ERNs) for different categories of rare and complex conditions to facilitate cross-border health care via virtual case consultations in a secure Clinical Patient Management System (CPMS). The ERN for rare endocrine conditions (Endo-ERN) previously reviewed the CPMS, in which they detailed the difficulties physicians encountered with the system and proposed solutions to these that should enable the system to be used to a greater extent. This paper will further the endeavor of the first by performing a critical evaluation of the CPMS, assessing how these suggested improvements have been implemented, and if these have affected the usage of the system. The evaluation involves an assessment of CPMS usage statistics since its conception that takes into consideration the technical updates and the external factors that may have affected these, including data from a review survey following a training workshop for our new healthcare providers (HCPs) added in January 2022. It appears that the improvements made to the system since the first review, in particular the implementation of the Operational Helpdesk, have had a positive effect in increasing CPMS membership; however, the regular usage of the system continues to fluctuate. Several suggestions are made on how to further facilitate the use of CPMS by our members both individually and network-wide, by integrating CPMS activities with other network initiatives and further integrating these into national health care systems as well as looking for ways to measure patient satisfaction from the CPMS discussions outcomes.

Disease course and treatment effects of a JAK inhibitor in a patient with CANDLE syndrome.

BACKGROUND: CANDLE syndrome (an acronym for Chronic Atypical Neutrophilic Dermatosis with Lipodystrophy and Elevated Temperature) is a recently described rare autosomal recessive disorder charaterized by systemic autoinflammation. Clinical manifestations include presentation in the first year of life, episodes of fever accompanied by erythematous skin lesions, progressive lipodystrophy, violaceous periorbital swelling and failure to thrive. This syndrome is caused by loss of function mutations and malfunction of the immunoproteasome complex. Most patients have biallelic mutations in the PSMB8 gene that encodes the ß5i catalytic subunit of the immunoproteasome. Examples of digenic inheritance have been also described in CANDLE. CANDLE patients have strong type I interferon gene expression signature and they are responsive to treatment with JAK inhibitors. However, possible serious side-effects remain a concern. Here, we report another patient with CANDLE whose disease activity was well controlled by the treatment with baricitinib. CASE PRESENTATION: We report a Bulgarian patient of the Turkish ancestry who carries biallelic mutations in the PSMB8 gene: p.Ala92Val and p.Lys105Gln. The pathogenic variant p.Ala92Val has not been previously described in patients with CANDLE. We also comment on the unusual feature in this patient, nephrolithiasis, that has not been described in other patients, however it might be related to the positive family history for kidney stones. We have treated the patient with the JAK inhibitor baricitinib for the past year and we observed a significant amelioration of his inflammatory episodes, skin and joint manifestations, and improvements in physical activities and growth. The treatment with glucocorticoids (GC) was completely discontinued. No side effects have been observed, however they remain in consideration for a life-long therapy of this disease. CONCLUSIONS: CANDLE should be suspected in patients with early-onset systemic inflammatory disease and prominent skin manifestations. Molecular testing can confirm the clinical diagnosis and is very important in guiding therapies. Treatment with JAK inhibitors is highly efficacious and appears to be safe in children with CANDLE and other intereforonopathies.

Analysis of cell-free fetal DNA for non-invasive prenatal diagnosis in a family with neonatal diabetes.

AIMS: An early genetic diagnosis of neonatal diabetes guides clinical management and results in improved treatment in ~ 40% of patients. In the offspring of individuals with neonatal diabetes, a prenatal diagnosis allows accurate estimation of the risk of developing diabetes and, eventually, the most appropriate treatment for the baby. In this study, we performed non-invasive prenatal genetic testing for a fetus at risk of inheriting a paternal KCNJ11 p.R201C mutation causing permanent neonatal diabetes. METHODS: A droplet digital polymerase chain reaction assay was used to detect the presence of the mutation in cell-free circulating DNA (cfDNA) extracted from maternal plasma at 12 and 16 weeks' gestation. RESULTS: The mutation was not detected in the cfDNA samples, suggesting that the fetus had not inherited the KCNJ11 mutation. The fetal DNA fraction was estimated at 6.2% and 10.7%, which is above the detection limit of the assay. The result was confirmed by Sanger sequencing after the baby's birth, confirming that the baby's risk of developing neonatal diabetes was reduced to that of the general population. CONCLUSIONS: We report the first case of non-invasive prenatal testing in a family with neonatal diabetes. A prenatal diagnosis in families at high risk of monogenic diabetes informs both prenatal and postnatal management. Although the clinical impact of this novel technology still needs to be assessed, its implementation in clinical practice (including cases at risk of inheriting mutations from the mother) will likely have a positive impact upon the clinical management of families affected by monogenic diabetes.

Designing and implementing a kindergarten-based, family-involved intervention to prevent obesity in early childhood: the ToyBox-study.

The development of the ToyBox-intervention was based on the outcomes of the preliminary phase of the ToyBox-study, aiming to identify young children's key behaviours and their determinants related to early childhood obesity. The ToyBox-intervention is a multi-component, kindergarten-based, family-involved intervention with a cluster-randomized design, focusing on the promotion of water consumption, healthy snacking, physical activity and the reduction/ breaking up of sedentary time in preschool children and their families. The intervention was implemented during the academic year 2012-2013 in six European countries: Belgium, Bulgaria, Germany, Greece, Poland and Spain. Standardized protocols, methods, tools and material were used in all countries for the implementation of the intervention, as well as for the process, impact, outcome evaluation and the assessment of its cost-effectiveness. A total sample of 7,056 preschool children and their parents/caregivers, stratified by socioeconomic level, provided data during baseline measurements and participated in the intervention. The results of the ToyBox-study are expected to provide a better insight on behaviours associated with early childhood obesity and their determinants and identify effective strategies for its prevention. The aim of the current paper is to describe the design of the ToyBox-intervention and present the characteristics of the study sample as assessed at baseline, prior to the implementation of the intervention.

Applying the Intervention Mapping protocol to develop a kindergarten-based, family-involved intervention to increase European preschool children's physical activity levels: the ToyBox-study.

Although sufficient physical activity is beneficial for preschoolers' health, activity levels in most preschoolers are low. As preschoolers spend a considerable amount of time at home and at kindergarten, interventions should target both environments to increase their activity levels. The aim of the current paper was to describe the six different steps of the Intervention Mapping protocol towards the systematic development and implementation of the physical activity component of the ToyBox-intervention. This intervention is a kindergarten-based, family-involved intervention implemented across six European countries. Based on the results of literature reviews and focus groups with parents/caregivers and kindergarten teachers, matrices of change objectives were created. Then, theory-based methods and practical strategies were selected to develop intervention materials at three different levels: (i) individual level (preschoolers); (ii) interpersonal level (parents/caregivers) and (iii) organizational level (teachers). This resulted in a standardized intervention with room for local and cultural adaptations in each participating country. Although the Intervention Mapping protocol is a time-consuming process, using this systematic approach may lead to an increase in intervention effectiveness. The presented matrices of change objectives are useful for future programme planners to develop and implement an intervention based on the Intervention Mapping protocol to increase physical activity levels in preschoolers.

Developing the intervention material to increase physical activity levels of European preschool children: the ToyBox-study.

Early childhood is an important period for adopting positive health-related behaviours. More than 95% of European preschool children attend kindergartens, making these settings ideal for the implementation of health promotion interventions. The ToyBox-intervention addressed preschool children, their parents/caregivers and teachers. The aim of the intervention was to improve four energy balance-related behaviours (i.e. healthy snacking, water consumption, physical activity and sedentary behaviour) by implementing a kindergarten-based, family-involved intervention in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain). The intervention material was developed following the intervention mapping protocol, taking into account local and cultural differences among the intervention countries. The present paper focuses on the development of the physical activity component of the intervention. Parental involvement was addressed by providing parents/caregivers with two newsletters, two tip cards and a poster. Teachers received a handbook with guidance on environmental changes in the classroom, 26 physical education sessions and suggestions for fun, interactive classroom activities aiming at total class participation to increase preschoolers' physical activity levels. The ToyBox-intervention material was distributed according to a standard time frame. Teachers received their material prior to the start of the intervention and parents/caregivers received their material during the intervention when each energy balance-related behaviour was implemented.

Concepts and strategies on how to train and motivate teachers to implement a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study.

The key person for the implementation of kindergarten-based behavioural interventions is the kindergarten teacher. When conducting intervention studies in kindergartens, training sessions are needed to train and motivate kindergarten teachers for programme implementation. This paper presents the systematic development of the teachers' trainings executed in the ToyBox-intervention - a kindergarten-based and family-involved obesity prevention programme for children aged 4-6. Based on concepts for the education of kindergarten teachers, on general strategies for successful programme implementation and on the ToyBox programme-specific requirements, the aims of the teachers' trainings were defined and an overall concept was deduced. Regarding the concept for the ToyBox teachers' training sessions, it is concluded that the training modules should focus on presenting information on the practical implementation of the intervention. Furthermore, these modules should also include self-efficacy enhancing components and should give kindergarten teachers opportunities to share experiences. Regarding the didactic methods applied in the ToyBox teachers' training sessions, constructivist learning approaches that facilitate active participation, reflective thinking and personal involvement were implemented. Emphasis was put not only on the content but especially on the didactic methods of teachers' trainings in order to enhance devotion to, and quality and sustainability of the ToyBox-intervention.

Designing and implementing teachers' training sessions in a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study.

Since school-based interventions are mainly delivered by the school staff, they need to be well-trained and familiarized with the programme's aims, procedures and tools. Therefore, the institute, research group, governmental or non-governmental body in charge of the coordination and implementation of the programme needs to devote time and resources to train the school staff before programme's implementation. This is particularly crucial in multi-centre studies where more than one research teams are involved. Both research teams and school staff need to be trained, using standard protocols and procedures, to ensure that the intervention will be delivered in a standardized manner throughout the intervention centres. The ToyBox-intervention, a multi-component, kindergarten-based, family-involved intervention, focusing on water consumption, snacking, physical activity and sedentary behaviours in preschool children, was implemented over the academic year 2012-2013 in six European countries. As part of this intervention, three teachers' training sessions were delivered to motivate and train teachers in implementing the intervention. The local researchers were trained centrally before delivering the training sessions for the teachers and followed a common protocol using standardized presentations and procedures. The aim of the current paper is to describe the protocol and methodological issues related to the teachers' training sessions conducted within the ToyBox-intervention.

Tools, harmonization and standardization procedures of the impact and outcome evaluation indices obtained during a kindergarten-based, family-involved intervention to prevent obesity in early childhood: the ToyBox-study.

The ToyBox-intervention is a kindergarten-based, family-involved intervention targeting multiple lifestyle behaviours in preschool children, their teachers and their families. This intervention was conducted in six European countries, namely Belgium, Bulgaria, Germany, Greece, Poland and Spain. The aim of this paper is to provide a descriptive overview of the harmonization and standardization procedures of the baseline and follow-up evaluation of the study (and substudies). Steps related to the study's operational, standardization and harmonization procedures as well as the impact and outcome evaluation assessment tools used are presented. Experiences from the project highlight the importance of safeguarding the measurement process to minimize data heterogeneity derived from potential measurement error and country-by-country differences. In addition, it was made clear that continuing quality control and support is an important component of such studies. For this reason, well-supported communication channels, such as regular email updates and teleconferences, and regular internal and external meetings to ensure smooth and accurate implementation were in place during the study. The ToyBox-intervention and its harmonized and standardized procedures can serve as a successful case study for future studies evaluating the efficacy of similar interventions.

Reliability of anthropometric measurements in European preschool children: the ToyBox-study.

The ToyBox-study aims to develop and test an innovative and evidence-based obesity prevention programme for preschoolers in six European countries: Belgium, Bulgaria, Germany, Greece, Poland and Spain. In multicentre studies, anthropometric measurements using standardized procedures that minimize errors in the data collection are essential to maximize reliability of measurements. The aim of this paper is to describe the standardization process and reliability (intra- and inter-observer) of height, weight and waist circumference (WC) measurements in preschoolers. All technical procedures and devices were standardized and centralized training was given to the fieldworkers. At least seven children per country participated in the intra- and inter-observer reliability testing. Intra-observer technical error ranged from 0.00 to 0.03 kg for weight and from 0.07 to 0.20 cm for height, with the overall reliability being above 99%. A second training was organized for WC due to low reliability observed in the first training. Intra-observer technical error for WC ranged from 0.12 to 0.71 cm during the first training and from 0.05 to 1.11 cm during the second training, and reliability above 92% was achieved. Epidemiological surveys need standardized procedures and training of researchers to reduce measurement error. In the ToyBox-study, very good intra- and-inter-observer agreement was achieved for all anthropometric measurements performed.

Process evaluation design and tools used in a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study.

Process evaluation (PE) is used for the in-depth evaluation of the implementation process of health promotion programmes. The aim of the current paper was to present the PE design and tools used in the ToyBox-intervention. The PE design was based on a three-step approach, including the identification of ToyBox-specific PE elements (step 1), the development of PE tools and harmonization of procedures (step 2), and the implementation of PE using standardized protocol and tools across the intervention countries (step 3). Specifically, to evaluate the implementation of the intervention, teachers' monthly logbooks were recorded (dose delivered, fidelity, dose received); post-intervention questionnaires were completed by parents/caregivers and teachers (dose received); participation and attrition rates were recorded (recruitment, reach); and audit questionnaires and retrospective information on weather conditions were collected (physical and social environment within which the intervention was implemented). Regarding the teachers' training sessions, the researchers who performed the trainings completed evaluation forms and documented teachers' attendance after each training (dose delivered, fidelity, dose received) and teachers completed evaluation forms after each training (dose received). The PE performed in the ToyBox-intervention may contribute in the evaluation of its effectiveness, guide the revision of the intervention material and provide insights for future health promotion programmes and public health policy.

Establishing a method to estimate the cost-effectiveness of a kindergarten-based, family-involved intervention to prevent obesity in early childhood. The ToyBox-study.

Overweight and obesity in children are recognized as a major health problem. The ToyBox-intervention was developed with the aim of preventing obesity in pre-schoolers. Because it is increasingly important to inform policy makers not only on the effects of prevention interventions, but also on their costs and cost-effectiveness, our purpose was to establish a method to estimate the cost-effectiveness of the ToyBox-intervention. In order to estimate the long-term impact of the ToyBox-intervention on health and societal costs, extrapolations of the intervention effect will be conducted to predict children's weight status (based on the body mass index) at adult age. Effects of the adult weight status on the prevalence of obesity-related complications will be modelled through a Markov model, with a total time horizon of 70 years and a cycle length of 1 year. The model will be conducted in six European countries participating in the ToyBox-intervention, based on country-specific economic and epidemiological data. This study describes the methodological rationale and implementation of an analytic model to examine the cost-effectiveness of the ToyBox-intervention for six European countries, in order to inform decision-makers on the value for money of this intervention in the prevention of obesity in pre-schoolers.

Associations between two single nucleotide polymorphisms of the adiponectin gene, its circulating concentrations and cardiometabolic risk factors in prepubertal children with and without abdominal obesity.

BACKGROUND: The adiponectin gene has been identified as a susceptibility locus for metabolic syndrome, diabetes and cardiovascular disease. AIM: To examine the influence of two single nucleotide polymorphisms (SNPs) of this gene (+276G>T and +45T>G) on circulating adiponectin concentrations, and to evaluate their relationship with adiposity and cardiometabolic risk factors in prepubertal children with and without abdominal obesity. MATERIAL AND METHODS: 168 children (78M, 6-10 yr) were examined, divided into three groups based on waist circumference (WC). Auxological and biochemical parameters were measured by standard procedures. Adiponectin SNPs were genotyped using TaqMan allelic discrimination assays. RESULTS: Adiponectin concentration correlated inversely with measures of adiposity (rBMIz-score=-0.211, pBMIz-score=0.007; rwc=-0.210, pwc=0.008; rwc/height=-0.215, pwc/height=0.006), and was significantly influenced by blood glucose, insulin and systolic blood pressure (SBP). The +276T-allele carriers had higher SBP and diastolic BP compared to GG-homozygotes (p<0.05), and expressed higher obesity-related measures and lower adiponectin concentrations. As to the +45T>G SNP, the GGsubject had higher total cholesterol and LDL-C concentrations compared to the T-allele carriers (p<0.05), showing worse obesity measures, higher triglyceride, glucose and insulin and lower serum adiponectin values. CONCLUSION: Genetic variants of the adiponectin gene had an impact on adiposity, adiponectin concentrations and some cardiometabolic variables among prepubertal children.

A systematic approach for the development of a kindergarten-based intervention for the prevention of obesity in preschool age children: the ToyBox-study.

The increasing childhood obesity epidemic calls for appropriate measures and effective policies to be applied early in life. Large-scale socioecological frameworks providing a holistic multifactorial and cost-effective approach necessary to support obesity prevention initiatives in this age are however currently missing. To address this missing link, ToyBox-study aims to build and evaluate a cost-effective kindergarten-based, family-involved intervention scheme to prevent obesity in early childhood, which could potentially be expanded on a pan-European scale. A multidisciplinary team of researchers from 10 countries have joined forces and will work to realize this according to a systematic stepwise approach that combines the use of the PRECEDE-PROCEED model and intervention mapping protocol. ToyBox-study will conduct systematic and narrative reviews, secondary data analyses, focus group research and societal assessment to design, implement and evaluate outcome, impact, process and cost effectiveness of the intervention. This is the first time that such a holistic approach has been used on a pan-European scale to promote healthy weight and healthy energy balance-related behaviours for the prevention of early childhood obesity. The results of ToyBox-study will be disseminated among key stakeholders including researchers, policy makers, practitioners and the general population.

Weight status of European preschool children and associations with family demographics and energy balance-related behaviours: a pooled analysis of six European studies.

This study aimed to (i) gain insight in the prevalence of overweight indices in European preschoolers (4-7 years); (ii) identify energy balance-related behaviours associated with overweight/obesity; and (iii) identify children at risk for overweight/obesity. Secondary analyses of six European data sets were conducted according to standardized protocols. Based on objectively measured height and weight, prevalence of overweight and obesity across the countries ranged from 8% to 30% and 1% to 13%, respectively, with highest rates in Southern European countries (i.e. Spain and Greece). Positive associations between sedentary behaviours and overweight indices were found. Physical activity and dietary behaviours were not associated, possibly because of methodological limitations. Children of parents with high body mass index or low socioeconomic status were at increased risk of overweight/obesity. In conclusion, large differences in prevalence of overweight and obesity among preschoolers across Europe were observed. Future obesity prevention interventions in preschoolers should target screen time giving specific attention to children from overweight and/or low socioeconomic status parents. There is a need for high methodological quality studies, preferably with a long-term prospective design using sensitive, valid and reliable measures of behaviours, assessing whether and which physical activity and dietary behaviours are associated with overweight in preschoolers.

Assessment tools of energy balance-related behaviours used in European obesity prevention strategies: review of studies during preschool.

Valid and reliable measures of energy balance-related behaviours are required when evaluating the effectiveness of public health interventions aiming at prevention of childhood obesity. A structured descriptive review was performed to appraise food intake, physical activity and sedentary behaviour assessment tools used in obesity intervention strategies targeting mainly preschool children across Europe. In total, 25 papers are described, addressing energy balance-related behaviours as study outcomes and targeting individuals or clusters of individuals at school- or home-based environment. Parentally reported food records and 24-h recalls were commonly used to assess food intake. Subjective levels of physical activity and sedentary behaviour were commonly accessed via parentally reported questionnaires. Accelerometry was used to obtain objective measures of physical activity. Insufficient evidence of tool evaluation was provided. When feasible, food records and accelerometry are recommended as the most appropriate methods to assess food intake in young children. Sedentary behaviour could be assessed via questionnaires that include key indicators of sedentarism and are able to differentiate individual practices. The choice of methodology for the assessment of specific intervention effects should be equally balanced between required accuracy levels and feasibility, and be guided by the intervention targets.

Influencing factors of screen time in preschool children: an exploration of parents' perceptions through focus groups in six European countries.

Preschoolers already spend significant proportions of their waking hours being sedentary. Screen time (i.e. television/DVD viewing and computer use) has been negatively associated with several health outcomes but interventions aiming to reduce preschoolers' sedentary behaviour are scarce. This study aimed to explore parents' perceptions of their preschool children's screen time. One hundred twenty-two parents of low and medium-high socioeconomic status from six European countries with children between 4 and 6 years old were involved in 24 focus groups. Following a qualitative content analysis, the available information and key findings were centrally analysed. Results showed that children tend to like watching television (TV) and most parents do not express worries about their children's TV viewing time. Education is considered to be the main benefit of watching TV and in general, parents only have informal rules about TV viewing. Computer and active games use are less frequent compared with TV viewing. No univocal results are found about the influence of siblings or friends on children's screen time. Weather conditions and parental habits at home are the most important factors influencing children's screen time. Alternatives for screen activities and information on how to set rules for screen time should be provided to parents to assist them in decreasing their preschool children's screen time.

Television food advertising directed towards Bulgarian children.

BACKGROUND: Childhood obesity is a serious health problem worldwide with a prevalence rising to epidemic proportions. Television viewing is suspected as an important contributor and along with food advertisements significantly influence children's unhealthy dietary habits, purchase requests and adiposity. OBJECTIVES: To examine the exposure of Bulgarian children to television food advertising and to make a content analysis of the food/beverage advertisements during children's television programmes. DESIGN: 41.5 h of children's television programming on three national networks, were videotaped. All recorded food advertisements were evaluated to identify the marketing strategies used for the stimulation of children's purchase requests. RESULTS: Food/beverage advertisements accounted for 124 (33.4%) of all commercials, with 96.8% being for unhealthy foods. 57% of them were aimed specifically at children as the most advertised products were salty/sweetened snacks and cereals, sweets, soft drinks/carbohydrate juices and salty foods, with no fruit or vegetable commercials. Food advertisements used more themes of adventure, animation, music and gifts to attract children's attention, and gave information based on the product's taste, physical qualities, novelty, presence of premiums/prizes. Of all food/beverage advertisements, 27.4% contained health-related information about the products; three-quarters of the advertisements were shot with young normal-weight actors with a good/healthy appearance. CONCLUSION: Almost all recorded food advertisements do not support the Bulgarian dietary recommendations for healthy and balanced eating. More activities to reduce the unhealthy food promotion to children are mandatory as restrictions by type of advertised food, target group or limits on the advertisements' account and times shown, as well as parental/self-regulation.

Early mortality in EURODIAB population-based cohorts of type 1 diabetes diagnosed in childhood since 1989.

AIMS/HYPOTHESIS: The aims of this study were to provide a contemporary picture of mortality and causes of death in Europe following a diagnosis of type 1 diabetes made before the 15th birthday, and to examine excess mortality by country for possible links to incidence level or national prosperity. METHODS: Thirteen population-based EURODIAB registers in 12 countries followed-up 28,887 children diagnosed since 1989, either by record linkage to population registers or through contact with doctors providing care. RESULTS: There were 141 deaths in the cohort during 219,061 person-years of follow-up compared with 69.1 deaths expected from national mortality rates, a standardised mortality ratio (SMR) of 2.0 (95% CI 1.7-2.4). The SMR varied from 0 to 4.7 between countries, but showed little relationship with the country's incidence rate or gross domestic product (US$ per capita). The SMR did not change significantly with attained age, calendar period or time since diagnosis. The female SMR (2.7; 95% CI 2.0-3.5) was greater than the male SMR (1.8; 95% CI 1.4-2.2), although absolute numbers of excess deaths were similar in the two sexes. One-third of deaths were classified as directly attributable to diabetes (many with mention of ketoacidosis) and half were unrelated to diabetes. There was a non-significant excess of accidental/violent deaths (48 observed vs 40.7 expected; SMR 1.2; 95% CI 0.9-1.6) but little excess in suicides (11 observed, 10.2 expected; SMR 1.1; 95% CI 0.5-1.9). CONCLUSIONS/INTERPRETATION: Before the onset of late complications, significant excess mortality existed following the diagnosis of type 1 diabetes in childhood, even in recent years. Variation between countries in this excess could not be explained.