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Conflicts of interest (COIs) have been defined by the American Thoracic Society as "a divergence between an individual's private interests and his or her professional obligations such that an independent observer might reasonably question whether the individual's professional actions or decisions are motivated by personal gain, such as direct financial, academic advancement, clinical revenue streams, or community standing." In the context of guideline development, the concerns are not simply about identifying and disclosing direct financial or indirect COIs. Despite this recognition, the management of COIs in guidelines is often unsatisfactory. In response to requests from its international membership and informed by existing syntheses of the evidence and policies of international organizations, the Guidelines International Network Board of Trustees developed guidance on the disclosure of interests and management of COIs. Current approaches are relatively similar throughout the guideline development community, with an increasing recognition of the importance of disclosing and managing indirect COIs. Although there are differences in detail among the approaches, the similarities allow for the formulation of 9 core principles for managing COIs. In formulating these principles, the Guidelines International Network Board of Trustees recognizes that COIs cannot be totally avoided when panel members are being chosen for certain guidelines or in certain settings; thus, the important issue is the management of COIs in a fair, judicious, transparent manner.

The clinical presentation of type 1 diabetes at a very young age is associated with severe metabolic decompensation, poorly preserved residual beta-cell function, strong humoral autoimmunity against islet cells and insulin, and strong HLA-defined disease susceptibility.

The determinants of the degree of metabolic decompensation at the diagnosis of type 1 (insulin dependent) diabetes mellitus (IDDM) and the possible role of diabetic ketoacidosis in the preservation and recovery of residual P cell function were examined in 745 Finnish children and adolescents. Children younger than 2 years or older than 10 years of age were found to be more susceptible to diabetic ketoacidosis than children between 2 and 10 years of age (<2 It is well known that the capacity of residual 5 cells to secrete insulin is decreased at the time of diagnosis of IDDM, often improving in a few weeks after the initiation of exogenous insulin treatment.8'-`The extent of improvement in insulin secretory capacity has been observed to be associated with age at diagnosis,' degree of metabolic decompensation,9 mild clinical symptoms at diagnosis,2910 and strict initial blood glucose control.2 13 Diabetic ketoacidosis is a serious consequence of insufficient insulin secretion.'4 In addition to possible acute complications, it may also influence the later outcome of diabetes.To study the effect of age, sex, and socioeconomic factors on the clinical condition of the patient at the diagnosis of IDDM, and to find out whether metabolic decompensation at diagnosis is related to subsequent endogenous insulin secretion and impaired metabolic control, 745 Finnish children and adolescents, aged 0.8-14.9 years, were evaluated at the time of diagnosis of IDDM and then observed for two years. Methods PATIENTSAs a part of the Finnish nationwide 'Childhood diabetes in Finland' study,'5 801 probands younger than 15 years, diagnosed as having IDDM during the recruitment period from 1 September 1986 to 30 April 1989, were offered the possibility of participating in the study. Of these 745 had analyses of blood pH, serum C peptide concentrations, and blood glycated haemoglobin levels at the time of hospital admission. At the time of admission, a clinical examination including assessment of consciousness and dehydration was performed, and the parents were asked to fill out a questionnaire concerning the socioeconomic status of the family. The subjects were then followed up in their own outpatient clinics (n = 31) for two years. At six month intervals, the recommended amount of insulin was recorded, blood specimens werc taken for glycated haemoglobin and serum C peptide concentrations, and a clinical examination including height and weight recording was performed.The mean age of the probands was 8.4 years (range 0.8 to 14.9 years). The majority of them were males (n = 412; 55.3%). The subjects were divided into two groups: those with and without diabetic ketoacidosis at diagnosis. In the longitudinal study the groups were compared at the time of diagnosis and at six, 12, 18, and 24 months after diagnosis. LABORATORY MEASUREMENTSCapillary or venous blood pH was measured at the time of hospital admission. Diabetic

BackgroundFinnish clinical guidelines are evolving toward integration of knowledge modules into the electronic health record in the Evidence-Based Medicine electronic Decision Support project. It therefore became important to study which factors affect professionals' intention to use clinical guidelines generally in their decision-making on patient care. A theory-based approach is a possible solution to explore determinants of professionals' behaviour. The study's aim was to produce baseline information for developers and implementers by using the theory of planned behaviour.MethodsA cross-sectional internet-based survey was carried out in Finnish healthcare organisations within three hospital districts. The target population (n = 2,252) included physicians, nurses, and other professionals, of whom 806 participated. Indicators of the intention to use clinical guidelines were observed by using a theory-based questionnaire. The main data analysis was done by means of multiple linear regressions.ResultsThe results indicated that all theory-based variables--the attitude toward the behaviour, the subjective norm, and the perceived behaviour control--were important factors associated with the professionals' intention to use clinical practice guidelines for their area of specialisation in the decisions they would make on the care of patients in the next three months. In addition, both the nurse and the physician factors had positive (p < 0.01) effects on this intention in comparison to other professionals. In the similar models for all professions, the strongest factor for the physicians was the perceived behaviour control, while the key factor for the nurses and the other professionals was the subjective norm. This means that context- and guideline-based factors either facilitate or hinder the intention to use clinical guidelines among physicians and, correspondingly, normative beliefs related to social pressures do so for nurses and other healthcare professionals.ConclusionsThe results confirm suggestions that the theory of planned behaviour is a suitable theoretical basis for implementing clinical guidelines in healthcare practices. Our new finding was that, in general, profession had an effect on intention to use clinical guidelines in patient care. Therefore, the study reaffirms the general contention that different strategies need to be in place when clinical guidelines are targeted at different professional groups.

Mutations in genes encoding the ATP-regulated potassium (K(ATP)) channels of the pancreatic beta-cell (SUR1 and Kir6.2) are the major known cause of persistent hyperinsulinemic hypoglycemia of infancy (PHHI). We collected all cases of PHHI diagnosed in Finland between 1983 and 1997 (n = 24). The overall incidence was 1:40,400, but in one area of Central Finland it was as high as 1:3,200. Haplotype analysis using polymorphic markers spanning the SUR1/Kir6.2 gene cluster confirmed linkage to the 11p region. Sequence analysis revealed a novel point mutation in exon 4 of SUR1, predicting a valine to aspartic acid change at amino acid 187 (V187D). Of the total cases, 15 affected individuals harbored this mutation in heterozygous or homozygous form, and all of these had severe hyperinsulinemia that responded poorly to medical treatment and required subtotal pancreatectomy. No K(ATP) channel activity was observed in beta-cells isolated from a homozygous patient or after coexpression of recombinant Kir6.2 and SUR1 carrying the V187D mutation. Thus, the mutation produces a nonfunctional channel and, thereby, continuous insulin secretion. This unique SUR1 mutation explains the majority of PHHI cases in Finland and is strongly associated with a severe form of the disease. These findings provide diagnostic and prognostic utility for suspected PHHI patients.

The detected deficit in bone density in survivors of childhood ALL may predispose these patients to osteoporotic fractures later in adulthood. A follow-up of BMD in survivors of childhood ALL should facilitate the identification of patients who would require specific therapeutic interventions to prevent further decrease of their skeletal mass and preserve their BMD.

To test whether weaning to a bovine insulinfree cow's milk formula (CMF) reduces type 1 diabetes mellitus-associated autoantibodies in children at genetic risk.