Practice and consensus-based strategies in diagnosing and managing systemic juvenile idiopathic arthritis in Germany

Background: Systemic juvenile idiopathic arthritis (SJIA) is an autoinflammatory disease associated with chronic arthritis. Early diagnosis and effective therapy of SJIA is desirable, so that complications are avoided. The PRO-KIND initiative of the German Society for Pediatric Rheumatology (GKJR) aims to define consensus-based strategies to harmonize diagnostic and therapeutic approaches in Germany. Methods: We analyzed data on patients diagnosed with SJIA from 3 national registries in Germany. Subsequently, via online surveys and teleconferences among pediatric rheumatologists with a special expertise in the treatment of SJIA, we identified current diagnostic and treatment approaches in Germany. Those were harmonized via the formulation of statements and, supported by findings from a literature search. Finally, an in-person consensus conference using nominal group technique was held to further modify and consent the statements. Results: Up to 50% of patients diagnosed with SJIA in Germany do not fulfill the International League of Associations for Rheumatology (ILAR) classification criteria, mostly due to the absence of chronic arthritis. Our findings suggest that chronic arthritis is not obligatory for the diagnosis and treatment of SJIA, allowing a diagnosis of probable SJIA Malignant, infectious and hereditary autoinflammatory diseases should be considered before rendering a diagnosis of probable SJIA There is substantial variability in the initial treatment of SJIA. Based on registry data, most patients initially receive systemic glucocorticoids, however, increasingly substituted or accompanied by biological agents, i.e. interleukin (IL)-1 and IL-6 blockade (up to 27.2% of patients). We identified preferred initial therapies for probable and definitive SJIA, including step-up patterns and treatment targets for the short-term (resolution of fever, decrease in C-reactive protein by 50% within 7 days), the mid-term (improvement in physician global and active joint count by at least 50% or a JADAS-10 score of maximally 5.4 within 4 weeks) and the long-term (glucocorticoid-free clinically inactive disease within 6 to 12 months), and an explicit treat-to-target strategy. Conclusions: We developed consensus-based strategies regarding the diagnosis and treatment of probable or definitive SJIA in Germany

Lower Frequency of Insulin Pump Treatment in Children and Adolescents of Turkish Background with Type 1 Diabetes: Analysis of 21,497 Patients in Germany

Icks A, Razum O, Rosenbauer J, et al. Lower Frequency of Insulin Pump Treatment in Children and Adolescents of Turkish Background with Type 1 Diabetes: Analysis of 21,497 Patients in Germany. Diabetes Technology &amp; Therapeutics. 2012;14(12):1105-1109.Aim: This study investigated insulin pump therapy in pediatric patients with type 1 diabetes and Turkish origin compared with those without migration background in Germany. Subjects and Methods: Using a nationwide documentation program, we estimated the prevalence of insulin pump therapy in patients <20 years of age with Turkish origin and those without migration background. Logistic regression was used to adjust for age, sex, diabetes duration, body mass index SD score (BMI-SDS), glycated hemoglobin, number of outpatient visits, number of daily blood glucose self-measurements, and area-based socioeconomic conditions. Results: In 1,695 pediatric type 1 diabetes patients with Turkish background and 19,802 patients without migration background (respectively: 51.2% and 53.0% boys; mean age, 12.4 +/- 4.1 and 12.6 +/- 4.2 years; mean diabetes duration, 4.7 +/- 3.9 and 5.3 +/- 4.0 years), fully adjusted prevalences of insulin pump therapy were 18.5% and 30.9%, respectively (odds ratio 0.51, 95% confidence interval 0.43-0.60, P < 0.001). Age, sex, BMI-SDS, outpatient visits, and blood glucose self-control were significantly associated with the prevalence of insulin pump therapy but did not alter the difference substantially. Conclusions: The prevalence of insulin pump therapy is roughly half among pediatric diabetes patients with Turkish background compared with those without migration background. Several covariates could not explain this difference. Individual characteristics or access barriers within the healthcare system may play a role. Further research is needed

Incidence of COVID-19 and Risk of Diabetic Ketoacidosis in New-Onset Type 1 Diabetes

OBJECTIVES: With this study, our aim was to quantify the relative risk (RR) of diabetic ketoacidosis at diagnosis of type 1 diabetes during the year 2020 and to assess whether it was associated with the regional incidence of coronavirus disease 2019 (COVID-19) cases and deaths. METHODS: Multicenter cohort study based on data from the German Diabetes Prospective Follow-up Registry. The monthly RR for ketoacidosis in 2020 was estimated from observed and expected rates in 3238 children with new-onset type 1 diabetes. Expected rates were derived from data from 2000 to 2019 by using a multivariable logistic trend regression model. The association between the regional incidence of COVID-19 and the rate of ketoacidosis was investigated by applying a log-binomial mixed-effects model to weekly data with Germany divided into 5 regions. RESULTS: The observed versus expected frequency of diabetic ketoacidosis was significantly higher from April to September and in December (mean adjusted RRs, 1.48-1.96). During the first half of 2020, each increase in the regional weekly incidence of COVID-19 by 50 cases or 1 death per 100 000 population was associated with an increase in the RR of diabetic ketoacidosis of 1.40 (95% confidence interval, 1.10-1.77; P 5.006) and 1.23 (1.14-1.32; P <.001), respectively. This association was no longer evident during the second half of 2020. CONCLUSIONS: These findings suggest that the local severity of the pandemic rather than health policy measures appear to be the main reason for the increase in diabetic ketoacidosis and thus the delayed use of health care during the pandemic

The association between educational status and diabetes outcomes: results of the DIAS study in children with diabetes type 1 in Germany

Objective To evaluate the association between parents' educational status and diabetes outcomes in German children and adolescents and to compare educational status and individual socioeconomic status (SES). Methods The study included a total of 1781 patients < 18 years old with type 1 diabetes mellitus from 13 German diabetes centers. The analysis was based on data from the DIAS study collected from June 2013 until June 2014 in order to analyse the associations of SES and various diabetes outcomes. The DIAS study measured SES with a composite index based on parents' educational status, occupational status and household income and presented unfavourable outcomes for patients with a low SES. In a secondary analysis of the DIAS data, analyses have been run again with parents' educational status only in order to examine its applicability as a short indicator of SES. Data were collected within the multicenter DPV ( Diabetes Prospective Follow- up) registry. Multivariable regression models ( linear, logistic, negativ-binomial or Poisson- models depending on the distributional characteristics of the outcomes) were applied to analyze the associations of parents' educational status and diabetes outcomes, adjusted for age, sex, diabetes duration, and eventually migration background. Results Low educational status was significantly associated with higher hemoglobin A1C (HbA1c) compared to medium/high educational status (8,1 % compared to 7,8 %, p < 0,0001/ 7,6 %, p < 0,0001), and lower proportion of insulin pump therapy (42,7 % versus 56,3 %, p < 0,0001/52,5 %, p < 0,01). Patients with a background of low educational status also reported fewer daily self- monitored blood glucose (SMBG) measurements, higher Body-Mass-Index, and more inpatient days per year. Severe hypoglycemic events and ketoacidosis were not more frequent in patients with low educational status. The educational status measure was able to discriminate between the social groups as well as the complex SES measure. Conclusion Parents' low educational status is an important predictor for unfavorable outcomes in German children with type-1 diabetes. We should incorporate this aspect in targeted diabetes care and education. As a short and practicable indicator, parents' educational status can estimate the social status of the patients in routine collection of diabetes data

The association between socio-economic status and diabetes care and outcome in children with diabetes type 1 in Germany: The DIAS study (diabetes and social disparities)

Objective To evaluate the association between socioeconomic status (SES) and diabetes outcomes in German children and adolescents. Methods A total of 1829 subjects <18 years old with type 1 diabetes mellitus from 13 German diabetes centers were included from June 2013 until June 2014. Data were collected within the multicenter DPV (Diabetes Prospective Follow-up) registry. SES was measured with a composite index. Multivariable regression models were applied to analyze the association of SES and outcomes adjusted for age, sex, diabetes duration, and migration status. Results Low SES was significantly associated with worse diabetes outcomes: higher hemoglobin A1C (HbA1c) (64.3 mmol/mol), lower proportion of insulin pump therapy (43.6%), fewer daily self-monitored blood glucose (SMBG) measurements (5.7), more inpatient days per patient-year (5.8) compared to patients with medium/high SES (HbA1c: 61.3 mmol/mol, P < 0.001/59.8 mmol/mol, P < 0.0001; proportion of pump therapy: 54.5%, P < 0.01/ 54.9%, P < 0.01; SMBG: 6.0, P < 0.01/ 6.1, P < 0.01; inpatient days: 4.5, P < 0.0001/3.4, P < 0.0001). The inclusion of migration status in the models resulted in only minor changes in the outcomes. Conclusion Despite free health care, low SES is associated with unfavorable diabetes outcomes in Germany. The poorer diabetes outcomes of children with diabetes have been attributed to their migration status and may be partly explained by low SES. Both factors must become part of targeted diabetes care in children and adolescents with type 1 diabetes