Use of Continuous Glucose Monitoring in Pump Therapy Sensor Augmented Pump or Automated Insulin Delivery in Different Age Groups (0.5 to <26 Years) With Type 1 Diabetes From 2018 to 2021: Analysis of the German/Austrian/Swiss/Luxemburg DPV Registry.

AIM: Insulin pump, continuous glucose monitoring (CGM), and sensor augmented pump (SAP) technology have evolved continuously leading to the development of automated insulin delivery (AID) systems. Evaluation of the use of diabetes technologies in people with T1D from January 2018 to December 2021. METHODS: A patient registry (Diabetes Prospective Follow-up Database [DPV]) was analyzed for use of SAP (insulin pump + CGM ≥90 days, no automated dose adjustment) and AID (HCL or LGS/PLGS). In total 46,043 people with T1D aged 0.5 to <26 years treated in 416 diabetes centers (Germany, Austria, Luxemburg, and Switzerland) were included and stratified into 4 groups A-D according to age. Additionally, TiR and HbA1c were analyzed. RESULTS: From 2018 to 2021, there was a significant increase from 28.7% to 32.9% (sensor augmented pump [SAP]) and 3.5% to 16.6% (AID) across all age groups, with the most frequent use in group A (<7 years, 38.8%-40.2% and 10.3%-28.5%). A similar increase in SAP and AID use was observed in groups B (7 to <11 years) and C (11 to <16 years): B: +15.8 PP, C: +15.9 PP. HbA1c improved significantly in groups C and D (16 to <26 years) (both P < .01). Time in range (TiR) increased in all groups (A: +3 PP; B: +5 PP; C: +5 PP; D: +5 PP; P < 0.01 for each group). Insulin pumps (61.0% versus 53.4% male) and SAP (33.5% versus 28.9% male) are used more frequently in females. CONCLUSION: In recent years, we found an increasing use of new diabetes technologies and an improvement in metabolic control (TiR) across all age groups.

Association of the use of diabetes technology with HbA1c and BMI-SDS in an international cohort of children and adolescents with type 1 diabetes: The SWEET project experience.

OBJECTIVE: To examine the association between the use of diabetes technology (insulin pump [CSII], glucose sensor [CGM] or both) and metabolic control (HbA1c) as well as body adiposity (BMI-SDS) over-time in a cohort of children and adolescents with type 1 diabetes (T1D), that have never used these technologies before. SUBJECTS AND METHODS: Four thousand six hundred forty three T1D patients (2-18 years, T1D ≥1 year, without celiac disease, no CSII and/or CGM before 2016) participating in the SWEET prospective multicenter diabetes registry, were enrolled. Data were collected at two points (2016; 2019). Metabolic control was assessed by glycated hemoglobin (HbA1c) and body adiposity by BMI-SDS (WHO). Patients were categorized by treatment modality (multiple daily injections [MDI] or CSII) and the use or not of CGM. Linear regression models, adjusted for age, gender, duration of diabetes and region, were applied to assess differences in HbA1c and BMI-SDS among patient groups. RESULTS: The proportion of patients using MDI with CGM and CSII with CGM significantly increased from 2016 to 2019 (7.2%-25.7%, 7.8%-27.8% respectively; p < 0.001). Linear regression models showed a significantly lower HbA1c in groups that switched from MDI to CSII with or without CGM (p < 0.001), but a higher BMI-SDS (from MDI without CGM to CSII with CGM p < 0.05; from MDI without CGM to CSII without CGM p < 0.01). CONCLUSIONS: Switching from MDI to CSII is significantly associated with improvement in glycemic control but increased BMI-SDS over-time. Diabetes technology may improve glucose control in youths with T1D although further strategies to prevent excess fat accumulation are needed.

Diabetes care in pediatric refugees from Africa or Middle East: experiences from Germany and Austria based on real-world data from the DPV registry.

OBJECTIVE: With increasing migration to Europe, diabetes diagnosis and treatment of refugees became challenging. To describe the current experience with pediatric refugees in Germany and Austria. DESIGN AND METHODS: 43,137 patients (<21 years) with type 1 diabetes from the diabetes patient follow-up registry (DPV) were studied and divided by refugee status into patients born in Middle East (n = 365) or Africa (n = 175) and native patients (child and parents born in Germany/Austria; G/A: n = 42,597). Groups were compared using multivariable regression adjusted for age, sex and diabetes duration (SAS 9.4). In refugees the first year after arrival was studied, and for native children the most recent year of care. RESULTS: After adjustment, HbA1c was highest in refugees (1. ME and 2. AFR vs 3. G/A: 72.3 ± 1.0 and 75.0 ± 1.4 vs 66.0 ± 0.1 mmol/mol, 1 vs 3: P < 0.001 and 2 vs 3: P < 0.001) and microalbuminuria (9.9 and 13.6 vs 6.5%, 1 vs 3: P = 0.039 and 2 vs 3: P = 0.002) was more prevalent. African children experienced severe hypoglycemia (17.8 ± 4.3 and 25.4 ± 8.7 vs 11.5 ± 0.3 per 100 patient years, 1 vs 3: P > 0.05 and 2 vs 3: P = 0.045) significantly more often, whereas hypoglycemia with coma (5.1 ± 1.1 and 4.1 ± 1.6 vs 2.6 ± 0.1 per 100 patient years, 1 vs 3: P = 0.006 and 2 vs 3: P > 0.05) and retinopathy (2.1 and n/a vs 0.2%, 1 vs 3: P < 0.001) were significantly more common in children from Middle East compared to natives. Insulin pumps were used in a markedly larger proportion of native patients (7.4 and 13.2 vs 43.0%, 1 vs 3: P < 0.001 and 2 vs 3: P < 0.001). CONCLUSIONS: A relevant number of pediatric refugees with type 1 diabetes are treated in German/Austrian diabetes clinics. Refugee children, parents and caregivers are faced with several problems in diabetes therapy and outcome that should be addressed more intensively by pediatric diabetes teams.

[Psychodynamic-multisystemic Therapy of School Phobia due to Separation Anxiety in Day Clinic]. / Psychodynamisch-multisystemische Behandlung von Schulphobie mit Trennungsangst im tagesklinischen Setting.

Psychodynamic understanding and systemic approach in the multi-family treatment of a day care clinic are illustrated following the case report of a seven-year old girl with school phobia due to separation anxiety. The treatment modalities of the day clinic at the University Medical Center Muenster are described focussing on the multi-systemic approach. Using psychodynamic and systemic hypotheses the process of treatment is developed. Specific interventions, differentiated into reorganizations of inner and outer world issues, are traced to psychodynamic and systemic hypotheses. In conclusion it is argued that the integration of psychodynamic and multisystemic therapy methods in day clinic parent-child treatment provide a promising treatment approach.

Impact of Physical Activity on Glycemic Control and Prevalence of Cardiovascular Risk Factors in Adults With Type 1 Diabetes: A Cross-sectional Multicenter Study of 18,028 Patients.

OBJECTIVE: Physical activity (PA) can improve cardiovascular risk in the general population and in patients with type 2 diabetes. Studies also indicate an HbA(1c)-lowering effect in patients with type 2 diabetes. Since reports in patients with type 1 diabetes are scarce, this analysis aimed to investigate whether there is an association between PA and glycemic control or cardiovascular risk in subjects with type 1 diabetes. RESEARCH DESIGN AND METHODS: A total of 18,028 adults (≥18 to <80 years of age) from Germany and Austria with type 1 diabetes from the Diabetes-Patienten-Verlaufsdokumentation (DPV) database were included. Patients were stratified according to their self-reported frequency of PA (PA0, inactive; PA1, one to two times per week; PA2, more than two times per week). Multivariable regression models were applied for glycemic control, diabetes-related comorbidities, and cardiovascular risk factors. Data were adjusted for sex, age, and diabetes duration. P values for trend were given. SAS 9.4 was used for statistical analysis. RESULTS: An inverse association between PA and HbA(1c), diabetic ketoacidosis, BMI, dyslipidemia (all P < 0.0001), and hypertension (P = 0.0150), as well as between PA and retinopathy or microalbuminuria (both P < 0.0001), was present. Severe hypoglycemia (assistance required) did not differ in PA groups (P = 0.8989), whereas severe hypoglycemia with coma was inversely associated with PA (P < 0.0001). CONCLUSIONS: PA seemed to be beneficial with respect to glycemic control, diabetes-related comorbidities, and cardiovascular risk factors without an increase of adverse events. Hence, our data underscore the recommendation for subjects with type 1 diabetes to perform regular PA.

Direction of associations between added sugar intake in early childhood and body mass index at age 7 years may depend on intake levels.

Dietary factors, especially during early childhood, have been discussed as potentially critical for the development of childhood overweight. This study evaluated associations between added sugar intake during early childhood and BMI and body fat at age 7 y. Analysis was based on data from 216 participants of the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study. Life-course plots were constructed to evaluate the association between added sugar intake at different ages (0.5, 1, 1.5, and 2 y) and BMI SD score (BMI-SDS) and % body fat (%BF) at age 7 y. Multivariable analyses were performed for the periods identified as critical for later BMI and body fat. Added sugar intake at age 1 y and the change in intake levels during the second year of life emerged as potentially critical. At age 1 y, a higher total added sugar intake was related to a lower BMI-SDS at age 7 y [adjusted ß ± SE: -0.116 ± 0.057 BMI-SDS/percent energy (%En) added sugar; P = 0.04]. Conversely, an increase in total added sugar in the second year of life (Δ%En between age 1 and 2 y) tended to be associated with a higher BMI-SDS (adjusted ß ± SE: 0.074 ± 0.043 BMI-SDS/Δ%En added sugar; P = 0.09). No associations were observed with %BF. In conclusion, added sugar intake at low intake levels during early childhood does not appear to be critical for BMI and body fat at age 7 y. However, detrimental effects on BMI development may emerge when added sugar intakes are increased to higher levels.

Initial insulin therapy in children and adolescents with type 1 diabetes mellitus.

OBJECTIVE: The aim of the study was to define parameters that influence the initial insulin dosage in young subjects with type 1 diabetes regarding the amount of daily insulin, the ratios of basal and prandial insulin, and the insulin/carbohydrate ratios. STUDY DESIGN: We used a computer-based registry (with prospectively collected data) in Germany and Austria, a software for the management and data documentation of diabetic patients (DPV), to analyze the initial insulin therapy in 2247 children with newly diagnosed type 1 diabetes to identify factors that influence diabetes therapy within the first 10 d. RESULTS: For both genders, glucosylated hemoglobin A1c (HbA1c), blood pH at diabetes onset, and pubertal status are the major factors determining the initial insulin dosage calculated as the amount of daily insulin per kilogram body weight (kg), the basal and prandial insulin dose per kilogram, and day and the insulin/carbohydrate ratios for meals. The frequency of hypoglycemia correlated with increasing quotient of applied to calculated insulin dosage. CONCLUSION: The predictive factors of insulin requirement may exert beneficial effects on the assessment and adjustment of insulin therapy in young diabetic subjects at disease onset. On the basis of a multiple, linear regression, we suggest a formula to calculate the initial insulin therapy.

Screening frequency for celiac disease and autoimmune thyroiditis in children and adolescents with type 1 diabetes mellitus--data from a German/Austrian multicentre survey.

OBJECTIVE: Type 1 diabetes mellitus (T1DM) is associated with other autoimmune diseases such as celiac disease (CD) and Hashimoto thyroiditis. The aim of this study was to evaluate the screening frequency for CD and thyroid antibodies in a multicentre survey. METHODS: The Diabetes Patienten Verlaufsdokumentationssystem (DPV) initiative is based on standardized, prospective, multicentre documentation in children and adolescents with diabetes. Data from 31,104 patients <18 yr of age (52% males, mean age 13.1 yr) with T1DM from 177 paediatric centres in Germany and Austria from 1995 until 2007 were analysed. RESULTS: Of 31,104 patients, 16,994 patients (55%) were screened at least once for CD. In 1995, 44% of the patients were screened for CD compared with 68.6% in 2006. Annual screening for CD has also increased (11.9% in 1995 compared with 43.6% in 2006). Eleven per cent of the patients had positive antibodies for CD. Patients with positive antibodies were significantly younger at diabetes onset and had a significantly longer duration of diabetes (p < 0.001). Compared with screening for CD, screening for thyroid antibodies was performed more frequently (at least once in 62% of the patients). Fifteen per cent of the patients had positive thyroid antibodies. Screening for thyroid antibodies also increased from 62.6 to 72.9%, and annual screening frequency increased from 15.9 to 48.9%. CONCLUSION: Screening for associated autoimmune diseases in children with T1DM has increased during the past decade. Eleven per cent of the patients had positive CD-specific antibodies, and 15% had positive thyroid antibodies. Screening for thyroid antibodies is performed more frequently than screening for CD.

Use of complementary and alternative medicine in children with type 1 diabetes mellitus - prevalence, patterns of use, and costs.

BACKGROUND: Complementary and alternative medicine (CAM) is increasingly used in adults and children. Studies on CAM in diabetes have mainly focused on the adult population and its use among children with type 1 diabetes has not been well characterized. OBJECTIVES: This study determines prevalence, parental reasons and motivations, perceived effectiveness, costs, and communication of CAM use. Moreover, caregiver-related variables associated with the use of CAM were investigated. METHODS: A self-completed anonymous questionnaire was administered to parents of children with type 1 diabetes in four pediatric diabetes centers in Germany (Leipzig, Berlin, Stuttgart, and Bonn). RESULTS: Two hundred and twenty eight (65.9%) of 346 families completed the survey. Mean age of the diabetic patients was 11.9 +/- 3.8 yr. Forty two (18.4%) received one or more types of CAM, with the most common types being homeopathy (14.5%), vitamins and minerals (13.7%), modified diet (12.9%), aloe vera (7.3%), and cinnamon (5.6%). Users had a significantly higher family income and parental tertiary education (p < 0.05) and stated a significantly stronger interest in self-care (p < 0.01). Parents' motivations for using CAM were the hope for an improved well-being (92.1%), to try everything (77.8%), and assumption of fewer side effects (55.2%). Costs for the entire treatment varied between less than euro100 and up to euro5000, with mostly no reimbursement. CONCLUSIONS: Use of CAM in children with type 1 diabetes is less common than that documented for adults. Parents using CAM do not question the need for insulin. When using CAM, improved well-being and quality of life are important considerations where CAM can have a role.

Diabetic nephropathy in 27,805 children, adolescents, and adults with type 1 diabetes: effect of diabetes duration, A1C, hypertension, dyslipidemia, diabetes onset, and sex.

OBJECTIVE: To give an up-to-date profile of nephropathy and the involvement of risk factors in a large, prospective cohort of patients with type 1 diabetes and largely pediatric and adolescent onset of disease. RESEARCH DESIGN AND METHODS: A total of 27,805 patients from the nationwide, prospective German Diabetes Documentation System survey were included in the present analysis. Inclusion criteria were at least two documented urine analyses with identical classification. Urine analyses, treatment regimens, diabetes complications, and risk factors were recorded prospectively. Baseline characteristics were age at diagnosis 9.94 years (median [interquartile range 5.8-14.3]), age at last visit 16.34 years (12.5-22.2), and follow-up time 2.5 years (0.43-5.3). Cumulative incidence of nephropathy was tested by Kaplan-Meier analysis and association with risk factors by logistic regression. RESULTS: Nephropathy was classified as normal in 26,605, microalbuminuric in 919, macroalbuminuric in 78, and end-stage renal disease (ESRD) in 203 patients. After calculated diabetes duration of 40 years, 25.4% (95% CI 22.3-28.3) had microalbuminuria and 9.4% (8.3-11.4) had macroalbuminuria or ESRD. Risk factors for microalbuminuria were diabetes duration (odds ratio 1.033, P < 0.0001), A1C (1.13, P < 0.0001), LDL cholesterol (1.003, P < 0.0074), and blood pressure (1.008, P < 0.0074), while childhood diabetes onset (1.011, P < 0.0001) was protective. Male sex was associated with the development of macroalbuminuria. CONCLUSIONS: Diabetes duration, A1C, dyslipidemia, blood pressure, and male sex were identified as risk factors for nephropathy. Therefore, besides the best possible metabolic control, early diagnosis and prompt treatment of dyslipidemia and hypertension is mandatory in patients with type 1 diabetes.

Congenital hypothyroidism caused by new mutations in the thyroid oxidase 2 (THOX2) gene.

OBJECTIVE: Congenital primary hypothyroidism (CH) occurs in one of 4000 births and in 20% of the cases CH is due to a defect in thyroid hormonogenesis. Candidate genes were examined to determine the precise aetiology of suspected dyshormonogenesis in CH. DESIGN: The genes that code for thyroid peroxidase (TPO), pendrin (PDS), sodium iodide symporter (NIS) and thyroid oxidase 2 (THOX2) were sequenced directly from genomic DNA. PATIENTS: Two girls found to have CH in the neonatal screening programme and suspected of having thyroid dyshormonogenesis were investigated to identify their molecular defect. RESULTS: Patient A had a novel heterozygous 1 bp insertion in the THOX2 gene (ins602g). This insertion results in a frameshift that predicts a premature stop at codon 300. Analysis of cDNA, transcribed from lymphocyte RNA, showed that this mutation causes skipping of exon 5, resulting in a frameshift and a premature stop at codon 254. The euthyroid mother was also a heterozygous carrier of the mutation whereas the father was homozygous for the wild-type THOX2 gene. In patient B, compound heterozygous mutations (ins602g-->fsX300 and D506N) were identified. D506N was present in one allele of the clinically unaffected mother and in a brother, whereas the euthyroid father was heterozygous for ins602g. Sixty normal individuals did not harbour the mutations. Sequencing of the TPO, PDS and NIS genes revealed no mutations. CONCLUSIONS: The identified THOX2 mutations, which have not been described previously, are the probable causes of CH in the patients. Mutations in the THOX2 gene should be considered as the molecular cause of CH in young patients with thyroid dyshormonogenesis.

Effects of regular physical activity on control of glycemia in pediatric patients with type 1 diabetes mellitus.

OBJECTIVE: To evaluate the effect of regular physical activity (RPA) on the control of glycemia (glycosylated hemoglobin A(1c) level) and the frequency of severe hypoglycemia in a large cohort of patients with type 1 diabetes mellitus. DESIGN: Cross-sectional analysis of data for 19 143 patients, comparing control of glycemia and rate of hypoglycemia by frequency of RPA. SETTING: One hundred seventy-nine pediatric diabetes clinics in Germany and Austria. PARTICIPANTS: Patients aged 3 to 20 years with type 1 diabetes mellitus. Main Exposure Patients were grouped by the frequency of RPA per week as follows: RPA0, none; RPA1, 1 or 2 times per week; and RPA2, 3 or more times per week. MAIN OUTCOME MEASURES: Glycosylated hemoglobin A(1c) level, body mass index (calculated as weight in kilograms divided by the square of height in meters) z score, and frequency of severe hypoglycemia. RESULTS: Glycosylated hemoglobin A(1c) level was higher in the groups with less frequent RPA (8.4% in group RPA0 vs 8.1% in group RPA2; P<.001). This effect was found in both sexes and in all age groups (P<.001). In female patients but not in male patients, the body mass index z score decreased from 0.60 in group RPA0 to 0.51 in group RPA2 (P<.001). Multiple regression analysis revealed that RPA was one of the most important factors influencing the glycosylated hemoglobin level. No association was noted between frequency of RPA and frequency of severe hypoglycemia or hypoglycemia with loss of consciousness or seizure. CONCLUSIONS: In pediatric patients with type 1 diabetes mellitus, frequency of RPA is a major factor influencing the control of glycemia without increasing the risk for severe hypoglycemia. Regular physical activity should be recommended in pediatric patients with type 1 diabetes mellitus.

Rate of hypoglycaemia and insulin dosage in children during the initial therapy of type 1 diabetes mellitus.

UNLABELLED: Hypoglycaemia is a major side-effect of insulin treatment. It is known that young children with type 1 diabetes mellitus (T1DM) show a higher risk of hypoglycaemia than older children. This study was performed to analyse the incidence of hypoglycaemia within the first 14 days (day 1-day 14) of insulin treatment in children at the onset of T1DM and to evaluate the influence of age and insulin dosage. The Paediatric Quality Initiative (DPV), including data from 121 centres in Germany and Austria, provided anonymous data of 1,680 patients (age 0.7-18.8 years; 799 girls) at the onset of T1DM. Hypoglycaemia was defined as a blood glucose level (BG) <2.8 mmol/l (50 mg/dl). The hypoglycaemia rate rose continuously from day 2 (4.8%) to day 5 (11.2%) and then remained stable between 8.7%-11.2% until day 14. The hypoglycaemia rate was higher in younger than in older children (P <0.0001). Multiple regression analysis revealed an influence of age (P <0.0001), insulin dosage (P = 0.0034), and route of initial treatment (P = 0.0052) on the hypoglycaemia rate. From day 2 to day 14, the insulin dosage itself was higher in females than in males (P = 0.0147), in patients with high HbA1c (P = 0.0001), high BG (P <0.0001), or low pH (P <0.0001). There was no influence of age on the insulin dosage. CONCLUSION: During the first 14 days after onset of type 1 diabetes mellitus, young children, intravenous-treated patients and patients receiving a high insulin dosage are at particular risk of developing hypoglycaemia. In order to avoid hypoglycaemia, blood glucose should be measured frequently and the insulin dosage should be carefully adjusted. Low blood glucose levels should be treated promptly.