181
European Journal of Endocrinology -18-0898 hypoglycemia withcoma(5.1 25.4 P 66.0 Results: and fornativechildrenthemostrecentyearofcare. regression adjustedforage,sexanddiabetesduration(SAS9.4).Inrefugeesthefirstyearafterarrivalwasstudied, patients (childandparentsborninGermany/Austria;G/A: (DZD), MunichNeuherberg,Germany, 1 Claudia Steigleder-Schweiger Jürgen Grulich-Henn Nicole Prinz data fromtheDPVregistry Germany andAustriabasedonreal-world Africa orMiddleEast:experiencesfrom Diabetes careinpediatricrefugeesfrom that shouldbeaddressedmore intensivelybypediatricdiabetesteams. clinics. Refugeechildren,parents andcaregiversarefacedwithseveralproblemsin diabetestherapyandoutcome Conclusions: 43.0%, 1vs3: compared tonatives.Insulinpumpswereusedinamarkedly largerproportionofnativepatients(7.4and13.2vs and retinopathy(2.1n/avs0.2%,13: were studiedanddividedbyrefugeestatusintopatientsborninMiddleEast( Design andMethods: To describethecurrentexperiencewithpediatricrefugeesinGermanyandAustria. Objective: Abstract *(N PrinzandKKonradcontributedequallytothiswork) Centre HospitalierdeLuxembourg,Luxembourg Paracelsus MedicalUniversitySalzburg,Austria,and Health, BielefeldUniversity,Bielefeld,Germany, Germany, Pediatrics, ProtestantHospitalBielefeldgGmbH,Bielefeld,Germany, Düsseldorf, Germany, Düsseldorf, Germany, Health Economics,GermanDiabetesCenter(DDZ),LeibnizInstituteforResearchatHeinrichHeineUniversityDüsseldorf, Pediatric andAdolescentMedicine,HospitalLeverkusengGmbH,Leverkusen,Germany, 6 4 Department ofPediatricsandAdolescentMedicine,ProtestantHospitalOberhausen, Oberhausen,Germany, Department ofPediatricandAdolescentMedicine,Elisabeth-HospitalEssen, Germany, Institute ofEpidemiologyandMedicalBiometry(ZIBMT),UniversityUlm,Germany, = 0.039 and2vs3: https://doi.org/ https://eje.bioscientifica.com Clinical Study ± ± 8.7 vs11.5 0.1 mmol/mol, 1vs3: Afteradjustment,HbA1cwashighestinrefugees(1.ME and2.AFRvs3.G/A:72.3 13 WithincreasingmigrationtoEurope,diabetesdiagnosisandtreatmentofrefugeesbecamechallenging. Department ofPediatrics,PediatricHospitalAmsterdamerStraße,Cologne,Germany, 10.1530/EJE Arelevantnumberofpediatricrefugeeswithtype1diabetes aretreatedinGerman/Austriandiabetes 1 , P 2 ,
*, Katja Konrad < 0.001 and2vs3: 9 ± Institute forHealthServicesResearchandEconomics, FacultyofMedicine, Heinrich HeineUniversity -18-0898 0.3 per100patientyears,1vs3: 43,137patients( P 10 = 0.002) wasmoreprevalent.Africanchildrenexperienced severehypoglycemia(17.8 , Norbert Jorch 10 1 Department ofPediatrics,UniversityHeidelberg,Germany, P © ±
3 < Department ofPediatricandAdolescent Medicine,UniversityofCologne, Germany, 2019EuropeanSociety ofEndocrinology 1.1 and4.1 15 3 0.001 and2vs3: , 4 others N Prinz,KKonradand , Michael Witsch , *, Christoph Brack P
< < 15 0.001). 21 years) withtype1diabetesfromthepatientfollow-upregistry(DPV) Department ofPediatrics,UniversityHospital 11 , Christian Kastendieck Printed inGreatBritain ± 1.6 vs2.6 P
< 0.001) weresignificantlymorecommoninchildrenfrom MiddleEast 16 P Department ofPediatricandAdolescentMedicine,
16 < and P 0.001) andmicroalbuminuria(9.913.6vs6.5%,1 3: 12 5
> , Eva Hahn ± Department ofPediatrics,ClinicBremen-Mitte,Bremen, 0.05 and2vs3: 0.1 per100patientyears,1vs3: Reinhard W Holl n = 42,597). Groupswerecomparedusingmultivariable Diabetes inpediatricrefugees Published byBioscientifica Ltd. 6 12 , Antje Herbst , Kirsten Mönkemöller 8 Institute forHealthServicesResearchand 2 German CenterforDiabetesResearch P = 0.045) significantlymoreoften,whereas 5 Pediatric Practice,Celle,Germany, 1 , 2 14 onbehalfoftheDPVInitiative School ofPublic n = 365) orAfrica( 7 , Andrea Icks 11 7 Downloaded fromBioscientifica.com at09/30/202107:10:00PM Department of Department of P ± = 0.006 and2vs3: 1.0 and75.0 13 , Oliver Razum (2019) Endocrinology European Journalof nicole.prinz@uni-ulm.de Email to NPrinz should be addressed Correspondence n 2 , = 175) andnative 8 , 9 181 , 181 :1 , 31–38 ±
1.4 vs ± 14 4.3 and P ,
31 > 0.05) –38 via freeaccess European Journal of Endocrinology https://eje.bioscientifica.com www.d-p-v.eu (DPV; ‘Diabetes-Patienten-Verlaufsdokumentation’, from thestandardized diabetes patientfollow-up Data werecollectedduring routinecareandretrieved Data collection Methods and outcome. patients inordertodescribecurrentdiabetestreatment the ME and Africa and to compare the results to native stay inGermany/Austriaamongpediatricrefugeesfrom study wastoinvestigatediabetescareinthefirstyear of and experience among pediatric refugees. The aim of this provide auniquesource to studycurrentdiabetespractice data interaction withrefugeesexist.Real-worldregistry health care, prejudice and uncertainty toward the social Despite lawsandagreementsregulatingtheaccessto an exceptionalsituationafterarrivalinthehostcountry. diseases suchastype1diabetesandtheirfamiliesarein in diabetestherapyandoutcomewerepresent( depending ontheregionoforigin,additionaldifferences those withoutmigration background ( diabetes patientswithTurkish backgroundcomparedto was reportedtoberoughlyhalfamongpediatrictype1 our previous DPV analyses, rate of insulin pump therapy migrant children to the care codified in the UNCRC ( found thatmostEuropeancountries(80%)donotentitle ( in thehostcountry equivalenttothoseofthelocalpopulation health services ( in theUNConventiononRightsofChild(UNCRC) diabetes care. leads forexampletolanguageproblemsandchallenges structure andtheincreasingculturaldiversitythat care systemsarefacedwiththechangingpopulation states. Diabeteshealthcareteamsandthenational of refugeesexistfromNorthAfrica,mainlytheMaghreb Syria, IraqandAfghanistan( diabetes is on the rise.Themajorityarestillcomingfrom refugees fromAfrica(AFR)ortheMiddleEast(ME)with medically. With increased migration, the number of are facedwithachallengepolitically, socially, andalso Central Europe,countriessuchasGermanyandAustria Due totheincreasingnumberofrefugeesinWestern and Introduction 2 ). It states that child refugees should have access to Clinical Study Refugee childrenwithnon-infectiouschronic The right to health care for refugee children is codified The righttohealthcareforrefugeechildreniscodified ), a German/Austrian/Luxembourgian and 2 ). Arecentpublicationhowever 1 ), althoughanotherflow others N Prinz,KKonradand 4 ). Inaddition, 5 ). 3 ). In
between January 1995andMarchbetween January 2018.Bothpatients in ouranalysis.Patients’medicaldataweredocumented 1.7%) orotherspecifictypesofdiabetes( type 1 diabetes ( We initiallyincluded45,400patients( Patients approved theanonymizeddatacollection. the institutionalreviewboardsofeachparticipatingclinic of UlmUniversityhasapprovedtheDPVinitiativeand contributed datatothisanalysis.TheEthicalCommittee taking careofpediatricrefugeesfromAfricaand/or the ME 182 Germandiabetescentersand11fromAustria data arereportedbacktothecentersforcorrection. for centralanalysis( care facilities,usingtheDPVsoftware,toUlm,Germany, are transmitted twice a year from participating health Swiss databaseforpeoplewithdiabetes.Anonymizeddata were mathematicallystandardized totheDCCTreference adjust fordifferencesamong laboratories,HbA1cdata Glycemic control was evaluated by HbA1c. In order to Metabolic control applied forrefugeechildren. children from Africa or the ME, the KiGGS data were also (KiGGS) ( forChildren and Adolescents Examination Survey and reference datafromtheGermanHealthInterview deviation scores(BMI-SDS)werecalculatedusingnational To adjustforageandsex,bodymass index standard Anthropometry Diabetes careprocessesandoutcomes data wereaggregated. year ofcare.Incasemultiplevisitsperpatientyear, wasstudied,fornativepatientsthemostrecent country refugees, thefirstyearofcareafterarrivalinhost child and both parents born in Germany or Austria. In refugees, respectively. Nativepatients were definedas and Tunisia (5.3%)contributedmorethan5%ofAfrican (9.0%), Libya (7.9%), Somalia (7.9%), Ethiopia(5.8%) were considered; Morocco (25.4%),Egypt(12.7%), Eritrea or Africawereclassifiedasrefugees.InAfrica,allcountries Children born in ME(Syria, Afghanistan, Iran and Iraq) ofbirthwasused. patients byrefugeestatus,country ofbirth.Toand parentsareaskedfortheircountry group Diabetes inpediatricrefugees 7 ). Astherearenoreliablereferencedatafor n
= 43,137; 95.0%), type 2 diabetes ( 5 , 6 Downloaded fromBioscientifica.com at09/30/202107:10:00PM ). Implausibleandinconsistent 181 :1 < n 1 years)with 21 49 3.3%) =1489; n 774; =774; 32 via freeaccess
European Journal of Endocrinology software package(version 9.4;SASInstituteInc.). Statistical analysiswasperformed usingtheSASstatistical Statistical analysis admissions per100patientyearswasstudied. and TG > Cut-off valueswereasfollows:totalcholesterol permanently decreasedhigh-density cholesterol. low-density cholesterol,triglycerides(TGs)or consecutive measurements)increasedtotalcholesterol, drugs orhadpermanently(definedbyatleasttwo was diagnosedifpatientsweretakinglipid-lowering the KiGGSreferencepopulation( elevated bloodpressureabovethe95thpercentile of defined as taking antihypertensive medication and/or the respectiveyearofstudy. Arterialhypertensionwas patients had at least one abnormal eye examination within (non-proliferative or proliferative) was diagnosed if year. Diabeticretinopathy urine samples)within1 urine tests(spoturine,overnightcollectionor24-h Microalbuminuria was defined as at least two positive Long-term diabetescomplications consciousness orseizure. sub-group ofseverehypoglycemiaassociatedwithloss from others.Hypoglycemiawithcomawasdefinedasa glucose, glucagonorothercorrectiveactionswithouthelp self-reported cognitiveimpairment,beingunabletotake care. Severe hypoglycemic episodes were defined as < Diabetic ketoacidosis was defined as blood pHvalue Acute diabetescomplications were studied. per kilogrambodyweightanddailynumberofSMBG points) orinsulinpumptherapy(CSII).Dailydose intensive insulintreatment(ICT; 4–8dailyinjectiontime insulin therapy(CT; 1–3dailyinjectiontimepoints), Insulin treatment regimen wasclassified asconventional Treatment modalities multiple ofthemean(MOM)method( range of20.77–42.62 7.3 oraclinicaldiagnosisassociatedwithinpatient mlL LDL 5.2 mmol/L, Clinical Study > 1.5 mmol/L. Moreover, numberofinpatient > mmol/mol (4.05–6.05%)usingthe mlL HDL 3.4 mmol/L, others N Prinz,KKonradand 6 8 ). ). Dyslipidemia < 0.9 mmol/L
considered statisticallysignificant. Austria, wasperformed.Atwo-sided abroad priortomigrationvsafterGermany/ information ontheplaceofdiabetesmanifestation,i.e. patients, asub-analysison437refugeeswithadditional manifestation ontreatmentregimenintype1diabetes To investigate the impact of the region of diabetes Kramer was used to adjust for multiple comparisons. number ofevents)wereapplied.ThemethodTukey– outcomes and negative binomial regression for for binary regression forcontinuousvariables,logistic duration, multivariableregressionanalyses(linear adjust forconfoundingeffectsofsex,ageanddiabetes variables were comparedby was used.Binary comparison ofcontinuousvariables,Kruskal–Wallis test range (IQR)oraspercentage. Forunadjustedgroup All measuresarepresentedasmedianwithinterquartile diabetes ( refugees studied.Sixout of 24patientshadMODY other specifictypesofdiabetes documentedforthe performed. evaluation ofdiabetescareprocessandoutcomewas n n East withtype2diabetes(AFR:0.9%, number of refugee children born in Africa or the Middle ( type 2 diabetes ( Although a relevant number of pediatric patients with of diabetes Data ontype2diabetesorotherspecifictypes the migrationtoGermanyorAustria. prior to diagnosed with diabetes in theirhome country information ontheplaceofdiabetesmanifestationwere n than halfofrefugeechildrenfromME(73.4%out Africa ( between 2014and2018,whereasmostrefugeesfrom refugee childrenfromtheME( background, heredefinedasrefugees.Themajorityof children (1.3%)withAfricanorMiddleEasternmigration Among thepediatricpatientsstudied,weidentified584 Results Diabetes inpediatricrefugees n
; E 1.3%, ME: =5; = =
= 338) orAfrica(56.7%outof 13) or other specific types of diabetes (AFR: 0.3%, 1489) hasbeen documented in the database, the n
= Table 1 137, 72.5%)immigratedpriorto2014.More al 1 Table n ).
= n 774) orother specific types of diabetes
= summarizesthevariouscausesof 19) waslow. Hence,nostatistical Downloaded fromBioscientifica.com at09/30/202107:10:00PM n 272, 67.3%) immigrated 67.3%) =272, https://eje.bioscientifica.com n 2) ih available with =120) 181 P value :1 n ; E 1.7%, ME: =7; < χ 2 0.05 was test.To 33 via freeaccess European Journal of Endocrinology https://eje.bioscientifica.com AFR, Africa;BMI-SDS,bodymassindex standarddeviationscore;ME,MiddleEast. comparisons usingthemethodofTukey–Kramer. *Adjusted mean ≥ 2 or3visitsperyear,% 1 visitperyear,% BMI-SDS Diabetes duration,years Age, years Girls, % false discoveryratealgorithm. median withinterquartilerangeoraspercentage,exceptfor BMI-SDS. Duetomultiplecomparisons, Table 2 and lowestvaluesinnativechildren. groups, withhighestHbA1clevelsinrefugeesfromAfrica duration. Glycemiccontroldifferedsignificantlyamong analyses withadjustmentsforage,sexanddiabetes 3 Table Metabolic controlanddiabetesoutcome native childrenandrefugees. and diabetesduration,BMI-SDSwassimilarbetween with Africanbackground.Afteradjustmentforage,sex shorter diabetesduration,withlowestvaluesinchildren refugees fromtheMEorAfricawereyoungerandhad G/A: 71.0vs70.373.6%).Comparedtonativechildren, diabetes careteamatleastfourtimesayear(MEvsAFR patients bothrefugeesandnativeshavebeenseenbythe in and theaveragenumberofvisitsperyeararesummarized type 1diabetes(AFR: Among therefugeechildrenstudied,539patientshad Data ontype1diabetes Not otherwisespecified Drug-induced diabetes Diabetes duetodiseasesofthe Mitochondrial diabetes Diabetes duetoothergeneticdiseases Diabetes indownsyndrome Diabetes inthalassemia MODY diabetes in refugeechildrenfromAfricaorMiddleEast. Table 1 4 visitsperyear,% Clinical Study exocrine pancreas al 2 Table summarizesresultsofmultivariableregression * Demographics ofpediatrictype1diabetespatients,stratified byrefugeestatus.Dataareexpressedasnon-adjusted Different causesofotherspecifictypesdiabetes , stratifiedbyrefugeestatus.Themajorityof ±
s . e . m . , basedonmultivariablelinearregression modelwithadjustment forage, sexand diabetesduration; n 7, ME: =175, 71.0 14.5 14.5 11.8 (8.2–15.3) 41.9 0.21 1.8 (0.4–6.0) 1. ME( ± 0.05 ( n others N Prinz,KKonradand = 365) n 6) Demographics =365). n = Africa ( 359 n = 5) 1 2 1 1 – – – – )
70.3 18.9 10.8 12.4 (8.5–15.8) 41.7 0.27 0.6 (0.3–3.6) East 2. AFR( Refugee status Middle ± 0.07 ( ( 1 2 3 2 2 4 5 – n = 19) n = 175) n = 171 children comparedtorefugeesfromeitherAfricaorthe markedly higher use of insulin pump therapy in native Treatment modalitiesdifferedbetweengroups,with Treatment regimen admissions washigherinrefugees( not differamonggroups.Overall,thenumberofhospital status. Frequenciesofdyslipidemiaandhypertensiondid more commoninchildrenwithMiddleEasternrefugee more oftencomparedtonatives,whereasretinopathywas microalbuminuria waspresentinrefugeessignificantly among groups. coma significantlymoreoften.DKAdidnotdiffer refugees fromtheMEexperiencedhypoglycemiawith common inrefugees with African background, whereas complications suchasseverehypoglycemiaweremore therapy was documented more frequently in children in contrasttorefugeesfromAfrica,whereinsulinpump and Africawasofminorclinicalrelevance( although thedifferencebetweenrefugeesfromME weight comparedtorefugeesfromAfricaornativepatients, from theMErequiredmoreinsulinperkilogrambody treatment modalityinrefugees( ME. Intensiveinsulintherapywasthemostcommon country priortomigration(12.0vs5.4%, country children whowerediagnosedwithdiabetesintheirhome was diagnosedinGermanyorAustriacomparedto status usedinsulinpumptherapymoreoftenifdiabetes diabetes duration,childrenwithMiddleEasternrefugee Although notsignificantafteradjustmentforage,sexand seemed tohaveanimpactontreatmentmodality. Diabetes inpediatricrefugees ) With regardtolong-termdiabetescomplications, Compared to native patients, acute diabetes Interestingly, theregion of diabetes manifestation 73.6 19.1 15.6 (12.0–17.5) 46.6 7.3 0.27 5.2 (2.3–8.9) 3. Native( ± 0.01 ( n = 42,597) n = 41,960 Downloaded fromBioscientifica.com at09/30/202107:10:00PM ) 0.006 1 vs2 P ns ns ns ns ns ns valueswereadjustedusing Fig. 1 P Table 3 valueadjustedformultiple 181 ). Refugeechildren < < < P 1 vs3 0.001 0.001 0.001 :1 value ns ns ns ns P ). .9. hs is This =0.09). Table 3 < < ). 2 vs3 0.001 0.001 ns ns ns ns ns 34 via freeaccess
European Journal of Endocrinology between refugees(ME/AFR)and nativechildren(G/A). duration. regression modelswithadjustments forsex,ageanddiabetes ME, MiddleEast.Adjustedproportions frommultivariable therapy; G/A,Germany/Austria; ICT,intensifiedinsulintherapy; subcutaneous insulininfusion;CT,conventional stratified byrefugeestatus.AFR,Africa;CSII,continuous Treatment regimeninpediatrictype1diabetespatients, Figure 1 ME: 76.6vs85.4%, Germany/Austria vsdiabetesdiagnosispriortomigration, the placeofdiabetesdiagnosis(diabetesin most commontreatmentinallgroups,independentfrom vs 5.3%, Austria, although statistical significance islacking(13.7 with diabetesdiagnosispriortomigrationGermany/ AFR, Africa;DKA,diabeticketoacidosis;ME,MiddleEast;pat.yrs.,patientyears;SMBG,self-monitoringofbloodglucose. used toadjustformultiplecomparisons. Adjusted meanswith Inpatient admissions, Retinopathy, % Microalbuminuria, % Dyslipidemia, % Hypertension, % DKA, per100pat.yrs. Hypoglycemia withcoma, Severe hypoglycemia, SMBG, perday Insulin dose,IU/kg*day HbA1c, % HbA1c, mmol/mol Table 3 Clinical Study per 100pat.yrs. per 100pat.yrs. per 100pat.yrs. ** Metabolic controlanddiabetescomplicationsinpediatrictype1patients,stratifiedbyrefugeestatus. P P
= < 0.001 and 0.18). Intensifiedinsulintherapywasthe s . e . m P .
frommultivariableregressionmodelswithadjustments forage,sexanddiabetes duration.ThemethodofTukey–Kramerwas
= 0.15; AFR:88.1vs78.5%, * P
< 0.992 0.01 forthecomparison 4.29 72.3 3.0 1. ME( 8.77 ± ± ± 77.0 17.8 ± 5.1 1.1 ( 0.12 ( 0.016 ( others N Prinz,KKonradand 1.0 ( 28.7 26.1 2.1 9.9 ± ± n ± ± = 365) 1.1 0.09 n 5.0 4.3 n n = = n = 346 = 361 323 358 ) ) ) ) 0.917 P 4.46 75.0 3.7 =0.22). 2. AFR( Refugee status 9.01 ± ± ± 79.1 25.4 ± 4.1 1.9 ( 0.18 ( 0.023 ( 1.4 ( 13.6 31.4 26.8 n/a ± ± n ± ± 1.6 0.13 = 175) n 7.4 8.7 n n = = n = unknown medical history andculturaldifferenceswereunknown medicalhistory children. In the Netherlands, frequentrelocations, may alsochallengeadequate diabetescareforrefugee and unawareness of national health system procedures limited transportandmobility tospecializedclinics other hand,languagebarriers,differenthealthbeliefs, limits refugees’accesstohealthcare( of caregiversonthe grant ofhealthcareservices system duetoinadequateaccesshealthcare( of patients. sensitive diabetescareinthisparticularvulnerablegroup may suggestsanincreasedneedforintensified,culture- This among refugeesfromAfricaortheMEwereobserved. in metaboliccontrol,diabetestreatmentandoutcome to nativetype1diabetespatients,significantdifferences on alargewell-establisheddiabetesregistry. Compared diabetes careafterarrivalinGermanyorAustria,andbased the MEdiagnosedwithdiabetes,describingfirstyearof This isthefirstreportonpediatricrefugeesfromAfricaor Discussion (8.6 vs8.4%, forrefugeesfromtheME no differencewasobserved was in Germany or Austria (7.6 vs 4.9%, documented slightlymorefrequentlyifdiabetesdiagnosis In African refugees, conventional insulin therapy was seekers in Germany ( previous articlesstillcriticizerestrictionsforasylum Diabetes inpediatricrefugees 160 = 174 156 172 ) ) Despite overallhighercostsforthehealthcare ) ) 0.865 4.88 66.0 2.0 3. Native( P ± ± ± ± 8.19 =0.96). 0.1 ( 0.01 ( 0.001 ( 53.1 11.5 0.1 ( 2.6 25.3 30.6 0.2 6.5 ± ± n n ± ± n 0.1 0.01 = 42,597) n = 0.4 0.3 = n = 10 41,554 = 41,826 38,876 , Downloaded fromBioscientifica.com at09/30/202107:10:00PM 41,837 11 , ) ) ) 12 ) ). Insufficient knowledge https://eje.bioscientifica.com 1 vs2 0.02 n/a ns ns ns ns ns ns ns ns ns 181 :1 P < < < < < .2, whereas =0.52), 1 vs3 P 0.001 0.001 0.039 0.006 0.001 0.001 0.001 value ns ns ns ns 12 ). Onthe < < 0.002 0.045 2 vs3 0.001 0.001 n/a ns ns ns ns ns ns 35 9 via freeaccess ), ),
European Journal of Endocrinology https://eje.bioscientifica.com A worse metabolic control prior to migration and an refugees fromAfricaorME compared tonativechildren. or diabeticretinopathythat weremoreprevalentin long-term complications such asmicroalbuminuria in newlyarrivedrefugees. CSII initiationorotherlong-standingtherapydecisions granting therightofasylummayfurthercomplicate regimen mayplayarole.The uncertain procedurefor whether the patient will manage a complex diabetes offers ( techniques orinsufficientknowledgeabouthealthcare and apotentiallylowerrateofacceptancenew be differenttherapeuticconceptsinthehomecountry diabetes education.Other possible contributors could and thecomplexitynecessityofintensive be duetothehighcosts,lackofhealthcareinsurance Europe or Eastern Europe ( us forothermigrantgroupsfromTurkey, Southern children fromAfricaortheME.Ashypothesizedby diabetes technologysuchasinsulinpumpsinrefugee our study, amarkedlyloweruseofmodern weobserved ( among childrenandadolescentswithtype1diabetes differences inHbA1c( blood cell turnover are also speculated to explain ethnic non-glycemic hemoglobin-relatedfactorssuchasred and whites ( explains HbA1cdifferencesbetweenAfricanAmericans differences intheglycationofhemoglobinpartially from that,asreportedbyBergenstal diabetes careforthepatientandcaregiver. Apart refugees andthehostpopulationfurtherchallenge ( compared tothenativepopulationaspotentialreasons and anoverallloweradherencetotreatmentregimen ( between migrationandpoorhealthcareoutcomes number ofstudiespreviouslyreportedanassociation in our study.to native children, as observed A large type 1diabetesrefugeesfromAfricaorME,compared hypoglycemia orwithcomainpediatric the worsediabetescontrolandhigherratesofsevere have beenreported( care settingamong Somali patientsina US primary literacy andsuboptimaldiabetesdiseasecontrol for deliveringhealthcare( reported bypediatriciansasthemostfrequentbarriers 5 5 20 Clinical Study , , 6 ). DataonCSIIuseinAfricaortheMEarelacking.In 17 Besides acute diabetes complications, we also observed Besides acutediabetescomplications,wealsoobserved In developedcountries,CSIIisfrequentlyused , 15 ). Life style and eating habits often differ between 4 , , 5 16 ). Moreover, clinicians’individualassessment ) andmentioneddifferentself-carebehavior 18 ). Although clear evidence is lacking, 14 19 ). Altogether, maycontributeto ). 13 4 , ). Recently, lowdiabetes 5 others N Prinz,KKonradand ), the lower use might t al. et , ‘racial’
that mightexplaindisparitiesamongrefugeesandthe level variablessuchasmentalillnessesordiabetesdistress diabetes. Additional,potentiallyimportantindividual- access tospecializeddiabetesclinicsorundiagnosed with diabetesmightbemissedduetolimited/unknown in mind.Aconsiderablenumberofpediatricrefugees refugees. Nevertheless,someweaknessesshouldbekept adapted tothecurrentsituationofdiabetescarein diabetes-specific parametersthatarenotspecifically comprisespre-defineddemographicandclinical registry from astandardizeddiabetespatientregistry. The from AfricaandtheME,availabilityofdata number ofpediatricdiabetescasesamongrefugees retinopathy andnephropathy( between populationsandinfluencesusceptibilitytoboth, evidence ofavarietypolymorphismsthatdiffer possible explanations.Apartfromthat,thereisincreasing might be inadequate diabetes care in the home country The authors declare that there is no conflict of interest that could be could that interest of conflict perceived asprejudicingtheimpartiality ofthisstudy. no is there that declare authors The Declaration ofinterest the future. diabetes controlandtopreventcomplications in particularly vulnerablepopulationinordertoimprove the healthcaresystemandclinicalpracticetotargetthis study maysuggesttheneedforadditionaladaptations in diabetes teams are faced with several challenges. The suboptimal. Pediatricrefugees,theirparentsandpediatric diabetes careandoutcomeofthesechildreniscurrently specialized diabetesclinics.Comparedtonativepatients, with type1diabetesaretreatedinGerman/Austrian number ofpediatricrefugeesfromAfricaandtheME our findings. of forexamplehypoglycemiceventsmightbias group. Lastly, underestimation due to under-reporting situation we are not able to differentiate this particular management ( that cannotprovideadequatesupportforthediabetes unaccompanied childrenoften live innursinghomes diabetes patients in the Netherlands ( from Turkey orMoroccocomparedtonativetype1 distress werereportedtobehigherinethnicminorities adolescents ( illnesses (13.7%)amongunaccompaniedasylum-seeking German pilotstudyfoundahighprevalenceofmental host populationwerenotavailable.Across-sectional Diabetes inpediatricrefugees Major strengthsofourstudyaretherelativelylarge In summary, ourreportindicatesthatarelevant 22 24 ). Depressivesymptomsanddiabetes ). As our datadonot include the family Downloaded fromBioscientifica.com at09/30/202107:10:00PM 21 ). 181 23 :1 ). Furthermore, 36 via freeaccess
European Journal of Endocrinology References for contributinganonymizeddatatothepresentstudy. centers DPV participating all to gratitude our express authors the Finally, DPV data managementsupport (all clinical data managers,University of Ulm). for Bollow E and Fink K and support, software documentation DPV for statisticalanalyses.Theauthorsalsothank A Hungele and R Ranzfor Special thankstoDrSLanzinger,MScEpidemiology,UniversityofUlm Acknowledgments to bepublished. as such has full access to the data. All authors approved the final version the manuscript and is the principal investigator of the DPV initiative and conceptualized the study, contributed to discussion, reviewed and edited data, contributed to discussion, reviewed and edited manuscript; R W H B, EH,AI,JG-H,NJ,CK,KM,OR,S-SandMWresearched contribution toconceptionanddesigninterpretationofdata;C N PandKwrotethemanuscript,editedsubstantial Author contributionstatement report forpublication. and interpretation ofdata;writing the reportordecision to submit the sponsor was not involved in the design of the study; the collection, analysis and ‘The Leona M. and Harry B.Helmsley Charitable Trust’. The study Union’s Horizon2020 and innovation program and‘EFPIA’,‘JDRF’ research Undertaking (INNODIA; grant number: 115797) supported by the European Diabetes Association(DDG)andtheInnovative Medicines Initiative 2 Joint the European Foundation for the Study of Diabetes (EFSD); the German Education of grant number: 82DZD0017G); the German RobertKoch Institute (RKI); Ministry Federal the by and Research within the German CenterforDiabetesResearch(DZD; supported is initiative DPV The Funding 6 5 4 3 2 1 Clinical Study Rosenbauer J, Dost A,Karges B,Hungele A, Stahl A,Bächle C, Scheuing N, Wiegand S, Bächle C,Fröhlich-Reiterer E,Hahn E, Icks A, Razum O, Rosenbauer J, Bächle C, Hungele A, Mönkemöller K, Hjern A, Østergaard LS,Norredam M,deLuna CM&Goldfeld S. Williams B, Cassar C,Siggers G&Taylor S. Medicalandsocial issues European Commission.Eurostat.Wheredoasylumapplicantscome dc11-0993) and Austria. a trendanalysisusingprospectivemulticenter datafromGermany metabolic controlinchildrenandadolescents withtype1diabetes: Gerstl EM, Kastendieck C,Hofer SE, Holl RW pone.0135178) PLoS ONE outcome in27,643childrenandadolescentsfromtheDPVRegistry. ofbirthontype-1-diabetestherapyand Impact ofmaternalcountry Icks A, Ludwig KH,Mönkemoller K,Razum O,Rosenbauer J 14 21,497 patientsinGermany. adolescents ofTurkish background withtype1diabetes:analysisof Lower frequencyofinsulinpumptreatmentinchildrenand Müller-Godeffroy E, Heidtmann B,Kapellen T, Scheuing N 2017 Health policiesformigrantchildreninEuropeandAustralia. 839–842. of childrefugeesinEurope. asylum_applicants_come_from.3F explained/index.php from? 2018.(availableat: 1105–1109. 389 249. 2015 (https://doi.org/10.1136/archdischild-2016-310657) Diabetes Care (https://doi.org/10.1016/S0140-6736(17)30084-3 (https://doi.org/10.1089/dia.2012.0138) 10 e0135178. ?title=Asylum_quarterly_report#Where_do_ 2012 www.ec.europa.eu/eurostat/statistics- Archives ofDiseaseinChildhood Diabetes Technology &Therapeutics (https://doi.org/10.1371/journal. 35 ). Accessedon03July2018. 80–86. others N Prinz,KKonradand (https://doi.org/10.2337/ et al. Improved 2016 et al. et al. Lancet 2012
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