[Course of the COVID-19 pandemic in pediatric rheumatological patients in Germany during the first 3 years (2020-2022)]. / Verlauf der COVID-19-Pandemie bei pädiatrisch-rheumatologischen Patienten in Deutschland über die ersten 3 Jahre (2020 bis 2022).

Coronavirus disease 2019 (COVID-19) has influenced the world over the last 3 years. Although the risk of a severe course is low in children, it can be influenced by chronic rheumatic diseases or treatment with immunosuppressive drugs or immunomodulatory medication. The German register for biologics in pediatric rheumatology (BIKER) documented systematic data from 68 centers on the occurrence, presentation and outcome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in children with rheumatic diseases. Between March 2020 and December 2022, a total of 927 SARS-CoV­2 infections in 884 patients could be reported and analyzed in pediatric patients with rheumatic diseases. Juvenile idiopathic arthritis (JIA) was the most frequent diagnosis (716 infections) followed by genetic autoinflammation (103 infections), systemic autoimmune diseases (78 infections), idiopathic uveitis (25 infections) and vasculitis (5 infections). Only four patients were treated as inpatients. A 3.5-year-old female patient died during the first wave from encephalopathy and respiratory failure. The patient was treated with methotrexate (MTX) and steroids for systemic JIA. Genetic tests revealed a previously unknown congenital immune defect. No other patient had to be ventilated or treated on the intensive care unit. A case of uncomplicated pediatric inflammatory multisystem syndrome (PIMS) was registered in a patient with JIA treated with MTX. At the time of the infection over 60% of the patients were treated with standard disease modifying antirheumatic drugs (DMARD) and/or biologics. Although the patients treated with MTX showed a slightly longer duration of symptoms, the antirheumatic treatment did not appear to have a negative influence on the severity or outcome of the SARS-CoV­2 infection.

Update of evidence- and consensus-based guidelines for the treatment of juvenile idiopathic arthritis (JIA) by the German Society of Pediatric and Juvenile Rheumatic Diseases (GKJR): New perspectives on interdisciplinary care.

BACKGROUND: New therapeutic strategies for juvenile idiopathic arthritis (JIA) have evolved within the past ten years, and as a result, an update of the 2011 recommendations of the German management guidelines was initiated. METHODS: A systemic literature review was performed, overarching principles were proposed and pre-selected via an online survey followed by two multidisciplinary consensus conferences. Pharmacological and non-pharmacological treatments were discussed, statements were proposed and ultimately agreed upon by nominal group technique (NGT). RESULTS: 12 overarching therapeutic principles, as well as 9 recommendations on pharmacological and 5 on non-pharmacological treatments for JIA were agreed upon. CONCLUSION: This report summarizes the recent update of the interdisciplinary, consensus-based German guidelines on the management of JIA. The multi- and interdisciplinary participation of all caregivers was central for this patient-focused update. With these guidelines, physicians can choose an evidence-based approach, which allows better tailored treatment in this vulnerable cohort of children and adolescents.

MRP8/14 serum levels as diagnostic markers for systemic juvenile idiopathic arthritis in children with prolonged fever.

OBJECTIVES: Differential diagnosis in children with prolonged fever is challenging. In particular, differentiating systemic-onset JIA (SJIA) from infectious diseases is difficult. Biomarkers are needed that support the diagnostic work-up. The aim of this study was to validate the usefulness of Myeloid-related protein 8/14 (MRP8/14) measurements in the diagnostic work-up of febrile children and to transfer it to clinical practice. METHODS: Data for 1110 paediatric patients were included and divided into two cohorts: (cohort A) for validation of MRP8/14 test performance with three different testing systems: the experimental ELISA, commercial ELISA and an innovative (point-of-care test) lateral flow immunoassay (LFIA); (cohort B) to validate the diagnostic accuracy with the two latter assays. RESULTS: In cohort A (n = 940), MRP8/14 was elevated in SJIA (12 110 ± 2650 ng/ml mean ± 95% CI) compared with other diagnoses (including infections and autoinflammatory diseases; 2980 ± 510 ng/ml) irrespective of fever and anti-inflammatory treatment (P < 0.001). In untreated patients with fever (n = 195) MRP8/14 levels in SJIA (19 740 ± 5080 ng/ml) were even higher compared with other diagnoses (4590 ± 1160 ng/ml) (P < 0.001, sensitivity 73%, specificity 90%). In group B1, the performance of the tests was confirmed in untreated patients with fever (n = 170): commercial ELISA (sensitivity 79%, specificity 89%) and LFIA (sensitivity 84%, specificity 81%). Compared with ferritin, IL-18, ESR, soluble IL-2 receptor and procalcitonin, MRP8/14 showed the best accuracy. CONCLUSION: MRP8/14 serum analyses have been validated as a helpful tool supporting the diagnosis of SJIA in febrile children. The results could be confirmed with commercial ELISA and LFIA enabling a rapid diagnostic point-of-care screening test.

Treat-to-target study for improved outcome in polyarticular juvenile idiopathic arthritis.

BACKGROUND: Juvenile idiopathic arthritis is one of the most prevalent chronic inflammatory diseases in children. Evidence suggests that early effective treatment minimises the burden of disease during childhood and in further life. We hypothesise that a guided treat-to-target (T2T) approach is superior to routine care in polyarticular juvenile idiopathic arthritis (pJIA) in terms of reaching a clinical remission after 12 months of treatment. METHODS: Patients with early and active pJIA were enrolled. Targets for treatment were the following: Recognisable Juvenile Arthritis Disease Activity Score (JADAS) improvement after 3 months, acceptable disease at 6 months, minimal disease activity at 9 months and as primary endpoint remission after 12 months. Initially, patients received methotrexate. Failure to meet a defined target required treatment modification at the specified intervals. The choice of biologics was not influenced by the protocol. Finally, T2T patients were compared with a cohort of matched controls of patients with pJIA with unguided therapy documented by BIKER. RESULTS: Sixty-three patients were enrolled. Treatment targets after 3/6/9 and 12 months were reached by 73%/75%/77% and 48% of patients. Fifty-four patients completed the protocol. Compared with matched controls, on T2T guidance significantly more patients reached JADAS remission (48% vs 32%; OR 1.96 (1.1-3.7); p=0.033) and JADAS minimal disease activity (JADAS-MDA) (76% vs 59%; OR 2.2 (1.1-4.4); p=0.028). Patients from the T2T cohort received a biologic significantly more frequent (50% vs 9% after 12 months; OR 9.8 (4.6-20.8); p<0.0001). CONCLUSION: The T2T concept was feasible and superior to unguided treatment. High rates of patients reached JADAS-MDA and JADA remission after 12 months. Approximately half of the patients achieved their therapy goals without a biologic.

The German version of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR).

The Juvenile Arthritis Multidimensional Assessment Report (JAMAR) is a new parent/patient reported outcome measure that enables a thorough assessment of the disease status in children with juvenile idiopathic arthritis (JIA). We report the results of the cross-cultural adaptation and validation of the parent and patient versions of the JAMAR in the German language. The reading comprehension of the questionnaire was tested in 10 JIA parents and patients. The participating centres were asked to collect demographic and clinical data along the JAMAR questionnaire in 100 consecutive JIA patients or all consecutive patients seen in a 6-month period and to administer the JAMAR to 100 healthy children and their parents. The statistical validation phase explored descriptive statistics and the psychometric issues of the JAMAR: the three Likert assumptions, floor/ceiling effects, internal consistency, Cronbach's alpha, interscale correlations, test-retest reliability, and construct validity (convergent and discriminant validity). A total of 319 JIA patients (2.8% systemic, 36.7% oligoarticular, 23.5% RF negative polyarthritis, and 37% other categories) and 100 healthy children were enrolled in eight centres. The JAMAR components discriminated well healthy subjects from JIA patients. All JAMAR components revealed good psychometric performances. In conclusion, the German version of the JAMAR is a valid tool for the assessment of children with JIA and is suitable for use both in routine clinical practice and in clinical research.

Long-term safety of etanercept and adalimumab compared to methotrexate in patients with juvenile idiopathic arthritis (JIA).

IMPORTANCE: Published evidence on the long-term safety of etanercept (ETA) and adalimumab (ADA) in patients with polyarticular juvenile idiopathic arthritis (pJIA) is still limited. OBJECTIVES: To investigate the rates of serious adverse events (SAE) and of events of special interest (ESI) under ETA and ADA treatment. DESIGN, SETTING AND PARTICIPANTS: Patients with pJIA were prospectively observed in the national JIA biological register, Biologika in der Kinderrheumatologie, and its follow-up register, Juvenile arthritis Methotrexate/Biologics long-term Observation. MAIN OUTCOMES AND MEASURES: We calculated the relative risks of SAE and ESI for ETA and ADA compared with methotrexate (MTX). RESULTS: Among the 1414 patients treated with ETA (n=1414; 4461 exposure years (EY)) and ADA (n=320; 493 EY), significantly more SAE, infections and medically important infections were observed (ETA: 4.5, 5.7, 0.9; ADA: 4.7, 11.4, 0.4 per 100 EY) compared with those treated with MTX alone (n=1455; 2.907 EY; 2.6, 5.5, 0.5 per 100 EY). The risk for malignancies was not significantly increased for ETA and ADA compared with MTX (0.09, 0.27 and 0.07/100 person-years). Patients under ETA monotherapy developed more frequently incident inflammatory bowel disease (IBD) and incident uveitis (0.5 and 0.8/100 EY) than patients treated by ETA in combination with MTX (0.1 and 0.2/100 EY) or MTX alone (0.03 and 0.1/100 EY). CONCLUSIONS AND RELEVANCE: Our data confirm the acceptable long-term tolerability of ETA and ADA in pJIA. However, whether the onset of IBD and uveitis during ETA monotherapy is a paradoxical effect or an inadequate response to therapy remains unclear and requires further investigation in this growing cohort.

Efficacy and safety of pharmacological treatments for Lyme neuroborreliosis in children: a systematic review.

BACKGROUND: Many aspects of pharmacological treatment of Lyme neuroborreliosis in children, such as choice of drug, dosage, and duration are subject to intense debates, leading to uncertainties in patients' parents and healthcare providers alike. To assess the available evidence for pharmacological treatment for children with Lyme neuroborreliosis we conducted a systematic review. METHODS: The comprehensive systematic literature search included randomized-controlled trials (RCTs) and non-randomized studies (NRS) on treatment of Lyme neuroborreliosis in children (age <18 years). Our primary outcome was neurological symptoms after treatment. Risk of bias was assessed with the Cochrane risk of bias tools for RCTs and NRS. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: Two RCTs and four NRS were eligible for inclusion. Risk of bias in RCTs and NRS was generally high. Reporting of studies was generally poor. Regarding the primary outcome neurological symptoms at 1-3 months, no statistically significant difference could be found in cohort studies between doxycycline and beta-lactam antibiotics. In two RCTs comparing penicillin G and ceftriaxone, no patient experienced residual neurological symptoms at the last reported time points. Quality of evidence according to GRADE was judged very low. CONCLUSIONS: Data is scarce and with limited quality. Several issues could not be addressed due to scarcity of information. No eligible study compared different treatment durations. According to the available evidence, there seems to be no difference between different antibiotic agents for the treatment of Lyme neuroborreliosis in children regarding neurological symptoms. We found no evidence that supports extended antibiotic regimes. REVIEW REGISTRATION: Systematic review registration: CRD42014008839 .

Complications in hospitalized children with acute gastroenteritis caused by rotavirus: a retrospective analysis.

UNLABELLED: Acute gastroenteritis (AGE) caused by rotavirus (RV) is a common disease among infants and toddlers, often leading to hospitalization and, in resource-poor countries, to death. However, little is known on specific complications of severe RV-positive (RV+) AGE and on the clinical course in chronically ill children. This was a retrospective analysis of data for children <5 years of age hospitalized due to AGE during six rotavirus seasons in three large German pediatric hospitals. The primary study end point was the incidence and type of complications in RV+ versus RV-negative (RV-) cases. A total of 6,884 episodes of AGE in hospitalized children aged <5 years were included in this analysis. Of the 4,880 stools tested for RV, 2,118 (43.4%) were RV+. Hypernatremia was significantly more common in RV+ AGE (P < 0.001) and was associated with severe disease, need for intensive care treatment, and longer duration of hospitalization. Metabolic disorders, particularly hypoglycemia, were more common in RV+ AGE. In contrast, symptoms such as respiratory infections, neurological, and abdominal symptoms were more common in children with RV- AGE. CONCLUSIONS: Hypernatremia is a specific complication of RV+ AGE. RV would therefore appear to be the cause of infant toxicosis, the traditional descriptive term for severe dehydration and clinical deterioration following AGE.

[Recommendation for standardized medical care for children and adolescents with long COVID]. / Einheitliche Basisversorgung von Kindern und Jugendlichen mit Long COVID: Stellungnahme einer multidisziplinären Arbeitsgruppe der DGKJ-Konvent-Gesellschaften (Stand: Februar 2022).

This current consensus paper for long COVID complements the existing AWMF S1 guidelines for long COVID with a detailed overview on the various clinical aspects of long COVID in children and adolescents. Members of 19 different pediatric societies of the DGKJ convent and collaborating societies together provide expert-based recommendations for the clinical management of long COVID based on the currently available but limited academic evidence for long COVID in children and adolescents. It contains screening questions for long COVID and suggestions for a structured, standardized pediatric medical history and diagnostic evaluation for patients with suspected long COVID. A time and resource-saving questionnaire, which takes the clinical complexity of long COVID into account, is offered via the DGKJ and DGPI websites as well as additional questionnaires suggested for an advanced screening of specific neurocognitive and/or psychiatric symptoms including post-exertional malaise (PEM) and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). According to the individual medical history as well as clinical signs and symptoms a step by step diagnostic procedure and a multidisciplinary therapeutic approach are recommended.

Adalimumab with or without methotrexate in juvenile rheumatoid arthritis.

BACKGROUND: Tumor necrosis factor (TNF) has a pathogenic role in juvenile rheumatoid arthritis. We evaluated the efficacy and safety of adalimumab, a fully human monoclonal anti-TNF antibody, in children with polyarticular-course juvenile rheumatoid arthritis. METHODS: Patients 4 to 17 years of age with active juvenile rheumatoid arthritis who had previously received treatment with nonsteroidal antiinflammatory drugs underwent stratification according to methotrexate use and received 24 mg of adalimumab per square meter of body-surface area (maximum dose, 40 mg) subcutaneously every other week for 16 weeks. We randomly assigned patients with an American College of Rheumatology Pediatric 30% (ACR Pedi 30) response at week 16 to receive adalimumab or placebo in a double-blind fashion every other week for up to 32 weeks. RESULTS: Seventy-four percent of patients not receiving methotrexate (64 of 86) and 94% of those receiving methotrexate (80 of 85) had an ACR Pedi 30 response at week 16 and were eligible for double-blind treatment. Among patients not receiving methotrexate, disease flares (the primary outcome) occurred in 43% of those receiving adalimumab and 71% of those receiving placebo (P=0.03). Among patients receiving methotrexate, flares occurred in 37% of those receiving adalimumab and 65% of those receiving placebo (P=0.02). At 48 weeks, the percentages of patients treated with methotrexate who had ACR Pedi 30, 50, 70, or 90 responses were significantly greater for those receiving adalimumab than for those receiving placebo; the differences between patients not treated with methotrexate who received adalimumab and those who received placebo were not significant. Response rates were sustained after 104 weeks of treatment. Serious adverse events possibly related to adalimumab occurred in 14 patients. CONCLUSIONS: Adalimumab therapy seems to be an efficacious option for the treatment of children with juvenile rheumatoid arthritis. (ClinicalTrials.gov number, NCT00048542.)

Long-term safety and efficacy of abatacept in children with juvenile idiopathic arthritis.

OBJECTIVE: We previously documented that abatacept was effective and safe in patients with juvenile idiopathic arthritis (JIA) who had not previously achieved a satisfactory clinical response with disease-modifying antirheumatic drugs or tumor necrosis factor blockade. Here, we report results from the long-term extension (LTE) phase of that study. METHODS: This report describes the long-term, open-label extension phase of a double-blind, randomized, controlled withdrawal trial in 190 patients with JIA ages 6-17 years. Children were treated with 10 mg/kg abatacept administered intravenously every 4 weeks, with or without methotrexate. Efficacy results were based on data derived from the 153 patients who entered the open-label LTE phase and reflect >or=21 months (589 days) of treatment. Safety results include all available open-label data as of May 7, 2008. RESULTS: Of the 190 enrolled patients, 153 entered the LTE. By day 589, 90%, 88%, 75%, 57%, and 39% of patients treated with abatacept during the double-blind and LTE phases achieved responses according to the American College of Rheumatology (ACR) Pediatric 30 (Pedi 30), Pedi 50, Pedi 70, Pedi 90, and Pedi 100 criteria for improvement, respectively. Similar response rates were observed by day 589 among patients previously treated with placebo. Among patients who had not achieved an ACR Pedi 30 response at the end of the open-label lead-in phase and who proceeded directly into the LTE, 73%, 64%, 46%, 18%, and 5% achieved ACR Pedi 30, Pedi 50, Pedi 70, Pedi 90, and Pedi 100 responses, respectively, by day 589 of the LTE. No cases of tuberculosis and no malignancies were reported during the LTE. Pneumonia developed in 3 patients, and multiple sclerosis developed in 1 patient. CONCLUSION: Abatacept provided clinically significant and durable efficacy in patients with JIA, including those who did not initially achieve an ACR Pedi 30 response during the initial 4-month open-label lead-in phase.

[Recommendations on the approach when unusual neurological symptoms occur in temporal association with vaccinations in childhood and adolescence]. / Empfehlungen zum Vorgehen bei Auftreten ungewöhnlicher neurologischer Symptome in zeitlichem Zusammenhang mit Impfungen im Kindes- und Jugendalter: Aktualisierte Stellungnahme der Kommission für Infektionskrankheiten und Impffragen der DAKJ (Juni 2020).

Vaccinations are often administered at an age when many neurological diseases of childhood and adolescence also occur. Febrile seizures may occur following vaccination in patients with an appropriate genetic predisposition. The occurrence of narcolepsy has been described more frequently after pandemic influenza A-H1N1 vaccinations. The causality has not been proven. Data regarding an association between Guillain-Barré syndrome and influenza vaccinations are inconclusive. It was conclusively shown that vaccinations do not cause neurological disorders, such as autism and do not trigger multiple sclerosis. In summary, there is currently no confirmed evidence for the occurrence of chronic neurological diseases as a consequence of generally recommended vaccinations in Germany. If unusual neurological symptoms are observed in temporal association with vaccinations, a comprehensive evaluation is necessary to exclude a causal relationship and to diagnose the underlying neurological disease independent of the vaccination. This statement gives specific recommendations for the practical approach when neurological symptoms are observed in temporal association with vaccinations with respect to taking the patient history, initial diagnostic procedures, accurate and prompt documentation and the obligation to report the event. The committee also proposes procedures for further clarification and differential diagnostics of causal neurological diseases in childhood and adolescence.

[Infectious disease-related preventive measures for trainees in healthcare service and welfare]. / Infektiologische Präventivmaßnahmen bei Praktikantinnen und Praktikanten im Gesundheitsdienst und der Wohlfahrtspflege: Aktualisierte Stellungnahme der Kommission für Infektionskrankheiten und Impffragen der DAKJ (April 2021).

Training periods in healthcare and free welfare settings are frequently obligatory. Temporary trainees frequently lack sufficient knowledge regarding hygiene and prevention of infections. Therefore, specific preventive measures for trainees need to be implemented in a standardized fashion, similar to those applied for permanent employees. These are legally regulated by the European Biological Agents Ordinance and the German Standing Committee on Vaccinations (STIKO) recommendations. Criteria regarding immunization against hepatitis A and B, measles, mumps, rubella, varicella, pertussis, diphtheria, tetanus, polio, influenza and COVID-19 are described. Immunization gaps should be closed at any opportunity in general (e.g. in adolescents during regular physician contacts) and specifically in medical students during the first semester and in other healthcare trainees before the start of the training period. Furthermore, individual introduction of trainees to their work areas and in particular education in health measures to protect themselves and also individuals under their care is of high importance. Education should include information on the potential risks of infection, hand hygiene practice and other personal protection measures.

[Fever of unknown origin]. / Fieber unklarer Genese.

Fever of unknown origin is diagnosed when the fever (mostly defined as an elevated body temperature ≥38.3 °C measured by rectal or tympanic route) lasts longer than expected, i.e. 5-10 days after the onset of fever. The search for the cause can be difficult and necessitates the special attention of an experienced general pediatrician in collaboration with specialists in pediatric infectious diseases, rheumatic diseases and oncology, nursing personnel, radiologists and others. In approximately half of the cases an infectious cause is finally found; other causes are primarily inflammatory, malignant and noninflammatory diseases. Individual causes with the imminent threat of a severe course should be treated immediately. For the other cases the diagnostic evaluation is paramount, which is wisely planned and executed with determination and openness. The patient history, physical examination, laboratory and device-based diagnostics, imaging and histological examinations can contribute to the final diagnosis. The parents must be escorted through a period of uncertainty and the child should be comforted wherever possible. Spontaneous recovery is also possible. The probatory administration of antibiotics rarely leads to an improvement. After extensive exclusion of infections and malignancies and increasing suffering from the fever itself, prescription of glucocorticoids may be justified in cases of high inflammatory activity, under the suspicion of a hyperergic state and after detailed informed consent. The management of fever of unknown origin is one of the greatest challenges in pediatrics.

[Prevention of infections by influenza virus and respiratory syncytial virus after removal of the lockdown measures]. / Prävention von Infektionen durch das Influenza- und respiratorische Synzytialvirus nach Aufhebung der Lockdown-Maßnahmen: Gemeinsames Statement der Deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI) und der Gesellschaft für Pädiatrische Pneumologie (GPP).

There have recently been reports of unusual outbreaks of respiratory infections in children due to influenza virus and respiratory syncytial virus (RSV) during the summer in the southern hemisphere. This phenomenon is attributed to the termination of the drastic hygiene measures to contain the pandemic triggered by the coronavirus disease 2019 (COVID-19). The affected children were much older than anticipated. Coincident with the end of the present lockdown in summer, a similar situation could develop in Germany. Physicians and hospitals should be alerted to such a possibility. Interseasonal vaccines are not available for influenza but passive immunization against RSV could help to protect infants for whom appropriate indications exist according to the guidelines.

[Use of masks by children to prevent infection with SARS-CoV-2]. / Verwendung von Masken bei Kindern zur Verhinderung der Infektion mit SARS-CoV-2: Stellungnahme der Deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI), des Berufsverbandes der Kinder- und Jugendärzte (bvkj e. V.), der Deutschen Gesellschaft für Kinder- und Jugendmedizin (DGKJ), der Gesellschaft für Pädiatrische Pneumologie (GPP), der Deutschen Gesellschaft für Sozialpädiatrie und Jugendmedizin (DGSPJ), der Süddeutschen Gesellschaft für Kinder- und Jugendmedizin (SGKJ) und der Deutschen Gesellschaft für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie (DGKJP).

After initial reluctance masks have emerged as an important means of restricting the spread of SARS-CoV­2, the new coronavirus causing COVID-19. Other simple measures are keeping a distance of at least 1 ½â€¯m from other persons and observing hygiene recommendations, including washing or even disinfecting the hands, coughing into the crook of the arm and remaining at home when sick. Combining the initial letters of the German words for the three measures (Abstand-Hygiene-Alltagsmaske, distance-hygiene-face mask) the acronym AHA was formed, a colloquial German word meaning that the speaker understood the information presented. This acronym was later extended by the letter "L", initial letter of "Lüften" meaning air ventilation for indoor rooms and arriving at AHA­L, recommended by the federal German Health Institute the Robert Koch Institute. In fact, masks including surgical masks and face coverings can form an effective barrier against the spread of the virus: protecting other people from droplets expelled from the throat of the speaker wearing a mask and even in part protecting the wearer from inhaling droplets emanating from other peoples' throats. Studies to find out if wearing masks might impose risks did not find essential problems: alterations of respiratory parameters due to an increased airway resistance remained within normal limits in healthy adults and even in asthmatics whose disease was well controlled; however, many adults expressed their unease with masks describing them as cumbersome and inconvenient. Emotional resistance against masks made it increasingly more difficult for them to use a mask. Efficient application of masks requires, in addition to a logical explanation of its effect, the evocation of empathy for vulnerable people who can be protected from catching a possibly deadly disease. In children there are very few data on adverse effects of wearing a mask although there is ample experience in children with serious diseases compromising defense against infectious agents acquired via respiratory mucus membranes; however, when using masks appropriately in children relevant adverse effects have not been reported and are not to be expected. Masks should only be used in children when they are healthy and awake and can remove the masks themselves anytime they like. Children 10 years or older can use masks efficiently when they have been informed beforehand appropriate to their age. Under these conditions they can also be obliged to wear masks in certain situations, for example while walking through the school building to their desk in class. To limit the period of wearing a mask normally they will be allowed to remove the mask when sitting in class and keeping their distance. Children in primary schools may use masks, but they should not be obliged to wear them and children in kindergartens should not use masks. This exemption of younger children does not expose school and kindergarten teachers to additional risks since the infectivity with SARS-CoV­2 is age-dependent and increases with age reaching adult values only after 12 years of age.

Predictors of poor response to methotrexate in polyarticular-course juvenile idiopathic arthritis: analysis of the PRINTO methotrexate trial.

OBJECTIVES: To determine whether baseline demographic, clinical, articular and laboratory variables predict methotrexate (MTX) poor response in polyarticular-course juvenile idiopathic arthritis. METHODS: Patients newly treated for 6 months with MTX enrolled in the Paediatric Rheumatology International Trials Organization (PRINTO) MTX trial. Bivariate and logistic regression analyses were used to identify baseline predictors of poor response according to the American College of Rheumatology pediatric (ACR-ped) 30 and 70 criteria. RESULTS: In all, 405/563 (71.9%) of patients were women; median age at onset and disease duration were 4.3 and 1.4 years, respectively, with anti-nuclear antibody (ANA) detected in 259/537 (48.2%) patients. With multivariate logistic regression analysis, the most important determinants of ACR-ped 70 non-responders were: disease duration > 1.3 years (OR 1.93), ANA negativity (OR 1.77), Childhood Health Assessment Questionnaire (CHAQ) disability index > 1.125 (OR 1.65) and the presence of right and left wrist activity (OR 1.55). Predictors of ACR-ped 30 non-responders were: ANA negativity (OR 1.92), CHAQ disability index > 1.14 (OR 2.18) and a parent's evaluation of child's overall well-being < or = 4.69 (OR 2.2). CONCLUSION: The subgroup of patients with longer disease duration, ANA negativity, higher disability and presence of wrist activity were significantly associated with a poorer response to a 6-month MTX course.

[Lyme Borreliosis: Cutaneous and Neurologic Manifestations, Case Definitions and Therapy]. / Lyme-Borreliose: Kutane und neurologische Manifestationen, Falldefinitionen und Therapie.

Lyme borreliosis is the most common zoonosis in Germany with an incidence of up to 138/100 000. More than 90 % of all cases show dermatological manifestations. Early manifestations are erythema migrans, multiple erythemata migrantia, and (less frequently) borrelial lymphocytoma. A typical late manifestation is acrodermatitis chronica atrophicans. Lyme neuroborreliosis is much less common with an incidence of about 0.8/100 000 inhabitants in Germany. Bannwarth's syndrome (painful radiculoneuritis) is the most common manifestation of Lyme neuroborreliosis in adults followed by meningitis. International case definitions exist regarding the likelihood of Lyme neuroborreliosis on the basis of diagnostic test results. A CSF analysis should be performed in patients with suspected Lyme neuroborreliosis. The first line treatment for dermatological manifestations of Lyme borreliosis is doxycycline, in children and pregnant women amoxicillin. Doxycycline and beta-lactam antibiotics show similar efficacy regarding neurological symptoms and adverse effects for treatment of neurological manifestations. Treatment duration for early manifestations is 10 to 14 days, in Lyme neuroborreliosis it should not exceed 21 days. All manifestations, also Lyme neuroborreliosis, usually show a favourable prognosis after antibiotic treatment. Antibiotic treatment does not show any efficacy in patients with unspecific symptoms and concurrent positive anti-borrelial serology.