[Transition medicine-structural solutions]. / Transitionsmedizin ­ strukturelle Lösungsansätze.

Young adults suffering from chronic diseases represent a critical subgroup of patients that after reaching legal age have to be transferred to the colleagues from adult medicine. Thus in this patient group two evident problems come together: first, the adolescence phase that presents a challenge for any young adult and second, the transition to the novel structure and environment of adult medicine. It has been recognized for Germany that there are significant deficits for this transition phase. These deficits have already been addressed by other countries through the introduction of so-called transition clinics. In this article, we will summarize the challenges of this transition phase and the resulting points and needs that will have to be addressed by a structured program for transition. As an example, the Berliner TransitionsProgramm (BTP) will be presented where a framework structure is provided that allows for the transition of various chronic diseases. The BTP accompanies the transition process for a two-year time period by providing a framework structure consisting of transition consultations, a transition booklet, a structured summary of the previous disease course as well as a case manager who assures that the included patients stay within the program and do not get lost to assure treatment continuity. In addition, the program succeeded, at least from some insurance companies, in obtaining financial reimbursement for this time-consuming effort. Thus in our view, the BTP functions as role model for transition medicine in Germany.

Transition to adult diabetes care in Germany-High risk for acute complications and declining metabolic control during the transition phase.

OBJECTIVE: There is evidence that transition from pediatric to adult health care is frequently associated with deterioration of health in youths with type 1 diabetes (T1D). The aim of this study was to compare metabolic control, acute complications and microvascular complications in adolescents and young adults before and after transfer to an adult treatment center with respect to the time between first visit in the adult center and last visit in pediatric treatment. METHODS: All data were collected during routine care and retrieved from the German/Austrian DPV database. We analyzed data as of March 2017. RESULTS: We found 1283 young adults with available data of the last pediatric treatment year and the first year after transition to adult care. HbA1c increased significantly from 8.95% (74 mmol/mol) before to 9.20% (77 mmol/mol) in the first year after transition. Frequency of DKA with hospitalization (0.10-0.191 per annum, P < .0001) and severe hypoglycemia (0.23-0.46 per annum, P = .013) doubled during transition. Microvascular complications increased dramatically depending on the time between first visit in adult treatment and last visit in pediatric care. We could not find a significant correlation of this rise of microvascular complications to the duration of transition (short or long). CONCLUSION: This phase of life bears a high risk for detrimental outcome in young adults with T1D. Structured transition programs with case management are therefore needed to improve the transition process and outcomes.

Risk of recurrent severe hypoglycemia remains associated with a past history of severe hypoglycemia up to 4 years: Results from a large prospective contemporary pediatric cohort of the DPV initiative.

OBJECTIVES: In a contemporary cohort of youth with type 1 diabetes, we examined the interval between episodes of severe hypoglycemia (SH) as a risk factor for recurrent SH or hypoglycemic coma (HC). METHODS: This was a large longitudinal observational study. Using the DPV Diabetes Prospective follow-up data, we analyzed frequency and timing of recurrent SH (defined as requiring assistance from another person) and HC (loss of consciousness or seizures) in 14 177 youths with type 1 diabetes aged <20 years and at least 5 years of follow-up. RESULTS: Among 14 177 patients with type 1 diabetes, 72% (90%) had no, 14% (6.8%) had 1 and 14% (3.2%) >1 SH (HC). SH or HC in the last year of observation was highest with SH in the previous year (odds ratio [OR] 4.7 [CI 4.0-5.5]/4.6 [CI 3.6-6.0]), but remained elevated even 4 years after an episode (OR 2.0 [CI 1.6-2.7]/2.2 [CI 1.5-3.1]). The proportion of patients who experienced SH or HC during the last year of observation was highest with SH/HC recorded during the previous year (23% for SH and 13% for HC) and lowest in those with no event (4.6% for SH and 2% for HC) in the initial 4 years of observation. CONCLUSIONS: Even 4 years after an episode of SH/HC, risk for SH/HC remains higher compared to children who never experienced SH/HC. Clinicians should continue to regularly track hypoglycemia history at every visit, adjust diabetes education and therapy in order to avoid recurrences.

[Berlin transition program: from adolescents to adults in rheumatology treatment]. / Berliner TransitionsProgramm: Vom Jugendlichen zum Erwachsenen in der rheumatologischen Behandlung.

BACKGROUND: Transition is a crucial bridge between pediatric and adult rheumatology care and yet is often not a priority in either discipline. There is adequate evidence for the need of specific transition services. Various measures and transition programs have been proposed to support care during transition to adulthood; however, the implementation of youth-friendly services including transitional care has been frustratingly slow. Many structural and psychosocial barriers exist and prevent the widespread implementation of health transition support. Transition is resource consuming. It requires a reorganization of work flow to accommodate a clear, well-documented transitional pathway, including sufficiently long consultation times, age-appropriate communication, addressing of age-specific topics and a close cooperation between pediatric and adult rheumatologists. OBJECTIVES: This article presents the Berlin transition program (BTP) and its development. RESULTS AND PERSPECTIVES: The BTP presented here is the first structured transition program financed by statutory health insurances in Germany. Since January 2013 it can be used for patients with rheumatic and musculoskeletal diseases in some regions of Germany. The BTP supports care at transfer; however, it cannot guarantee a successful transition. There is a need to make the BTP available nationwide and to evaluate its effectiveness. This could be a precondition to recognize transition services as part of regular healthcare.

[The Obeldicks concept. An example for a successful outpatient lifestyle intervention for overweight or obese children and adolescents]. / Das Obeldicks-Konzept. Beispiel eines erfolgreichen ambulanten Therapieprogramms für Kinder und Jugendliche mit Übergewicht oder Adipositas.

The outpatient lifestyle interventions Obeldicks (for 8- to 16-year-old obese children; 1-year intervention), Obeldicks Light (for 8- to 16-year-old overweight children; 6-month intervention), and Obeldicks Mini (for 4- to 7-year-old obese children; 1-year intervention) are based on nutrition education, physical activity, behavior therapy, and individual psychological care. Only 17% dropped out of the intervention, and 79% of the more than 1,000 participants reduced their degree of overweight. The mean SDS-BMI reduction was 0.4 (~1.5-2 kg/m(2) BMI reduction) and was associated with a significant improvement of hypertension, dyslipidemia, and disturbed glucose metabolism in the participants compared to an untreated control group. This efficiency was also proven by a multicenter randomized controlled trial. Furthermore, the quality of life of the participants improved significantly. Even 4 years after the end of intervention, the achieved weight loss was sustained. Training manuals and training seminars for professionals assist in the implementation of these lifestyle interventions at further locations.

[Hypothyroidism in dizygotic premature twins due to excessive prepartal vaginal iodine application]. / Hypothyreose bei zweieiigen frühgeborenen Zwillingen durch exzessive präpartale vaginale Jodapplikation an die Mutter.

In dizygotic premature twins delivered by Caesarean section after prolonged efforts to effect premature birth we found markedly enhanced thyroid stimulating hormone levels. The mother had been subjected to local polyvidone iodine therapy for seven weeks with PVP suppositories to prevent vaginal infections. Control checks revealed persistently elevated TSH levels, whereas T3/T4 levels were always reduced. Greatly pronounced iodine excretion was seen in the urine of both the babies. This raised the suspicion of iodine-induced hypothyroidism in both children. Substitution with 1-thyroxine was initiated and a withdrawal trial performed after 12 weeks. The patients remained euthyroid after the treatment had been discontinued. Due to possible transfer of iodide to the fetus associated with the risk of iodine-induced hypothyroidism, it is recommended to abstain from vaginal application of iodine during pregnancy.