[Aftercare Following Inpatient Rehabilitation of Patients with Obesity: Feasibility of the KgAS-Concept]. / Ambulante Nachsorge nach stationärer Adipositasrehabilitation: Machbarkeit des KgAS-Nachsorgekonzeptes.

Even though the inpatient rehabilitation of children and adolescents with obesity shows beneficial effects in short term, the relapse rate afterwards is high. Previous attempts to implement successful aftercare programs that are open to all patients were either not successful or have been cancelled. Therefore, a new program was developed and evaluated in terms of feasibility. In a cooperation of a rehabilitation clinic with aftercare specialists, 25 families were enabled to participate. During the inpatient treatment a case management was established to accompany and transfer the patients to the ambulatory care afterwards. The process and the aftercare were evaluated by questionnaires (children/adolescents, parents, aftercare specialists) as well as one-on-one interviews and a focus group with the aftercare specialists that were also analyzed. Results show the feasibility of the program and good satisfaction rates among all participating groups (children/adolescents, parents, aftercare specialists, inpatient rehabilitation center). Thus, the program might be eligible in the treatment process. However, the evaluation of the effectiveness in a randomized controlled study is recommended.

[Rehabilitation of Children and Adolescents with Chronic Skin Diseases]. / Rehabilitation von Kindern und Jugendlichen mit chronischen Hauterkrankungen.

Chronic skin diseases are a common indication for inpatient rehabilitation in children and adolescents. Atopic eczema and psoriasis play the most important role. But other rare congenital dermatoses such as ichthyoses or epidermolysis bullosa can also be rehabilitated. Patients with skin diseases are often considerably stigmatized and report a limited quality of life and participation. The somatic and psychosocial development of the children is also often severely affected by severe forms of the diseases. The concept of inpatient rehabilitation is, on the one hand, the development of an individually adapted topical therapy plan, which often follows a step concept and is adapted to the severity of the skin symptoms. On the other hand, the disease management of children and affected families is promoted. Specific skills such as dealing with itching, learning of cream and dressing techniques, as well as the targeted application of medical baths with suitable additives are taught and practiced. In addition, the motivation for an adapted dealing with the disease and specific resources is promoted in order to comply better with the considerable psychosocial burdens.The results after the rehabilitation show, depending on the basic disease, not only an improved skin condition but also an improved quality of life and participation.

Overweight and Obesity Based on Four Reference Systems in 18,382 Paediatric Patients with Type 1 Diabetes from Germany and Austria.

AIM: To evaluate the prevalence of overweight and obesity in paediatric type 1 diabetes (T1D) subjects, based on four commonly used reference populations. METHODS: Using WHO, IOTF, AGA (German pediatric obesity), and KiGGS (German Health Interview and Examination Survey for Children and Adolescents) reference populations, prevalence of overweight (≥90th percentile) and obesity (≥97th percentile) and time trend between 2000 (n = 9,461) and 2013 (n = 18,382) were determined in 2-18-year-old T1D patients documented in the German/Austrian DPV database. RESULTS: In 2000, the overweight prevalence was the highest according to IOTF (22.3%), followed by WHO (20.8%), AGA (15.5%), and KiGGS (9.4%). The respective rates in 2013 were IOTF (24.8%), WHO (22.9%), AGA (18.2%), and KiGGS (11.7%). Obesity prevalence in 2000 was the highest according to WHO (7.9%), followed by AGA (4.5%), IOTF (3.1%), and KiGGS (1.8%). In 2013, the respective rates were WHO (9.6%), AGA (6.2%), IOTF (4.5%), and KiGGS (2.6%). Overall, the prevalence of overweight and obesity increased from 2000 to 2006 (p < 0.001) but showed stabilization thereafter in girls and overweight in boys. CONCLUSION: Overweight and obesity prevalence in T1D subjects differs significantly if it is assessed by four separate reference populations. More detailed assessment of each child is required to determine obesity-related risks.

Ethnicity and cardiovascular risk factors: evaluation of 40,921 normal-weight, overweight or obese children and adolescents living in Central Europe.

BACKGROUND AND AIMS: Cardiovascular disease (CVD) is a major global health problem and the leading cause of death in Europe. Risk factors such as obesity and hypertension that accelerate the development of CVD begin in childhood. Ethnicity is a known risk factor for CVD in adults. The aim of this study is to explore differences in the prevalence of hypertension and dyslipidemia among overweight/obese and normal-weight children/adolescents of three different ethnic origins living in Central Europe. METHODS AND PROCEDURES: Prevalence of hypertension and dyslipidemia was calculated among obese/overweight children/adolescents (n = 25,986; mean age 12.7 ± 3.0 years; range: 0-18 years; 46% males) documented in the German-Austrian-Swiss APV (Prospective Documentation of Overweight Children and Adolescents) registry and among normal-weight subjects (n = 14,935; mean age: 8.8 ± 5.1 years; range 0-18 years; 51% males) from the population-based cross-sectional German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study. In both cohorts, subjects were categorized into three ethnic groups (Central European: Germany, Austria, Switzerland; Southeastern European: Turkish; Southern European: Spain, Portugal, Italy, Greece, Cyprus, Malta) based on the country of birth of both parents. Regression models were used to examine ethnic differences after adjustment for age and gender and body mass index (BMI) category. RESULTS: Age-, gender- and BMI category-adjusted prevalence of hypertension were 38% and 39% for the ethnic minority groups, compared with 35% among German/Austrian/Swiss counterparts. Turkish ethnicity was significantly associated with hypertension (odds ratio (OR) 1.14; 95% confidence interval: 1.02-1.27; P = 0.0446). No significant ethnic differences were found in lipid levels. Prevalence of hypertension found among normal-weight subjects (Central European vs Southeastern vs Southern European: 6.8% vs 6.3% vs 7.2%) did not differ significantly. CONCLUSIONS: Turkish obese/overweight children/adolescents showed a significantly higher prevalence of hypertension relative to their peers of Central European descent. No significant ethnic difference in the prevalence of hypertension was found among normal-weight children/adolescents. The high prevalence of hypertension among Turkish obese/overweight children/adolescents indicates the need for greater preventive and therapeutic efforts to reduce cardiovascular risk factors among vulnerable populations.

Introducing excess body weight in childhood and adolescence and comparison with body mass index and waist-to-height ratio.

BACKGROUND: Weight status in children and adolescents is commonly defined using age- and gender-corrected standard deviation scores for body mass index (BMI-SDS, also called z-scores). Values are not reliable for the extremely obese however. Moreover, paediatricians and parents may have difficulties understanding z-scores, and while percentiles are easier to gauge, the very obese have values above the 99th percentile, making distinction difficult. The notion of excess body weight (EBW) is increasingly applied in adult patients, mainly in the context of bariatric surgery. However, a clear definition is not available to date for the paediatric population. METHODS: A simple definition of EBW for children and adolescents is introduced, with median weight as a function of height, age and gender (characterized by an asterisk): EBW (%) = 100x(weight-median weight*)/median weight*. EBW is compared with BMI-SDS and waist-to-height ratio (WHtR). Using two data sources (APV registry and German Health Interview and Examination Survey for Children and Adolescents (KiGGS)) including more than 14,000 children, the relationships between these anthropometric and various metabolic parameters are analysed for a group of overweight/obese children who have sought obesity therapy (APV), for the general paediatric population and for the subset of overweight/obese children from the general population (KiGGS). RESULTS: The three anthropometric parameters are strongly correlated, with the linear correlation coefficients exceeding 0.8 in the general population and 0.75 in those seeking obesity therapy. Moreover, their relationship to metabolic parameters is quite similar regarding correlations and area under the curve from receiver operating characteristic analyses. CONCLUSIONS: EBW has similar predictive value for metabolic or cardiovascular comorbidities compared with BMI and WHtR. As it is reliable at the extreme end of the obesity spectrum, easily communicable and simple to use in daily practice, it would make a very useful addition to existing tools for working with obese children and adolescents. Its usefulness in assessing weight change needs to be studied however.

[Morning hyperglycemia in children and adolescents with type 1 diabetes and different modes of therapy: an evaluation of the DPV data pool]. / Morgenhyperglykämie bei Kindern und Jugendlichen mit Typ-1-Diabetes bei unterschiedlichen Therapieformen: Eine Auswertung des DPV-Datenpools.

Early morning hyperglycemia is frequent among children and adolescents with type 1 diabetes. Reasons are a dawn phenomenon, a Somogyi phenomenon or a lack of insulin in the morning hours. Only few studies are published regarding incidence and relation to different modes of basal insulin treatment in this population.We analyzed all cases recorded in the DPV register from 1995 to 2010. 5 839 patients from 128 centers with at least 3 blood glucose measurements during the last night of a hospital stay were included.24.2% of patients showed a morning hyperglycemia above 200 mg/dl. 8.6% showed a dawn phenomenon, 7.0 % a lack of insulin and 2.0% a Somogyi phenomenon. A dawn phenomenon was significantly less frequent in patients treated with an insulin pump (1.1%) compared to long acting insulin analogs Glargin and Levemir (5.4%) or NPH insulin (8.2%). Lack of insulin was again less frequent during insulin pump treatment compared to other treatments (1.9% vs. 4.9% vs. 5.3%). Median rise of blood glucose levels was 33.4 mg/dl between midnight and 6 a.m. Mode of basal insulin treatment is an important factor: while treatment with an insulin pump led to a blood glucose fall of 28.5 mg/dl between 3 and 6 a.m., treatment with insulin analog or NPH insulin resulted in a rise of 28.5 or 35.9 mg/dl, respectively.This study shows that insulin pump treatment reduces the frequency of morning hyperglycemia caused by the dawn phenomenon or a lack of insulin.

Acupuncture in children and adolescents with bronchial asthma: a randomised controlled study.

OBJECTIVE: This randomised controlled trial evaluates the immediate effects of acupuncture as an add-on therapy in in-patient rehabilitation of children and adolescents with bronchial asthma. PATIENTS AND METHODS: In a pre-post design, the severity of symptoms, lung function, illness-specific quality of life (Paediatric Asthma Quality of Life Questionnaire - PAQLQ) and general and asthma-specific level of anxiety (State-Trait Anxiety Inventory for Children - STAIC) were investigated in 46 acupuncture and 47 control patients. In addition to asthma sports, climate therapy and behavioural training, the intervention group received acupuncture treatment with a standardised needle pattern (12 × 30 min.). RESULTS: With acupuncture, the peak expiratory flow variability differs significantly (p<0.01) from that of the control patients' group. Moreover, the acupuncture group differs significantly in their rehabilitation response at the time of discharge concerning perceived anxiety (STAIC-S). The lung function tests do not present differences between groups. CONCLUSION: After additional acupuncture, amelioration of peak expiratory flow variability and anxiety can be shown, without any difference in objective lung function tests and quality of life between study groups. Further studies might evaluate the effects of acupuncture on childhood asthma in an outpatient setting.

[Behavioral problems of somatic chronically ill adolescents: parent-child-agreement and differences]. / Verhaltensauffälligkeiten bei körperlich chronisch kranken Jugendlichen: Übereinstimmungen und Unterschiede im Selbst- und Elternurteil.

BACKGROUND: Adolescents with a chronic somatic disease often show comorbid mental health problems which interfere with adherence and disease management. As adolescents often pass their rehabilitation treatment without their parents and therapists frequently lack resources necessary for assessing information from both the patients and their parents, the question arises what conclusions can be drawn on the basis of self report data only and how general agreement between parent and adolescents can be rated. METHODS: Parent-child-agreement of chronically ill adolescents and their families are analyzed using intra-class-correlation (ICC). Data of 367 adolescents with obesity, chronic respiratory disease, skin disease and diabetes between the age of 12.0 and 16.11 years were collected at the beginning of rehabilitation treatment. Parents received their questionnaire via post. Psychological symptoms were identified using the German version of the Strength and Difficulties Questionnaire (SDQ-Deu). RESULTS: There was medium to high agreement between parent and child ratings regarding "emotional problems", "peer relationship problems" and "total difficulty score" for all diagnoses. CONCLUSIONS: Therapists of chronically ill adolescents can act on the assumption that parent-child-agreement is medium to high. Consequently, self-ratings appear a useful diagnostic indicator for rehabilitation treatment.

[Medical inpatient rehabilitation influences on self-esteem and self-efficacy of chronically ill adolescents]. / Einflüsse der medizinischen stationären Rehabilitation auf den Selbstwert und die Selbstwirksamkeit von chronisch kranken Jugendlichen.

BACKGROUND: In this article the development of self-esteem and self-efficacy in adolescents with chronic physical illness with and without psychological symptoms is measured over one year, following a medical inpatient rehabilitation treatment of four to six weeks. Gender- and diagnosis-related differences are analyzed. MATERIALS AND METHODS: 243 chronically ill adolescents were interviewed at the beginning of their rehabilitation treatment. After one year data of 99 chronically ill adolescents are available (age: M=14.6; SD=1.70), 50 boys. Self-esteem was measured using the revised Rosenberg Self-Esteem Scale. The revised Allgemeine Selbstwirksamkeitsskala was chosen for assessing self-efficacy at school and other social contexts. At the beginning of rehabilitation, psychological symptoms were identified using the German version of the Strengths and Difficulties Questionnaire. RESULTS: Therapy of chronically ill adolescents in medical rehabilitation affects their self-esteem positively, with differences in self-esteem found between adolescents who show clinically relevant psychological symptoms and those who do not. Only minor changes are however noticed in ratings of self-efficacy at school and other social contexts. Gender- and diagnosis-related differences have not been found.

[Self management in chronically ill adolescents: development of a short questionnaire]. / Entwicklung eines Kurz-Fragebogens zum Krankheitsmanagement chronisch kranker Jugendlicher.

PURPOSE: Behavioural interventions in chronically ill adolescents aim to improve disease-related self-management. The study presents a short questionnaire for examining the self-management strategies in paediatric patients with obesity, asthma, type I diabetes or atopic eczema. METHODS: For each indication, six favourable disease management strategies were identified: adherence to the subjective body perception, avoidance of trigger factors, adequate control of one's own behaviour, appropriate emergency treatment, and regular prolonged treatment including, depending on the disease at hand, adherence to alimentation. For each indication a "disease management" scale with six items was constructed. Psychometric properties (item statistics, reliability) were examined among 416 adolescents. Participants were diagnosed at least with one chronic illness and took part in an inpatient rehabilitation programme in a German rehabilitation clinic. RESULTS: For the scale obesity (KM-KJ-Adi) (n=192) difficulty of the items was 0.30-0.43, discrimination was 0.32-0.57 and Cronbach's alpha was 0.72. For the scale asthma (KM KJ AB) (n=164) difficulty of the items was 0.43-0.65, discrimination was 0.29-0.52 and Cronbach's alpha was 0.70. For the scale diabetes (KM-KJ-DM1) (n=78) difficulty of the items was of 0.42-0.74, discrimination was of 0.25-0.87 and Cronbach's alpha was 0.68. For the scale atopic eczema (KM-KJ-AE) (n=125) difficulty of the items was 0.31-0.71, discrimination was of 0.24-0.51 and Cronbach's alpha was 0.64. DISCUSSION: Up to now, no economic, indication-specific and reliable questionnaire exists for assessing the competences of adolescents in their disease self-management. The presented questionnaire fills this gap, the indication-specific scales with only a few items show satisfactory psychometric results. CONCLUSIONS: This questionnaire can be used as an instrument for self-management strategies in chronically ill adolescents. The responsiveness (change score) and validity have to be further investigated.

Changes in the use of analogue insulins in 37 206 children and adolescents with type 1 diabetes in 275 German and Austrian centers during the last twelve years.

AIMS: To describe changes in insulin treatment in children and adolescents in Germany/Austria regarding short acting (SA)- and long acting (LA) insulin analogues in different age groups over the last twelve years. METHODS: Use of different insulins and treatment regimens were analysed in 37 206 children and adolescents with the age of 0-20 years from 276 German and Austrian centers that were registered in the DPV-database (Dec. 2007). The group was subdivided into 4 age groups (A: 0-4 years; B:5-9 years;C:10-14 years,D:15-19 years). We further analysed the use of analogues from onset of diabetes. RESULTS: A significantly increasing percentage of pediatric patients in all age groups with Type 1 Diabetes use analogue insulins. In 2007, 48.5% used SA, 45.8% LA. 87.2% of pumps were running with short acting analogue. Age specific analysis: A: 2000: 9.1%SA, 0.7%LA vs. 2007: 50.0%SA, 10.0%LA; B: 2000:5.6%SA, 1.4%LA vs. 2007: 36.8%SA, 27.5%LA C: 2000:14.3%SA, 3.4%LA vs. 2007: 45.3%SA, 49.1%LA D: 2000:26.3%SA, 3.2%LA vs. 2007: 59.1%SA, 61.9%LA. This increase in usage of analogues was also found at onset of diabetes. Corrected for age, center and diabetes duration HbA1c was significantly lower in the group with regular insulin (8.18+/-0.047%) than with SA (8.32+/-0.048%) (p<0.0001) and BMI-SDS was only marginal lower in the group with regular insulin (0.45+/-0.01 kg/m (2)) than with SA (0.47+/-0.15) (p>0.007). Similar differences in HbA1c (8.09+/-0.05% vs. 8.40+/-0.05%) and BMI-SDS where seen when NPH was compared with LA respectively. After change to SA the reduction of severe hypoglycemia with (6.1/100 pat.years) and without coma (6.2/100 pat.years) was significant and after change to LA for severe hypoglycemia without coma respectively. CONCLUSIONS: Long-term data for the use of new drugs are sparse. In our analysis patients are followed not under study conditions. Still the higher BMI and HbA1c with either SA or LA usage have to be discussed carefully in the context of increasing use of both, long acting and short acting analogues and possible problems with reimbursement.

[Medication behavior of children and adolescents with asthma before and after in-patient rehabilitation--results of a multicenter study]. / Medikationsverhalten asthmakranker Kinder und Jugendlicher vor und nach stationärer Rehabilitation - Ergebnisse einer multizentrischen Studie.

The article presented is based on data of a multicenter study examining the effectiveness of an inpatient rehabilitation program for children and adolescents with asthma. The study took place from August 1996 to November 2001. It shows more noticeable long-term improvement of disease management and lung function parameters after in-patient rehabilitation (n = 226) than after out-patient rehabilitation programs (n = 92). The re-analysis of the data examines the influence of medication on these results. A decisive effect on treatment results for both in- and outpatients can be achieved by complying with the guidelines recommended by the medical societies. However, at the same time the results demonstrate that prescribing a correct treatment plan is not always sufficient. The significant improvement of outcome parameters (functional restriction, lung function, days absent from school, visits to a physician) of the rehabilitation group shows the importance of rehabilitation for teaching strategies for disease management and increase in compliance.

The 'accelerator hypothesis': relationship between weight, height, body mass index and age at diagnosis in a large cohort of 9,248 German and Austrian children with type 1 diabetes mellitus.

AIMS/HYPOTHESIS: The aim of this study was to investigate whether either increased weight or BMI are associated with the earlier manifestation of type 1 diabetes mellitus in children. METHODS: We evaluated anthropometric measurements in a large cohort of 9,248 patients of European extraction who were diagnosed in the years 1990-2003 in 116 pediatric clinics throughout Germany and Austria. RESULTS: Patients were divided into four groups according to age (0-4.9 years, 5-9.9 years, 10-14.9 years and 15-20 years). Significantly higher standard deviation scores (SDSs) for weight and BMI at diabetes onset were found for both boys and girls in the three younger age groups (up to 14.9 years of age) compared with the reference population (p<0.00001). In addition, the BMI SDS and the weight SDS were significantly higher in the 0-4.9-years age group than in all other groups (p<0.00001), and BMI SDS at onset gradually decreased with increasing age at manifestation (p<0.0001). Over the >10-year study period, there was a continuous rise in the weight-SDS and the BMI-SDS in the cohort (p<0.0001), especially in the 5-9.9-years and the 10-14.9-years age groups. Multivariate analysis revealed a significant influence of male sex and of year of manifestation on BMI SDS (p<0.0001) and demonstrated a negative association between the patients' BMI SDS and age at diagnosis, with a mean annual decrease in BMI SDS of -0.0248 (95% CI -0.0294 to -0.0202, p<0.0001). CONCLUSIONS/INTERPRETATION: A higher BMI was associated with a younger age at diabetes onset. Increased weight gain could therefore be a risk factor for the early manifestation of type 1 diabetes.

Health-related quality of life in children and adolescents with asthma: results from the ESTAR Study.

Our aim was to assess the psychosocial well-being of asthmatic children and adolescents, the influencing factors, and to determine the effect of inpatient rehabilitation on their quality of life; 226 asthmatic children and adolescents participated in the inpatient rehabilitation (IG). The comparison group (CG) included 92 asthmatic children and adolescents receiving standard medical treatments. Patients were aged between 8 and 16 years and were predominantly male. The health-related quality of life was measured with the German version of the "Paediatric Asthma Quality of Life Questionnaire." Interviews were carried out for IG 2 weeks before the commencement of their inpatient stay and 1 year after their stay ended. The same time schedule was carried out for CG. All patients reported a mild to moderate impairment of their quality of life. Girls described a slightly lower quality of life than boys. With increasing asthma severity, quality of life decreased. Inpatients described a lower quality of life than CG at enrollment. Inpatient rehabilitation resulted in a greater improvement of quality of life over time for IG than for CG. Gender and severity status had no effect on this time course. The only modestly affected quality of life may reflect the good adaptation to the disease and medical treatment. Children and adolescents in the IG recorded improvements in their quality of life. Differences in quality of life based on gender and disease severity were not shown to influence the improvements. In summary, inpatient rehabilitation results in an improvement of health-related quality of life. Further research concerning the psychosocial situation of children and adolescents in this setting is needed.

[Long-term effect of indoor rehabilitation on children and young people with moderate and severe asthma]. / Langzeiteffekt der stationären Rehabilitation bei Kindern und Jugendlichen mit mittelschwerem und schwerem Asthma bronchiale.

In a multi-centre trial the effect of indoor rehabilitation in case of bronchial asthma in childhood and adolescence was evaluated on a prospective basis in comparison to an ambulant group of patients. 195 children and adolescents aged between 8 and 16 suffering from bronchial asthma (grading of severity 3 and 4) were included in the trial. The rehabilitation group (RG) included 149 patients, whereas the out-patient reference group consisted of 46 patients. At the beginning of the trial (in the rehabilitation group about 14 days before rehabilitation started) and 12 months afterwards, the pulmonary function (FEV 1, peak flow and MEF50), asthma-related school day off, participation in school sport, asthma management and quality of life were recorded. 12 months after the indoor rehabilitation, the rehabilitation group had significantly better MEF50-values (P = 0.007) than the ambulant group. The rehabilitation group also had significantly better values (P < 0.01) with regard to the asthma management. Already at the beginning of the study both groups indicated a satisfactory participation in school sport with 3.5 hours a week which could not be increased further. The baseline values for asthma-related school day off and quality of life of the rehabilitation group were worse than those of the ambulant group. 12 months after rehabilitation, however, the values were significantly better (P < 0.01) compared to baseline and almost similar to the levels of the ambulant group. Significantly improvements with regard to MEF50, asthma management, school day off and quality of life could thus be achieved by indoor rehabilitation.

Late results of jejunal interposition.

In 62 patients the late results of isoperistaltic jejunal interposition in reconstructive ulcer surgery are analyzed 1.5 to 9.5 years postoperatively (mean 3.1 years); a follow up was possible in 58 patients. 38 (65.5%) had a Visick I or II result; 16 (28%) a fair result (Visick III) and 4 a poor result (Visick IV). 12 of the 58 followed up patients developed a jejunal stomal ulceration in the mean time. These ulcerations were mostly (60%) asymptomatic, superficial and nonbleeding. The histology of the gastric remnant remained unchanged in the most patients and didn't show any benefit of bile diverting operation. The gastric acidity was high especially in the stomal ulcer patients, the gastric output was low. Only 64% of the patients with jejunal interposition showed a gastric bacterial overgrowth compared to 92% resp. 84% in the Billroth resection groups. The incidence of stomal ulceration (20.6%) is the result of the high unbuffered acid of the gastric remnant. Similar reports are found in the literature. Even an additional vagotomy doesn't prevent the ulcer formation sufficiently in every case. In conclusion reflux-preventive jejunal interposition is shown to be heavily ulcer-prone, it should be used in reconstructive ulcer surgery very carefully only with short (15 cm) segments and additional vagotomy.