Made available in DSpace on 2014-12-17T14:16:33Z (GMT). No. of bitstreams: 1 MelinaBL_DISSERT.pdf: 4468439 bytes, checksum: 05a71c9a22430196d211e6d7c8feea61 (MD5) Previous issue date: 2008-09-22 / Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico / Diabetes Mellitus (DM) and osteoposes are chronic diseases with great socioeconomic consequences, mainly due to the late complications and consequent disabilities. The potential effects of DM on bone metabolism remain a very conroversial issue, and disagreement exists with regard to the clinical implications of diabetic osteopenia and the mechanism of its ocurrence. The issue is further complicated by the contribuicion of the especific factors, such as duration of disease an dthe degree of metabolic control. The objective of this study is to identify the osteopathy in children and adolescents with DM 1 assisted in the hospital of pediatrics, UFRN, through biochemical markers of bone and mineral metabolism and the extent of bone mineral density. The study was composed by 74 diabetics type 1 patients (DM1) of both gender and aged 6 to 20 yars. Normoglic?mic group was composed by 97 healthy subjects of both genders, which showed the same age range of DM1, in addition to same socioeconomic class. These individuals qere students from the networks of public education in the city of Natal-RN, randomly invited to paticipate in our study. Both groups DM1 and NG were divided intofour subgroups, according to the classification of tanner , T1, T2, T3, T4 for achieving a benchmark. Diabetic individuals showed up with a poor glycemic control. the group DN1 T4 showed an incresead value for total protein, albumin, urea and microalbumiuria are predictors of grumelura injury in DM1 patients . The total alkaline phosphatase activitywas kept on high levels for both groups because they are in a stature development age. For osteocalcin there were decreased levels for groups Dm1 T1, T2, and T3 when compared to their NG (s), suggesting that this decrease could be associated with reduction in the number and/or differentiation os osteoblasts thereby contributing to reducing bone formation. There were no changes in the activity of TRAP. The serum concentrations of total and ionized calcium, phosphorus and magnesium were included within the RV. It was observed that the BMD (Z- SCORE ) has always been within the RV for both groups, despite to DM1 T4. Taking all together, our results support the hypothesis that children and adolescents with type 1 DM present the risk in the long run to suffer a reduction in the bone mass, associated to poor glicemic control and disease duration. It could limit the bone growth and increase the probality of development of osteopenia, as well as other complications surch as retinopathy and renal failure / Diabetes mellitus (DM) a osteoporose s?o doen?as cr?nicas com grandes consequ?ncias socioecon?micas, sobretudo devido ? complica??es tardias e consequente desabilidades. Os efeitos potenciais do DM no metabolismo ?sseo continua a ser uma quest?o controversa, e ainda n?o existe um consenso no que diz respeito ?s implica??es cl?nicas da osteopenia diab?tica e os mecanismos da sua ocorr?ncia. Entretanto, a contribui??o de fatores espec?ficos, tais como a dura??o da doen?a e o grau de controle metab?lico tem sido muito discutidos. O objetivo do presente estudo foi identificar precocemente a osteopatia diab?tica em crian?as e adolescentes com DM 1 atendidos no Hospital de Pediatria da UFRN atrav?s de marcadores bioqu?micos do metabolismo mineral e ?sseo, marcadores da fun??o renal e da medida da densidade mineral ?ssea (DXA; Z-score L1-L4) . O estudo foi constitu?do por uma amostra de 74 pacientes diab?ticos tipo 1 (DM1) de ambos os sexos, com faixa et?ria entre 6 a 20 anos. O grupo normoglic?mico (NG) foi constitu?do por 97 indiv?duos saud?veis, de ambos os sexos, os quais apresentaram a mesma faixa et?ria do DM1, al?m de compreenderem a mesma classe socioecon?mica. Estes indiv?duos eram alunos de escolas da rede p?blica de ensino da cidade de Natal-RN, convidados aleatoriamente a participar do nosso estudo. Tanto o grupo DM1 quanto o NG foram divididos em quatro subgrupos, de acordo com a Classifica??o de Tanner, T1, T2, T3, T4, para viabilizar uma avalia??o comparativa. Os indiv?duos diab?ticos apresentaram um controle glic?mico insatisfat?rio, com valores de glicemia e HbA1C significativamente superiores aos obtidos para os NG. O grupo DM1 T4 apresentou valores aumentados de prote?nas totais, albumina, ur?ia e microalbumin?ria, sugerindo assim um in?cio de comprometimento renal, visto que os valores elevados de microalbumin?ria s?o preditores de les?o glomerular em pacientes DM1. A atividade da fosfatase alcalina total mostrou-se acima dos VR nos grupos DM1 e NG por estes estarem numa faixa et?ria de desenvolvimento estatural. Observa-se uma diminui??o da concentra??o de osteocalcina para os grupos DM1 T1, T2 e T3 quando comparados aos respectivos NG (s), sugerindo que esta diminui??o estaria associada a diminui??o do n?mero e/ou da diferencia??o dos osteoblastos no seu est?gio final de matura??o, contribuindo consequentemente para a redu??o da forma??o ?ssea. N?o foram observadas altera??es na atividade da TRAP. As concentra??es s?ricas de c?lcio total e ionizado, f?sforo e magn?sio estavam compreendidos dentro dos VR, mas os grupos diab?ticos apresentaram hipozincemia e hiperzinc?ria. A DMO (Z-score L1-L4; DXA) esteve sempre dentro dos VR para os grupos estudados, entretanto os grupos DM1 apresentaram sempre valores abaixo do seu respectivo NG, alca?ando uma diferen?a significativa para DM1 T4. O conjunto de resultados obtidos indicam que o baixo controle glic?mico e o tempo de doen?a representaram fatores de risco importantes para o desenvolvimento precoce da osteopenia diab?tica, bem como para o comprometimento renal e sinais de retinopatia.

Background: Genome-wide association studies have identified variants within the FTO (fat mass and obesity associated) locus as the strongest predictors of obesity amongst all obesity-associated gene loci. Recent evidence suggests that variants in FTO directly affect human adipocyte function through targeting IRX3 and IRX5 and thermogenesis regulation. Aim: We addressed the relevance of this proposed FTO-IRX pathway in adipose tissue (AT) of children. Results: Expression of IRX3 was higher in adipocytes compared to SVF. We found increased adipocyte-specific expression of IRX3 and IRX5 with the presence of the FTO risk haplotype in lean children, whereas it was unaffected by risk variants in obese peers. We further show that IRX3 expression was elevated in isolated adipocytes and AT of lean compared to obese children, particularly in UCP1-negative adipocytes, and inversely correlated with BMI SDS. Independent of BMI, IRX3 expression in adipocytes was significantly related to adipocyte hypertrophy, and subsequent associations with AT inflammation and HOMA-IR in the children. Conclusion: One interpretation of our observation of FTO risk variants linked to IRX3 expression and adipocyte size restricted to lean children, along with the decreased IRX3 expression in obese compared to lean peers, may reflect a defense mechanism for protecting body-weight, which is pertinent for lean children.

Zusammenfassung Hintergrund Der Konsum von Alkohol ist unter Jugendlichen weitverbreitet und stellt in Europa noch vor Nikotin die am häufigsten konsumierte abhängigkeitserzeugende Substanz dar. Die individuellen und gesellschaftlichen Konsequenzen jugendlichen Alkoholgebrauchs sind weitreichend, so gilt dieser als wichtigster Risikofaktor für Morbidität und Mortalität bei jungen Menschen in der westlichen Welt (Rehm et al., 2006). Vor diesem Hintergrund hat in Deutschland und anderen europäischen Ländern seit Beginn der 2000er Jahre der besorgniserregende Trend steigender Zahlen stationär behandelter jugendlicher Alkohol-intoxikationen Aufmerksamkeit erhalten. Unbehandelt stellt eine Alkoholintoxikation mit sehr hoher Blutalkoholkonzentration eine lebensbedrohliche Situation dar. Die entsprechenden Behandlungszahlen für Minderjährige haben sich im Zeitraum von 2000 bis 2012 mehr als verdreifacht. Verglichen mit anderen Altersgruppen stellte die Gruppe der 15- bis 20-Jährigen im genannten Zeitraum die mit Abstand größte Altersgruppe dar, gemessen an der Zahl der Behandlungsfälle pro 100 000 Gleichaltriger. Für diese junge Patientenpopulation liegen jedoch noch keine aussagekräftigen Daten darüber vor, welche Faktoren mit problematischem habituellen Alkoholkonsum assoziiert sind und in welchem Ausmaß bereits Alkoholgebrauchsstörungen bestehen. Ebenso wenig existieren Informationen über längerfristige Entwicklungsverläufe der betroffenen Kinder und Jugendlichen, was jedoch ausschlaggebend für die Identifizierung besonders gefährdeter Patienten ist. Fragestellungen Auf der Grundlage der aktuellen Literatur ergeben sich für die vorliegende Arbeit folgende Fragen: - Welche biopsychosozialen Faktoren sind mit problematischem habituellen Alkoholkonsum bei Fällen jugendlicher Alkoholintoxikationen assoziiert? - Sind betroffene Jugendliche im Vergleich zu Peers aus der Allgemeinbevölkerung gefährdeter hinsichtlich Alkoholgebrauchsstörungen und Substanzgebrauch? - Haben Kinder und Jugendliche, die aufgrund einer Alkoholintoxikation stationär behandelt wurden, ein erhöhtes Risiko, im jungen Erwachsenenalter eine Alkoholgebrauchsstörung und andere psychosoziale Probleme zu entwickeln, verglichen mit minderjährigen Patienten, die aus nicht-alkoholassoziierten Gründen behandelt wurden? - Welche Faktoren, die zum Zeitpunkt der stationär behandelten Alkoholintoxikation im Kindes- bzw. Jugendalter bekannt sind, sagen psychosoziale Outcome-Variablen im jungen Erwachsenenalter voraus? Die genannten Fragen sollen mit drei Studien beantwortet werden. Material und Methode Studie 1: In dieser naturalistischen Querschnittsuntersuchung wurden 65 Kinder und Jugendliche (Durchschnittsalter: MW (SD) 15,2 (1,6) Jahre), die stationär aufgrund von Alkoholintoxikation in den beiden Dresdner Kinderkliniken behandelt wurden, am Tag nach der Aufnahme am Krankenbett mündlich und schriftlich befragt. Die Datenerhebung erfolgte zwischen Mai 2009 und September 2010. Neben der Prävalenz des Substanzkonsums und von Alkoholgebrauchsstörungen, wurden auch bekannte Risikofaktoren für problematischen Alkoholgebrauch erhoben, wie das wahrgenommene elterliche Erziehungsverhalten, die Familienanamnese für Alkoholprobleme, deviante Verhaltensweisen der Freunde, Alkoholtoleranz und Alter des Alkoholerstkonsums. Studie 2 und Studie 3: Beide Studien entstanden im Rahmen des RiScA-Projekts (Risiko- und Schutzfaktoren bei Alkoholvergiftungen im Kindes- und Jugendalter) und beziehen sich auf dieselbe Stichprobe. In diesem Projekt wurden die Krankenakten von 1603 Fällen von jugendlichen Alkoholintoxikationen, die im Zeitraum von 2000 bis 2007 in einem von fünf Kinderkliniken (Universitätsklinikum Carl Gustav Carus, Städtisches Klinikum Dresden-Neustadt, HELIOS Klinikum Pirna, Universitätsmedizin Rostock, Münchner Klinikum Schwabing) stationär behandelt wurden, analysiert (Intoxikationsgruppe). Die Akten wurden systematisch hinsichtlich geeigneter Prädiktorvariablen, die die psychosoziale Langzeitentwicklung nach der Krankenhausbehandlung vorhersagen sollen, ausgewertet. Die Langzeitkatamnese wurde realisiert, indem die ehemaligen Patienten zur Teilnahme an einem standardisierten Telefoninterview eingeladen wurden. Zusätzlich wurde eine hinsichtlich Alter, Geschlecht und geographischer Region gematchte Kontrollgruppe telefonisch interviewt, die im selben Untersuchungszeitraum und in den selben Kinderkliniken stationär behandelt wurde aufgrund anderer, nicht-alkoholassoziierter Gründe. In der Intoxikationsgruppe nahmen 277 (Durchschnittsalter: MW (SD) 24,3 (2,3) Jahre) und in der Kontrollgruppe 116 junge Erwachsene (MW (SD) 23,9 (2,1) Jahre) am Telefoninterview teil (Beobachtungszeitraum seit der Krankenhausbehandlung: 5–13 Jahre (MW (SD) 8,3 (2,3) Jahre)). Folgende Outcome-Variablen des Langzeitverlaufs wurden erhoben: Konsum von Alkohol, Tabak und illegalen Substanzen, Vorliegen von Alkoholgebrauchsstörungen, allgemeine Lebenszufriedenheit, Delinquenz und Inanspruchnahme psychiatrischer/psychotherapeutischer Behandlungen. Ergebnisse Studie 1: Es zeigten sich erhöhte Prävalenzwerte für Alkoholabhängigkeit und -missbrauch, Rauschtrinken, regelmäßiges Rauchen und Gebrauch illegaler Drogen im Vergleich zu Daten aus der Allgemeinbevölkerung. Kein Unterschied wurde jedoch in Bezug auf die Häufigkeit des Alkoholkonsums, verglichen mit der Allgemeinbevölkerung, gefunden. Weiterhin zeigte sich, dass Patienten, die problematischen habituellen Alkoholkonsum betrieben – verglichen mit Patienten, auf die dies nicht zutraf – signifikant häufiger deviante Verhaltensweisen bei ihrem Freundeskreis, eine signifikant höhere Anzahl von Familienmitgliedern, die ein Alkoholproblem haben, berichteten, eine höhere Alkoholtoleranz, gemessen durch den Self-Rating of the Effects of Alcohol (SRE) - Fragebogen, erreichten und häufiger elterliche Erziehungsverhaltensweisen berichteten, die durch weniger Aufsicht gekennzeichnet waren. Studie 2: Die Probanden der Intoxikationsgruppe betrieben signifikant häufiger problematischen habituellen Alkoholkonsum, berichteten häufiger delinquente Verhaltensweisen und den Gebrauch illegaler Drogen und erfüllten häufiger die DSM-5-Kriterien einer schweren Alkoholgebrauchsstörung verglichen mit der Kontrollgruppe. Die Mehrheit der Probanden berichtete jedoch keine psychosozialen Belastungen. Keine signifikanten Unterschiede zwischen beiden Gruppen zeigten sich beim Bildungsgrad, regelmäßigen Rauchen, der allgemeinen Lebenszufriedenheit und der Inanspruchnahme von psychiatrischer oder psychotherapeutischer Behandlungen. Studie 3: 277 junge Erwachsene (Rücklaufquote: 22,7%) konnten nach durchschnittlich 8 Jahren nach der Klinikbehandlung befragt werden. Es zeigte sich mittels logistischer und linearer Regressionsmodelle, dass vor allem die Variablen männliches Geschlecht, Gebrauch illegaler Drogen und deviante Verhaltensweisen im Jugendalter, wie mehrmaliges Schulschwänzen oder Weglaufen von Zuhause, psychosoziale Outcome-Maße im jungen Erwachsenenalter, wie Rauschtrinken, Alkoholabhängigkeit, den Gebrauch illegaler Drogen und eine geringe allgemeine Lebenszufriedenheit signifikant vorhersagten. Die durch die Regressionsmodelle erklärte Varianz der im jungen Erwachsenenalter erhobenen psychosozialen Outcome-Variablen lag jedoch nur bei 13 bis 24%. Schlussfolgerungen Für Kinder und Jugendliche, die mit einer Alkoholintoxikation stationär behandelt wurden, besteht ein erhöhtes Risiko, bis zum jungen Erwachsenenalter eine schwere Alkoholgebrauchsstörung oder andere psychosoziale Probleme entwickelt zu haben. Allerdings war die Mehrheit der Probanden sowohl im Kindes- und Jugendalter (Studie 1) als auch im jungen Erwachsenenalter (Studie 2 und 3) nicht von Alkoholgebrauchs-störungen oder anderen negativen Entwicklungsaspekten betroffen. Der überwiegende Teil der betroffenen Kinder und Jugendlichen war scheinbar unerfahren im Gebrauch von Alkohol und/oder besaß eine geringe Alkoholtoleranz. Es kann jedoch nicht ausgeschlossen werden, dass eine besonders belastete Subgruppe existiert, die bereits Suchterkrankungen und/oder andere Verhaltensprobleme aufweisen, wobei das exzessive Trinkverhalten, das der stationären Behandlung vorausging, möglicherweise auf zugrundeliegende Entwicklungsgefährdungen hinweist. Interventionen sollten daher das problematische Trinkverhalten nicht losgelöst vom sozialen Umfeld, wie beispielsweise den Eltern, betrachten. Um besonders gefährdete Kinder und Jugendliche besser identifizieren zu können, sollten vor allem die Verlaufsprädiktoren männliches Geschlecht, Gebrauch illegaler Drogen und Verhaltensauffälligkeiten wie Schulschwänzen und Weglaufen von zu Hause (Studie 3) z. B. in Präventions- und Interventions-maßnahmen Beachtung finden. / Summary Background Alcohol use by young people is widespread and alcohol is the most frequently used psychoactive substance in Europe still before nicotine. Individual and societal consequences of adolescent alcohol use are far reaching, as it is considered to be the most important risk factor for morbidity and mortality among young people in the Western world (Rehm et al., 2006). Against this background, the worrying trend of increasing numbers of adolescents admitted to inpatient treatment with alcohol intoxication (AIA) since the 2000s has gained attention in Germany and other European countries. Alcohol intoxication with a high level of blood alcohol concentration can be life-threatening if untreated. The number of AIA more than tripled in the period from 2000 to 2012 and compared with all other age groups, 15- to 20-year-olds were the largest group measured in terms of the number of treated individuals per 100 000 peers. However, meaningful empirical data concerning the prevalence of alcohol use disorders (AUD) in AIA and which factors are associated with problematic habitual alcohol use in this patient population are lacking. Moreover, the long-term psychosocial development of AIA is still unknown, while this information is crucial for identifying high-risk patients. Research questions The present thesis addresses the following research questions: Study 1: Which biopsychosocial factors are associated with problematic habitual alcohol use in cases of AIA? Are the prevalences of substance use and AUDs in AIA elevated compared to adolescents from the general population? Study 2: Do AIA have an increased risk to develop AUD and other adverse psychosocial outcomes in young adulthood compared to their peers? Study 3: Which variables at the time of hospital admission in adolescence predict psychosocial outcomes in young adulthood in cases of AIA? Methods Study 1: In this cross-sectional naturalistic study 65 AIA (M and SD age 15.2 ± 1.6 yr) completed questionnaires and were interviewed the morning after admission. The study was conducted between May 2009 and September 2010 in both pediatric hospitals in the City of Dresden, Germany, i.e., the University Hospital Carl Gustav Carus and the Municipal Hospital Dresden-Neustadt. Assessment included substance use, alcohol use disorders and known risk factors for problematic alcohol use such as perceived parental monitoring, family history of alcohol problems, deviant peer affiliations, alcohol tolerance, and age of first drink. Study2: Study 2 and study 3 originated from the RiScA project (Risk and Protective Factors in the Context of Acute Alcohol Intoxication in Childhood and Adolescence; German: Risiko- und Schutzfaktoren nach Alkoholvergiftungen im Kindes- und Jugendalter). In this study, 277 young adults (mean age 24.3 years (SD 2.3)) who had been hospitalized due to alcohol intoxication in one of five pediatric departments (University Hospital Carl Gustav Carus, Municipal Hospital Dresden-Neustadt, HELIOS Hospital Pirna, Municipal Hospital Schwabing, University Medicine Rostock) 5 – 13 years ago (mean 8.3 years (SD 2.3)) between 2000 and 2007 participated in a standardized telephone interview. The interview was also conducted with a control group consisting of 116 former patients (mean age 23.9 years (SD 2.1)) matched in terms of age, sex and geographic region who were admitted to the same hospitals in the same period due to conditions other than alcohol intoxication in adolescence. Long-term outcome measures included current DSM-5 AUD, drinking patterns, illicit substance use, regular smoking, general life satisfaction, use of mental health treatment, and delinquency. Study 3: 1603 cases of AIA who had been hospitalized in the same period and in the same hospitals as in Study 2 were identified. These former patients were invited to participate in a standardized telephone interview in young adulthood collecting the following long-term psychosocial outcomes: binge-drinking, alcohol abuse and alcohol dependence (according to DSM-IV), illicit substance use, general life satisfaction, delinquency, and use of psychiatric or psychotherapeutic treatment. Medical records of AIA were retrospectively analyzed extracting potential variables predicting psychosocial long-term outcomes in young adulthood. Results Study 1: Elevated prevalence rates were found for alcohol abuse, alcohol dependence, binge drinking, regular smoking, and illicit substance in AIA compared to adolescents from the general population. No difference was found with respect to frequency of alcohol use compared with the general population. Exploratory analyses revealed that deviant peer affiliations, a positive family history of alcoholism, an elevated alcohol tolerance, and a parenting style characterized by less supervision and strictness were associated with problematic habitual alcohol use. Study 2: AIA had a significantly elevated risk to engage in problematic habitual alcohol use, to exhibit delinquent behaviors, and to use illicit substances in young adulthood compared to the control group. Severe AUD also occurred considerably more often in the AIA than the control group. However, the majority of participants did not report adverse psychosocial outcomes. No significant differences between the study groups were found regarding level of education, regular smoking, general life satisfaction and use of psychiatric or psychotherapeutic treatment. Study 3: 277 young adults (response rate: 22.7%) could be interviewed 5–13 (mean 8.3 (SD 2.3)) years after hospital treatment. Logistic and linear regression models revealed that being male, using illicit substances and truancy or runaway behavior in adolescence predicted binge drinking, alcohol dependence, use of illicit substances and poor general life satisfaction in young adulthood, explaining between 13 and 24% of the variance for the different outcome variables. Conclusions AIA are at an elevated risk to develop severe AUD or other psychosocial problems in young adulthood. However, the majority of participants both in childhood and adolescence (Study 1) and young adulthood (Study 2 and 3) was not affected by AUD or other developmental hazards. It seems that the greater part of AIA were inexperienced drinkers and / or had a low alcohol tolerance. However, it cannot be ruled out that a particularly vulnerable subgroup exist which already developed AUD and / or other behavioral problems. To better identify high-risk AIA, the predictor variables being male, illicit substance use and behavioral problems such as truancy or runaway behavior in adolescence (Study 3) should be practically included in prevention programs and brief interventions.

Daten der SESAM 2-Studie wurden analysiert, um die Konsultationsprävalenz, Beratungsergebnisse und Therapie von Patienten mit den Symptomen Übelkeit und/oder Erbrechen sowie die Beratungsanlässe von Kinder und Jugendlichen auszuwerten. Dazu wurden 8874 Patienten in dem Zeitraum vom 01.10.1999 bis 30.09.2000 von 270 teilnehmenden sächsischen Hausärzten untersucht und die Ergebnisse in standardisierten Antwortbögen dokumentiert. Zusätzlich wurden die erhobenen Daten mit anderen internationalen Studien verglichen (Dutch Transition Project, Beach Studie). 9,1% der Patienten, die ihren Hausarzt aufsuchten, waren zwischen 0 und 19 Jahren alt. Kinder und Jugendliche stellen sich zumeist auf Grund von Husten, Fieber, Schnupfen und Halsbeschwerden bei ihrem Hausarzt vor. Die Konsultationsprävalenz dieser Patientengruppe lag zwischen 10,2% im April und 6,2% im August. Mit steigendem Alter ist eine Zunahme des Spektrums unterschiedlicher Beratungsanlässe zu verzeichnen. Es ist daher unerlässlich für den Allgemeinmediziner Erfahrungen in der Anamnese, Diagnostik und Behandlung von Erkrankungen im Kindes- und Jugendalter zu sammeln. Die Konsultationsprävalenz für Übelkeit und Erbrechen lag in unserer Studie für alle Altersgruppen zusammen bei 1,9%. Kinder und Jugendliche litten im Vergleich zu Erwachsenen häufiger unter diesen Symptomen. Geschlechtsspezifische Unterschiede fanden sich nicht. Bei lediglich 4,1% der diesbezüglichen Konsultationen wurden diagnostische Maßnahmen ergriffen, die über eine körperliche Untersuchung hinausgingen. Die am häufigsten gestellte Diagnose bei diesen Beschwerden war eine nicht-infektiöse Gastroenteritis. In 76,3% der Fälle wurden zur Behandlung Medikamente verordnet. Übelkeit und/oder Erbrechen ist ein häufiger Konsultationsanlass. Potentiell abwendbar gefährliche Verläufe sind selten.

Background: Long-term health sequelae of the Coronavirus Disease 2019 (COVID-19) are a major public health concern. However, evidence on post-acute COVID-19 syndrome (post-COVID-19) is still limited, particularly for children and adolescents. Utilizing comprehensive healthcare data on approximately 46% of the German population, we investigated post-COVID-19-associated morbidity in children/adolescents and adults. Methods and findings: We used routine data from German statutory health insurance organizations covering the period between January 1, 2019 and December 31, 2020. The base population included all individuals insured for at least 1 day in 2020. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through June 30, 2020. A control cohort was assigned using 1:5 exact matching on age and sex, and propensity score matching on preexisting medical conditions. The date of COVID-19 diagnosis was used as index date for both cohorts, which were followed for incident morbidity outcomes documented in the second quarter after index date or later.Overall, 96 prespecified outcomes were aggregated into 13 diagnosis/symptom complexes and 3 domains (physical health, mental health, and physical/mental overlap domain). We used Poisson regression to estimate incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs). The study population included 11,950 children/adolescents (48.1% female, 67.2% aged between 0 and 11 years) and 145,184 adults (60.2% female, 51.1% aged between 18 and 49 years). The mean follow-up time was 236 days (standard deviation (SD) = 44 days, range = 121 to 339 days) in children/adolescents and 254 days (SD = 36 days, range = 93 to 340 days) in adults. COVID-19 and control cohort were well balanced regarding covariates. The specific outcomes with the highest IRR and an incidence rate (IR) of at least 1/100 person-years in the COVID-19 cohort in children and adolescents were malaise/fatigue/exhaustion (IRR: 2.28, 95% CI: 1.71 to 3.06, p < 0.01, IR COVID-19: 12.58, IR Control: 5.51), cough (IRR: 1.74, 95% CI: 1.48 to 2.04, p < 0.01, IR COVID-19: 36.56, IR Control: 21.06), and throat/chest pain (IRR: 1.72, 95% CI: 1.39 to 2.12, p < 0.01, IR COVID-19: 20.01, IR Control: 11.66). In adults, these included disturbances of smell and taste (IRR: 6.69, 95% CI: 5.88 to 7.60, p < 0.01, IR COVID-19: 12.42, IR Control: 1.86), fever (IRR: 3.33, 95% CI: 3.01 to 3.68, p < 0.01, IR COVID-19: 11.53, IR Control: 3.46), and dyspnea (IRR: 2.88, 95% CI: 2.74 to 3.02, p < 0.01, IR COVID-19: 43.91, IR Control: 15.27). For all health outcomes combined, IRs per 1,000 person-years in the COVID-19 cohort were significantly higher than those in the control cohort in both children/adolescents (IRR: 1.30, 95% CI: 1.25 to 1.35, p < 0.01, IR COVID-19: 436.91, IR Control: 335.98) and adults (IRR: 1.33, 95% CI: 1.31 to 1.34, p < 0.01, IR COVID-19: 615.82, IR Control: 464.15). The relative magnitude of increased documented morbidity was similar for the physical, mental, and physical/mental overlap domain. In the COVID-19 cohort, IRs were significantly higher in all 13 diagnosis/symptom complexes in adults and in 10 diagnosis/symptom complexes in children/adolescents. IRR estimates were similar for age groups 0 to 11 and 12 to 17. IRs in children/adolescents were consistently lower than those in adults. Limitations of our study include potentially unmeasured confounding and detection bias. Conclusions: In this retrospective matched cohort study, we observed significant new onset morbidity in children, adolescents, and adults across 13 prespecified diagnosis/symptom complexes, following COVID-19 infection. These findings expand the existing available evidence on post-COVID-19 conditions in younger age groups and confirm previous findings in adults

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A dor é um evento estressante para crianças e adolescentes e pode ter consequências negativas fisiológicas, psicológicas e comportamentais ainda mais quando é acompanhada por uma doença crônica, sem possibilidades de cura. Nesse sentido, o Cuidado Paliativo Pediátrico é uma filosofia de cuidado que deve ser instituída desde o diagnóstico da doença até que esta não responda mais às intervenções curativas. Assim, o foco do cuidado passa a ser a maximização da qualidade de vida que a criança e o adolescente e seus familiares necessitam, enquanto o sofrimento e a dor são minimizados. Considerando-se o caráter único da experiência de dor da criança e do adolescente, em cuidados paliativos, optou-se por desenvolver um estudo com abordagem qualitativa. Utilizamos como referencial teórico a Teoria de Desenvolvimento Cognitivo de Piaget e, como referencial metodológico, a História Oral. Tais referenciais são fundamentais para ancorar os resultados encontrados neste estudo e responder ao objetivo geral de conhecer a experiência da criança e do adolescente em cuidados paliativos no manejo diário da dor e aos objetivos específicos de conhecer como a criança e o adolescente em cuidados paliativos descrevem a intensidade, a qualidade e a localização da dor e de conhecer como a criança e o adolescente em cuidados paliativos manejam a dor em seu cotidiano. Permitem, igualmente, que crianças e adolescentes, de 6 a 17 anos 11 meses e 29 dias, portadores de uma doença crônica que causava dor e que estavam em cuidados paliativos e matriculados em um Ambulatório de Dor e Cuidados Paliativos de um Hospital Escola Pediátrico de caráter público de nível terciário tenham voz. Crianças em idade escolar descreveram sua dor a partir de componentes sensoriais e avaliativos. Os adolescentes, por outro lado, expressaram sua dor utilizando componentes sensoriais, avaliativos, afetivos e de miscelânea. Dos seis colaboradores deste estudo, cinco ainda frequentam a escola e relacionam-se com crianças e adolescentes da mesma faixa etária. Todos os colaboradores fazem uso de medicamentos e de alternativas não farmacológicas para o alívio da dor, como massagem, hidroterapia, acupuntura e crioterapia, constatando melhora em sua dor. Alguns colaboradores precisam lidar com sua aparência física prejudicada pela doença. Apesar da dificuldade de se entrevistar crianças e adolescentes, percebemos que eles têm muito a dizer e a nos ensinar, principalmente como eles lidam com a dor em seu cotidiano. Este trabalho é importante para que os profissionais de saúde compreendam que, com um adequado manejo da dor, crianças e adolescentes conseguem ter uma vida mais próxima da normalidade, reduzindo seu sofrimento. / Pain is a stressful event for children and adolescents and can have negative consequences - physiological, psychological and behavioral ones even more when it is accompanied by a chronic disease with no possibility of cure. In this context, the Pediatric Palliative Care is a philosophy of care that must be instituted from the diagnosis until the illness no longer responds to curative interventions. Therefore, the focus of care is to provide the highest quality of life possible to children and adolescents and their families while minimizing suffering and pain. Considering the uniqueness of the experience of pain in children and adolescents in palliative care, we chose to develop a qualitative study. We used the Theory of Cognitive Development Piaget as theoretical framework and the Oral History as the methodological one. Such references are essential to support the results found in this study and to address the overall objective of knowing the experience of the child and adolescent in palliative care for the daily management of pain as well as the specific goals of knowing how the children and adolescents in palliative care describe the intensity, quality and location of pain and of knowing how children and adolescents in palliative manage pain in their daily lives. Moreover, these frameworks allow that children and adolescents (from 6 to 17 years 11 months and 29 days), suffering from a chronic disease that caused pain and in palliative care and who were enrolled in an Outpatient Pain and Palliative Care of a public tertiary Pediatric Teaching Hospital character, have a voice. School children described their pain using sensory and evaluative components. Teenagers, on the other hand, expressed their pain using sensory, evaluative, affective and miscellaneous ones. Of the six collaborators to this study, five are still in school and relate to children and adolescents of the same age. All collaborators use drugs and non-pharmacological alternatives for pain relief such as massage, hydrotherapy, acupuncture and cryotherapy, reporting improvement in their pain. Some collaborators need to deal with their physical appearance which is affected by the disease. Despite the difficulty of interviewing children and teenagers, we have realized that they have a lot to say and to teach us, especially with regard to how they deal with pain in their daily lives. The present work is important for health professionals to understand that, with adequate pain management, children and adolescents can live a life as normal as possible, thus reducing their suffering.

Background: The vast majority of infants born with congenital heart disease (CHD) reach adulthood because of the developments in cardiology in recent decades. This thesis aims to describe the psychosocial situation of child/adolescent cardiac patients and their families, investigate the situation faced by parents and siblings initially and over time, investigate the approaches paediatric cardiologists use in encountering the family, and describe the teamwork occurring in paediatric cardiology teams (PCTs) in Sweden. Theoretical framework: The theoretical framework was based on a quality of life model applied to children, a stress-coping model, and a psychosocial approach including support, profession, and teamwork. Methods: The research combines quantitative data collection/analysis and qualitative research interviews/content analysis. Results: Complexity: The three grades of medical complexity differed regarding the number and severity of psychosocial symptoms, the children with the most complex CHD having the most severe symptoms. The most frequent symptoms in the whole patient group regarding various spheres were: healthcare and treatment-related needs in the external sphere, family symptoms in the interpersonal sphere, and mental/psychosomatic symptoms in the personal sphere. Coping: Being informed of a child’s/sibling’s heart disease has emotional consequences, so information, communication, and support are essential. Breaking the news of a child’s disease can be described as a turning point still significant after ten years. The professionalism of the doctor’s approach in breaking the news is crucial. Profession: Among paediatric cardiologists, how to break bad news to a family is an important concern, evident in findings regarding the significance of trust and confidence and the use of various emotional positions. Paediatric cardiologists commonly wish to be skilled at handling this situation, and attaining the needed skills calls for reflection, education, and sharing experience. Team: PCTs in Sweden aim and try to work in a structured way. In PCTs, there is a need for leadership, resource coordination, coaching, and a forum for joint reflection. Dependence on the physician on the team was identified in all PCTs. The challenge of managing increasing complexity at both the family and system levels requires interprofessional teams. Conclusions: These studies illustrate the psychosocial complexity and the need of psychosocial support. Emotional consequences, communication, information and support are essential both for the children, parents/families and for the professionals. To manage this complexity organizational alteration action plans are required. There is a need for a forum to stimulate dialogue and common reflection in the local PCT and at the regional and national centres.

A dor é um evento estressante para crianças e adolescentes e pode ter consequências negativas fisiológicas, psicológicas e comportamentais ainda mais quando é acompanhada por uma doença crônica, sem possibilidades de cura. Nesse sentido, o Cuidado Paliativo Pediátrico é uma filosofia de cuidado que deve ser instituída desde o diagnóstico da doença até que esta não responda mais às intervenções curativas. Assim, o foco do cuidado passa a ser a maximização da qualidade de vida que a criança e o adolescente e seus familiares necessitam, enquanto o sofrimento e a dor são minimizados. Considerando-se o caráter único da experiência de dor da criança e do adolescente, em cuidados paliativos, optou-se por desenvolver um estudo com abordagem qualitativa. Utilizamos como referencial teórico a Teoria de Desenvolvimento Cognitivo de Piaget e, como referencial metodológico, a História Oral. Tais referenciais são fundamentais para ancorar os resultados encontrados neste estudo e responder ao objetivo geral de conhecer a experiência da criança e do adolescente em cuidados paliativos no manejo diário da dor e aos objetivos específicos de conhecer como a criança e o adolescente em cuidados paliativos descrevem a intensidade, a qualidade e a localização da dor e de conhecer como a criança e o adolescente em cuidados paliativos manejam a dor em seu cotidiano. Permitem, igualmente, que crianças e adolescentes, de 6 a 17 anos 11 meses e 29 dias, portadores de uma doença crônica que causava dor e que estavam em cuidados paliativos e matriculados em um Ambulatório de Dor e Cuidados Paliativos de um Hospital Escola Pediátrico de caráter público de nível terciário tenham voz. Crianças em idade escolar descreveram sua dor a partir de componentes sensoriais e avaliativos. Os adolescentes, por outro lado, expressaram sua dor utilizando componentes sensoriais, avaliativos, afetivos e de miscelânea. Dos seis colaboradores deste estudo, cinco ainda frequentam a escola e relacionam-se com crianças e adolescentes da mesma faixa etária. Todos os colaboradores fazem uso de medicamentos e de alternativas não farmacológicas para o alívio da dor, como massagem, hidroterapia, acupuntura e crioterapia, constatando melhora em sua dor. Alguns colaboradores precisam lidar com sua aparência física prejudicada pela doença. Apesar da dificuldade de se entrevistar crianças e adolescentes, percebemos que eles têm muito a dizer e a nos ensinar, principalmente como eles lidam com a dor em seu cotidiano. Este trabalho é importante para que os profissionais de saúde compreendam que, com um adequado manejo da dor, crianças e adolescentes conseguem ter uma vida mais próxima da normalidade, reduzindo seu sofrimento. / Pain is a stressful event for children and adolescents and can have negative consequences - physiological, psychological and behavioral ones even more when it is accompanied by a chronic disease with no possibility of cure. In this context, the Pediatric Palliative Care is a philosophy of care that must be instituted from the diagnosis until the illness no longer responds to curative interventions. Therefore, the focus of care is to provide the highest quality of life possible to children and adolescents and their families while minimizing suffering and pain. Considering the uniqueness of the experience of pain in children and adolescents in palliative care, we chose to develop a qualitative study. We used the Theory of Cognitive Development Piaget as theoretical framework and the Oral History as the methodological one. Such references are essential to support the results found in this study and to address the overall objective of knowing the experience of the child and adolescent in palliative care for the daily management of pain as well as the specific goals of knowing how the children and adolescents in palliative care describe the intensity, quality and location of pain and of knowing how children and adolescents in palliative manage pain in their daily lives. Moreover, these frameworks allow that children and adolescents (from 6 to 17 years 11 months and 29 days), suffering from a chronic disease that caused pain and in palliative care and who were enrolled in an Outpatient Pain and Palliative Care of a public tertiary Pediatric Teaching Hospital character, have a voice. School children described their pain using sensory and evaluative components. Teenagers, on the other hand, expressed their pain using sensory, evaluative, affective and miscellaneous ones. Of the six collaborators to this study, five are still in school and relate to children and adolescents of the same age. All collaborators use drugs and non-pharmacological alternatives for pain relief such as massage, hydrotherapy, acupuncture and cryotherapy, reporting improvement in their pain. Some collaborators need to deal with their physical appearance which is affected by the disease. Despite the difficulty of interviewing children and teenagers, we have realized that they have a lot to say and to teach us, especially with regard to how they deal with pain in their daily lives. The present work is important for health professionals to understand that, with adequate pain management, children and adolescents can live a life as normal as possible, thus reducing their suffering.

This master's thesis studies effective intervention in chat-based crisis support. This topic is especially relevant, as children, adolescents and young adults have been becoming more interested in such services in the Czech Republic. The theoretical part provides a window into the field of crisis support and elaborates on details of crisis intervention. It presents selected models, approaches, methods, and techniques of crisis intervention. The thesis also describes social support, effectivity, and effective intervention and connects these issues with the topic of crisis intervention. The main aim of this part is to focus on chat-based crisis intervention and its specific features when concerning children and young adults. The empirical part presents a mixed methods study conducted in the Safety line organization, which operates an important nation-wide hotline for children and young adults. In the study, clients and consultants were asked to evaluate the conversation that had just ended by filling out a questionnaire. The chat records were then analyzed in the next part of the study. Key words chat-based crisis intervention, chat counselling, children, adolescents, young adults, effectivity, effective approaches, Safety line / Child Helpline