I Sverige lever 44 procent av befolkningen med en kronisk sjukdom. En kronisk sjukdom definieras som ett långt sjukdomstillstånd eller livslång sjukdom, exempelvis typ 1-diabetes. Till varje person som lever med typ 1-diabetes finns anhöriga som blir delaktiga i sjukdomen. För anhöriga kan det väcka känslor som rädsla, ilska samt hjälplöshet. Trots detta är anhöriga åsidosatta av vården och lämnade med ett behov av stöd, information samt kontakt. Följaktligen väcktes en nyfikenhet hos författarna kring hur sjuksköterskan kan stödja anhöriga vilket gav upphov till studiens syfte. Studiens syfte är att belysa anhörigas behov av stöd utifrån deras upplevelse av att leva med en person med typ 1-diabetes. Studien är en litteraturöversikt där författarna har studerat tio vetenskapliga artiklar vilka svarade mot studiens syfte. Vidare analyserades artiklarna enligt Fribergs analysprocess, varav nio artiklar var kvalitativa samt en var kvantitativ. Analysen av artiklarna formade ett tema; En tillvaro präglad av förändring och att vara i ständig beredskap. Vidare påvisas detta tema med fem inkluderande subteman som innefattar behov av stöd i att bearbeta känslor, behov av strategier för att hantera vardagen, behov av kunskap, behov av strategier för att hantera oro samt behov av stöd vid olika skeenden samt tidpunkter i livet. I diskussionen sker en fördjupning av resultatet med stöd från ny forskning. Slutligen sammanfattas studien med kliniska implikationer samt förslag på fortsatt forskning. / In Sweden, 44 percent of the population lives with a chronic illness. A chronic illness is defined as a long-term illness or lifelong illness, for example type 1-diabetes. For every person living with type 1-diabetes, there are relatives who become involved in the disease. For relatives, it can arouse emotions such as fear, anger and helplessness. Despite this, relatives are ignored by the care and left with a need for support, information and contact. According to this curiosity was aroused with the authors about how the nurse can support relatives, which gave rise to the purpose of the study. The purpose of the study is to shed light on relatives' need for support based on their experience of living with a person with type 1 diabetes. The study is a literature review where the authors have studied ten scientific articles that answered the purpose of the study. Furthermore, the articles were analyzed according to Friberg's analysis process, of which nine articles were qualitative and one was quantitative. The analysis of the articles formed a theme; A life marked by change and being on constant alert. Furthermore, this theme is demonstrated with five sub-themes that include the need for support in processing emotions, the need for strategies for dealing with everyday life, the need for knowledge, the need for strategies for dealing with anxiety and the need for support at different events and times in life. In the discussion, there is an in-depth look of the results with support from new research that is being highlighted. Finally, the study is summarized with clinical implications and suggestions for further research.

Aims: Work-related diabetes distress (WRDD) can be defined as the combination of anxiety and exhaustion to combine work with diabetes in working life and this is a current problem. The aims of this study were to assess the prevalence of WRDD and covariation between WRDD and working life variables relevant to occupational health among professionals diagnosed with type 1 diabetes in Sweden. Method: This is a quantitative cross-sectional study in the form of a survey. The sample was a closed group on Facebook for people with type 1 diabetes, all members were offered to answer a questionnaire with validated questions about psychosocial working conditions, work requirements, work ability, diabetes acceptance and blood sugar levels. To investigate the occurrence of WRDD, descriptive analyses and cross-tabulation were carried out. Logistic regression analysis was used to investigate associations between the dependent variable (WRDD) and the independent variables (psychosocial working conditions, work requirements, work ability, diabetes acceptance and blood sugar levels). Main result: The survey was answered by 191 respondents. The incidence of WRDD in the sample was 71.7%. The multiple logistic regression analysis showed a significant relationship (p <0.05) between the independent variables work ability, blood sugar level, diabetes acceptance, and the dependent variable WRDD. The odds of having WRDD were three times higher in those individuals who experienced poorer work ability, had difficulty accepting their diabetes or maintained a higher blood sugar level at work. Conclusions: The results showed that WRDD is a problem causing working life consequences and should be given more attention both in healthcare and working life. Increased knowledge and understanding of the challenges WRDD can cause for people with type 1 diabetes in working life is necessary to be able to prevent WRDD. / Syfte: Work-related diabetes distress (WRDD) kan definieras som en kombination av oro för och utmattning av att förena arbete med diabetes i arbetslivet och är ett aktuellt problem. Studiens syfte var att studera förekomsten av WRDD och samvariationen mellan WRDD och andra arbetsrelaterade variabler relevanta för arbetshälsa bland yrkesverksamma diagnostiserade med typ 1 diabetes i Sverige. Metod: Studien var en kvantitativ tvärsnittsstudie i form av en enkätundersökning riktad till yrkesverksamma personer med typ 1 diabetes. Urvalet var en sluten grupp på Facebook för personer med typ 1 diabetes, alla medlemmar i gruppen fick erbjudande om att svara på en enkät innehållande validerade frågor om psykosociala arbetsförhållanden, arbetskrav, arbetsförmåga, diabetesacceptans och blodsockernivå. För att undersöka hur förekomsten av WRDD såg ut genomfördes deskriptiva analyser och korstabulering. Logistisk regressionsanalys användes för att undersöka om det fanns samband mellan den beroende variabeln (WRDD) och de oberoende variablerna (psykosociala arbetsförhållanden, arbetskrav, arbetsförmåga, diabetesacceptans och blodsockernivå). Huvudresultat: Enkäten besvarades av 191 respondenter. Förekomsten av WRDD hos de svarande var 71,7%. Den multipla logistiska regressionsanalysen visade ett signifikant samband (p <0.05) mellan arbetsförmåga, blodsockernivå, diabetesacceptans och WRDD. Oddsen för att ha WRDD var tre gånger högre hos de individer som upplevde sämre arbetsförmåga, hade svårt att acceptera sin diabetes eller höll en högre blodsockernivå på arbetet. Slutsatser: Resultaten visade att WRDD är ett problem med arbetslivskonsekvenser som behöver uppmärksammas mer både inom vården och i arbetslivet. Ökad kunskap och förståelse för de utmaningar WRDD kan medföra för personer med typ 1 diabetes i arbetslivet är nödvändigt för att kunna förebygga WRDD.

Bakgrund  Övergången från ung till vuxen med sin uppsjö av nya upplevelser ses ofta som en utmaning av många. Att få diagnosen diabetes mellitus typ 1 innebär en ny omställning och ett stort ansvarstagande för individen. Den unge vuxnes välbefinnande och hälsa beror till stor del på deras förmåga till egenvård. Sjuksköterskans kompetens samt undervisning- och handledningsförmåga är av stor betydelse för patienter som diagnostiseras med sjukdomen. Sjuksköterskor behöver därför ha förståelse för hur sjukdomen upplevs för att en god vägledning i den nya livsstilen ska kunna ges.  Syfte  Syftet med denna studie var att beskriva unga vuxnas upplevelser av egenvård vid diabetes mellitus typ 1.  Metod  En icke-systematisk litteraturöversikt genomfördes där 15 kvalitativa vetenskapliga artiklar inkluderades och låg till grund för resultatet. Med hjälp av olika sökkombinationer i databaserna PubMed och CINAHL kunde artiklarna inhämtas och kvalitetsgranskas utifrån Sophiahemmet Högskolas bedömningsunderlag. Därefter genomfördes en integrerad dataanalys av de valda resultatartiklarna och sorterades in i huvudkategorier och subkategorier.  Resultat  Tre huvudkategorier och nio subkategorier identifierade. Huvudkategorierna var: Känslomässiga upplevelser hos unga vuxna med diabetes, Utmaningar vid egenvården av diabetes och Stödet till egenvård vid diabetes. Resultatet visade på att rädsla och oro inför komplikationer som kan uppstå i vardagen var en gemensam känsla bland deltagarna, precis som känslan av trygghet från familj och vänner upplevdes som välbehövlig av samtliga.  Slutsats  Resultatet visade på gemensamma upplevelser kring utmaningar som de unga vuxna stöter på i sin vardag. Dessa upplevda utmaningar kan undvikas om omgivningen får rätt kunskap om sjukdomen och fortsätter stödja de unga vuxna i sin behandling. Ansvaret ligger huvudsakligen hos den unga vuxna, men med stöd från sjukvården samt familj och vänner stärks individens förmåga att klara av sin egenvård. / Background  The transition from juvenile to adult with its plethora of new experiences is often seen as a challenge by many. Receiving the life-long diabetes mellitus type 1 during this transitional phase, fundamentally changes an individual ́s everyday life and requires the individual to adapt to a new reality of self-care. A great deal of responsibility follows along being diagnosed with type 1 diabetes which means that guidance and support is in the nurses hands. The nurse's role in aiding the patient in their disease management is significant, hence the nurses need to have an understanding of how the disease is experienced in order to provide good guidance in the new lifestyle.  Aim  The aim of this study was to describe young adults' experiences of self-care in type 1 diabetes mellitus.  Method  A non-systematic literature review was conducted. Fifteen qualitative research articles were included. With the help of various search combinations from the databases PubMed and CHINAL, the articles were retrieved and quality reviewed based on Sophiahemmet Högskolas/University ́s assessment tools for classification and quality review. Thereafter an integrated data analysis was performed of the selected result articles and the data was sorted into main categories and subcategories.  Results  Three main categories and nine subcategories were identified. The main categories were: Emotional experiences of young adults with diabetes, Challenges in self-care of diabetes and Support for self-care in diabetes.  Conclusions  Common challenges that the young adults encountered in their everyday lives were shown in the results. These experienced challenges could be avoided if the surrounding people got the right knowledge about the disease and a continued support of the young adults with their self-management. With the support from healthcare providers, family and friends, the individual's ability to manage their own care will be strengthened.

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by loss of insulin-producing beta cells resulting in life-long insulin deficiency. Beta cell destruction by autoreactive CD8+ effector T-cells is thought to be the main cause of loss of insulin output. Autoreactive T-cells are similarly to autoantibodies, which have been established as markers of risk and progression of the disease, directed towards autoantigens of T1D. These are most notably, insulin, 65 kDa glutamic acid decarboxylase (GAD65, also known as GAD2), insulinoma-associated protein 2 (IA­2, also known as PTPRN or ICA512) or zinc transporter 8 (ZNT8). Most of the known T1D autoantigens are components of insulin secretory granules (SGs). T1D arises from an interplay of genetic and environmental factors, which are thought to act as triggers in susceptible individuals. Predisposing alleles in genetic loci for human leukocyte antigen (HLA) account for by far the highest contribution to the risk of disease development, followed by an array of polymorphisms thought to play a role in either immune cells or beta cells. Of environmental factors that potentially add to the risk of disease progression, the most evidence-supported are Enteroviruses (EVs). Most notably, their genome and viral proteins, as well as higher expression of cellular proteins involved in viral response were detected more often in blood and pancreata of patients with T1D than in healthy population. In addition, recent evidence from a large long-term observational study has implicated prolonged shedding of specifically species Enterovirus B in the stools of children as a risk factor in development of beta cell autoimmunity in children with high genetic risk of T1D. For these reasons, many researchers have studied the potential mechanisms of EV involvement in T1D pathogenesis. In our laboratory, we have investigated the effects of coxsackievirus B5 (CVB5) infection on murine insulinoma MIN6 cells. Previously, we have reported that glucose-stimulated translation of SG proteins can be carried out in a cap-independent manner and is not shut down as part of the early effects of CVB5 infection on MIN6 cells. We have also observed that mature forms of SG proteins are being degraded during viral infection. As intracellular protein degradation is one of the major pathways to supply peptides for presentation on HLA I for immune recognition, we hypothesized that concomitant production and degradation of SG proteins upon viral infection could lead to altered presentation of mainly peptides derived from insulin SG component proteins and potentially drive the response of autoreactive T-cells. To address this hypothesis, we aimed to identify appropriate conditions to study the impact of EV infection on antigen presentation of ECN90 cells. To that end, we established a panel of markers examined by SDS-PAGE and immunoblotting. Stage of viral infection was assessed based on the detection of the viral protein VP1 and cleavage of cellular factors such as eukaryotic translation initiation factor 4 G (eIF4G), poly(A)-binding protein (PABP1), polypyrimidine tract-binding protein 1 (PTBP1), poly (ADP-ribose) polymerase (PARP) and caspase 3, which is mediated by viral proteases. Furthermore, we assessed the levels of ICA512 and chromogranin A and their pro-forms to estimate the size of insulin SG stores, and the expression of HLA I and β2 microglobulin to confirm sufficient antigen presentation. Peptides presented on both HLA I and II were isolated by immunoaffinity purification and identified by liquid chromatography-tandem mass spectrometry analysis. About 500 unique HLA I-presented peptides were found on average per replicate and condition with purity of 89% (peptides predicted to bind HLA alleles expressed by ECN90 cells). The distribution of unique peptides presented by infected ECN90 cells significantly differed from those presented by control cells as 54 unique peptides were present only in all infected samples and none of uninfected and 13 peptides were only found in uninfected cells. In total, we identified 26 unique peptides from known T1D autoantigens associated with SGs (e.g. insulin, chromogranin A, ICA512) in both conditions. The majority of them were predicted to bind HLA I alleles B*40:01 and A*02:01, while two identified viral peptides were found to bind B*40:01 and A*03:01 alleles. Both of the viral peptides and almost half of the peptides originating from known T1D autoantigens have not been described before. In addition, on average 300 unique HLA II peptides were found per replicate and condition. Similarly to HLA I peptides, the distribution of unique peptides across infected and control cells differed as well, showing that antigen presentation was altered in infected cells. We identified two viral HLA II-eluted peptides and peptides originating from only two known T1D autoantigens, 35 originated from insulin and 157 from chromogranin A. As most of the newly identified HLA I peptides originating from T1D autoantigens and one peptide from viral proteins were restricted by the allele HLA-B*40:01, our further efforts were invested in the development of a recombinant disulfide-stabilized biotinylated peptide-receptive HLA molecule of this allele. This technology has been extensively validated, and will allow us to test the wide array of novel peptides identified by us for the ability to bind this allele, as well as asses frequencies and responses of specific T-cells in subject populations relevant for T1D.

Bakgrund: Äldre patienter med typ 1-diabetes påträffas allt oftare i hemsjukvård då patienterna behöver hjälpinsatser. Vården för typ 1-diabetes har under flera år utvecklats vilket har resulterat i mindre komplikationer och längre överlevnad. Viktigt inom diabetesvården är patientens egenvård, men när andra sjukdomstillstånd tillkommer kan det vara svår att upprätthålla denna själv. Syfte: Syftet är att beskriva specialistsjuksköterskors erfarenheter av att möta äldre patienter med typ 1-diabetes i hemsjukvård där förmågan till egenvård har försämrats. Metod: En kvalitativ intervjustudie med induktiv ansats gjordes. Åtta specialistsjuksköterskor som arbetade inom hemsjukvård intervjuades med semistrukturerade frågor. Datamaterialet analyserades med en kvalitativ innehållsanalys. Resultat: Analysen resulterade i tre kategorier; Att se skillnaden mellan typ 1- och typ 2-diabetes hos patienten, Att kommunicera kunskap mellan sjukvårdspersonal och Att ta över ansvaret av patientens egenvård. Fynden i studien visade att det fanns skillnader att behandla patienter med typ 1- och typ 2-diabetes. Kunskap saknades om typ 1-diabetes och därmed var det svårt att förmedla information till omvårdnadspersonal. Att ta över ansvaret av patients egenvård beskrevs som en viktig, men svår del för att patienten ska känna sig trygg i relation med omvårdnadspersonal. Slutsats: Specialistsjuksköterskorna upplever en svårighet att ta över patientens egenvård när de inte längre har förmågan att själva utföra den. Utbildning inom diabetesvård är viktigt då specialistsjuksköterskan har som arbetsuppgift att utbilda, handleda och delegera omvårdnadspersonal. Typ 1-diabetes är en sjukdom som kommer att öka inom den äldre populationen, vilket innebär att patienterna kommer att ha ett behov av hemsjukvård i likhet med övrig befolkning. / Background: Elderly patients with type 1-diabetes are increasingly found in home healthcare as patients need assistance. Care for type 1-diabetes has developed over several years, which has resulted in fewer complications and longer survival. Important in diabetes care is the patient's self-care, but when other disease states arise, it can be difficult to maintain this yourself. Aim: The aim is to describe specialist nurses' experiences of meeting elderly patients with type1- diabetes in home care where the ability to self-care has deteriorated. Method: A qualitative interview study with inductive approach was performed. Eight specialist nurses who worked in home care were interviewed with semi-structured questions. The data material was analyzed using a qualitative content analysis. Results: The analysis resulted in three categories; To see the difference between type 1- and type 2-diabetes in the patient, To communicate knowledge between nursing staff and To take over the responsibility of self-care. The findings of the study showed that there were differences in treating patients with type 1- and type 2-diabetes. Knowledge of type 1 -diabetes was lacking and thus it was difficult to convey information to nursing staff. Taking over the patient's responsibility for self-care was described as an important, but hard part to make the patient feel safe in relation to nursing staff. Conclusion: The specialist nurses experience a difficulty in taking over the patient's self-care when the patients no longer are able. Diabetes care training is crucial as the specialist nurse's task is to train, supervise and delegate nursing staff. Type 1 diabetes is a disease that is estimated to increase in the elderly population, which means that patients will have a need for home care similar to the rest of the population.

ABSTRAKT Bakgrund: Typ 1-diabetes (T1D) hos barn ökar. T1D är en kronisk sjukdom som barnet kommer behöva leva med hela livet vilket kan medföra att fler föräldrar behöver ta ansvar för barnets behandling med T1D. Sjukdomen har visat sig ha stor påverkan på föräldrarnas och hela familjens vardag. Syfte: Syftet med litteraturstudien var att belysa påverkan på vardagen hos föräldrar som vårdar ett barn med typ 1-diabetes. Metod: En litteraturstudie baserad på tio kvalitativa studier. Studierna granskades, analyserades och sammanställdes. Resultat: Upplevelsen av att behöva anpassa sig till sjukdomen framkom som ett genomgående tema i resultatet. Resultatet presenteras i följande kategorier; Att behöva rätta sig efter sjukdomen, Att uppleva att relationer förändras samt Att uppleva stöd och brist på stöd från andra. Konklusion: Föräldrarna uppskattade när stödet de fick från vården var individuellt anpassat och när vårdpersonalen kände till hela familjens omständigheter. En förändring hos en familjemedlem påverkar hela familjen. Med kunskap om detta kan sjuksköterskan bättre förstå behovet av familjefokuserad vård. Det behövs mer forskning om föräldrars och familjers behov av familjefokuserad vård. Även forskning om könsskillnader inom föräldraskapet behövs. Nyckelord: Typ 1-diabetes, föräldrar, vardag, modell för omvårdnad, familjefokuserad omvårdnad / ABSTRACT Background: Type 1 Diabetes (T1D) among children increases. This may lead to more parents who need to take responsibility for their child’s treatment. The disease has been shown to have a major impact on everyday life for parents and the whole family.   Aim: The aim of this study was to illuminate the impact on everyday life among parents that care for a child with Type 1 Diabetes. Methods: A literature study based on ten qualitative studies. The studies were reviewed, analyzed and compiled. Results: The experience of having to adapt to the disease emerged as a recurrent theme in the outcome. The results is presented in three categories; Having to comply with the disease, To experience that relationships change and To experience support and lack of support from others. Conclusion: Parents appreciated when the healthcare support was adjusted to the whole family’s circumstances. A change in one family member affects the entire family. With knowledge of this the nurse could better understand the need for family-focused care. There should be more research on parents’ and families’ need for family-focused care and also on gender differences in parenting.  Keywords: Type 1 Diabetes, parents, everyday life, model for nursing, family-focused care

Introduktion: Diabetes är ett samlingsnamn för en typ av sjukdomar som orsakar förhöjda sockervärden i blodet. Typ 1-diabetes uppkommer vanligen hos barn och ungdomar, men vissa får sjukdomen först i vuxen ålder. Det finns förutom typ 1-diabetes även graviditetsdiabetes och typ 2-diabetes, LADA (Latent Autoimmune Diabetes in The Adults), MODY (Maturity Onset Diabetes in The Youth) och några mer ovanliga diabetessjukdomar. Syfte: Syftet med examensarbete är att undersöka vilka faktorer som bidrar till den stora ökningen av typ 1-diabetes hos barn som sker i många länder världen över. Metod: Den metod som används i detta arbete är en strukturerad litteraturstudie baserad på vetenskapliga originalartiklar från databaserna CINAHL och PubMed. Artiklarnas vetenskapliga kvalitet granskades med hjälp av CASP. Elva artiklar inkluderades i studien och analyserades med hjälp av Fribergs analysmodell. Resultat: I detta arbete söktes svaret på frågan: Vilka faktorer kan förklara den ökande förekomsten av typ 1-diabetes bland barn och unga? Nedan presenteras resultatet uppdelat på fyra huvudteman som framkommit i analysen av materialet. Dessa teman är: immunologiska faktorer, kostens påverkan, livsstil och miljö samt föräldrarnas roll. Slutsats: Flertalet möjliga riskfaktorer utöver genetiska kan ses bidra till ökning av typ 1-diabetes bland barn och unga. Bland dessa kan nämnas tidig tillväxt på grund av felaktig eller överdriven mängd kost, virusinfektioner samt föräldrars utbildningsnivå och sociala status. / Diabetes is a group of diseases that cause elevated blood sugar levels. Type 1 diabetes typically develops in children and adolescents, but some people may develop the disease later in adulthood. In addition to type 1 diabetes, there is also gestational diabetes, type 2 diabetes, LADA (Latent Autoimmune Diabetes in Adults), MODY (Maturity Onset Diabetes in Youth), and a few other rare forms of diabetes. Aim: The aim of this study is to investigate thefactors contributing to the significant increase in type 1 diabetes among children in many countries worldwide. Method: The method used in this study is a structured literature review. The literature review only includes scientific original articles with 11 scientific articles being carefully examined. Results : This study aimed to answer the question: What factors can explain the increasing prevalence of type 1 diabetes among children and adolescents? The results are presented below, divided into four main themes that emerged from the analysis of the material. These themes are immunological factors, the influence of diet, lifestyle and environment, and the role of parents. Conclusion: Several possible risk factors in addition to genetics can be seen as contributing to the increase in type 1 diabetes among children and young people. Among these risks are early growth due to incorrect or excessive amount of diet, viral infections and parents level of education and social status.

No description available.

Background Regulatory T cells (Treg) are a subpopulation of CD4+ T cells that play an important role in the peripheral tolerance mechanisms of the immune system. Their suppressive function on autoreactive T cells can prevent autoimmunity. In type 1 diabetes (T1D), Treg have been inconsistently reported to be impaired in their capability to suppress autoreactive T cells (Tan, et al., 2014; Zhang, et al., 2012). Treg can be thymus derived (tTreg) or generated from naïve CD4+ CD25- T cells in the periphery (pTreg), which exhibit similar suppressive qualities as tTreg. They have also been reported to be actively induced (iTreg) under tolerogenic conditions (Kleijwegt, et al., 2010; Yuan and Malek, 2012). Although several Treg subpopulations have been described, the archetypical Treg express the major markers CD4, CD25 and FOXP3, while CD127 is heavily downregulated. However, activated conventional T cells (Tconv) show a similar phenotype, at least transiently (Miyara, et al., 2009). Since Treg and Tconv have opposing functions and therapeutic indications, it is important to obtain markers that confidently identify bona fide Treg. Scientific aim The aim of my thesis is to define the heterogeneity of human T cells with a specific emphasis to identify bona fide Treg. I examined heterogeneity of this population in healthy controls and T1D patients, as my model disease, and examined how T cells that are exposed to antigen can be defined as Treg or Tconv. Material and Methods For marker phenotyping I used samples from new onset T1D patients (age 7-11 years), autoantibody positive (Aab+) patients and age-matched healthy controls, which were tested by flow cytometry with an array of Treg-associated markers. Separately, freshly isolated CD4+CD25+CD127lo Treg and CD+CD25- Tconv were used for transcriptomic analysis, which was done by RNAseq on isolated whole RNA. For functional analysis of antigen specific gene expression patterns I developed a multi-dye proliferation assay. Treg (CD4+CD25+CD127lo) and Tconv (CD4+CD25-CD127+/lo) were sorted from isolated peripheral blood mononuclear cells (PBMC). I recombined the sorted and proliferation dye stained subsets with CD4- cells to simulate whole PBMC assays and stimulated them with tetanus-, influenza- or auto-antigens (GAD65, proinsulin). Cells were incubated for 5 days and responding proliferating cells as well as non-responding cells were single cell sorted and analyzed by multiplex qPCR. In investigating therapeutic approaches to expand or generate Treg, I examined in vitro approaches for de novo induction of Tregs with tolerogenic dendritic cells (tDCs). The tDCs were differentiated from monocytes either in the presence of 1α,25-OH(2)Vitamin D3 and/or Dexamethasone and matured with lipopolysaccharide. In a multistep assay, naïve T cells were incubated with DCs for two rounds and functional suppression assays were performed. The resultant T cells were analyzed at the DNA, protein, and functional level. Results Substantial phenotypic heterogeneity of peripheral blood CD4+ T cells was observed and documented for three major populations: resting Tconv (CD25-CD127+/lo), activated Tconv (CD25+CD127+) and Treg (CD25+CD127lo) in healthy controls. Despite this, I observed no differences between the Treg subpopulations from new onset T1D patients, Aab+ patients and healthy controls. In addition, there were no differences in the Treg transcriptome of T1D patients and healthy controls by RNAseq. I was, however, able to identify a small set of differentially expressed genes was discovered in Tconv suggesting a role of neutrophils in the onset of T1D. Heterogeneity of antigen-responsive Tconv and Treg was identified by gene expression profiling. I was able to define Treg specific as well as activation specific profiles, and found different expression profiles if T cells are foreign antigen or autoantigen activated and if the responding cells are Treg or Tconv. Genes that define the specific profiles include FOXP3, CD127, several cytokines, transcription factors and activation markers. The manipulation of naïve CD4+CD25- T cells by tDCs led to an unstable CD25+CD127loFOXP3+ phenotype of the generated cells. However, none of the subsequently performed functional assays could confirm that the resultant cells were iTreg or exhausted activated Tconv. In particular, methylation status of the Treg-specific demethylated region (TSDR) was inconsistent with stable Treg, suggesting that so-called tolerogenic protocols may not lead to a long-lived Treg phenotype. Conclusion CD4+CD25+ T cells are heterogeneous. I defined marker combinations that will help distinguish Treg from ex vivo and in vitro activated Tconv cells. With these tools, I was able to show that healthy controls and patients with type 1 diabetes cannot be distinguished by Treg phenotype. Comprehensive single cell analysis of antigen activated T cells provided the most promising avenue for identifying antigen-specific Treg and opens new possibilities to analyze immune therapeutic approaches, particularly when Treg expansion is the therapeutic objective. The findings will be used for monitoring children participating in antigen-based prevention studies in children at risk for T1D. / Hintergrund Regulatorische T Zellen (Treg) sind eine Subpopulation der CD4+ T Zellen, welche eine wichtige Rolle in den peripheren Toleranzmechanismen des Immunsystems spielen. Ihre suppressive Funktion auf autoreaktive T Zellen kann Autoimmunität verhindern. Verschiedene Studien berichteten widersprüchlich, dass Treg in Typ 1 Diabetes (T1D) in ihrer Fähigkeit beeinträchtigt sind autoreaktive T Zellen zu supprimieren (Tan et al., 2014; Zhang et al., 2012). Treg können im Thymus differenzieren (tTreg) oder aus peripheren naïven CD4+CD25- T Zellen generiert werden (pTreg), welche ähnliche suppressive Eigenschaften wie tTreg besitzen. Es wurde außerdem berichtet, dass Treg aktiv unter tolerisierenden Konditionen induziert werden können (iTreg) (Kleijwegt et al., 2010; Yuan and Malek, 2012). Obwohl verschiedene Treg Subpopulationen beschrieben wurden, exprimieren die archetypischen humanen Treg die Hauptmarker CD4, CD25 und FOXP3 exprimieren, während CD127 herunterreguliert ist. Jedoch zeigen auch aktivierte konventionelle T Zellen (Tconv) diesen Phänotyp (Miyara et al., 2009). Da Treg und Tconv gegensätzliche Funktionen und therapeutische Indikationen aufweisen, ist es wichtig Marker zu erhalten, die sicher bona fide Treg identifizieren. Fragestellung Das Ziel meiner Arbeit ist es, die Heterogenität von humanen T Zellen zu definieren mit einen spezifischen Fokus bona fide Treg zu identifizieren. Dafür untersuchte ich die Heterogenität dieser Zellpopulation in gesunden Individuen und T1D Patienten, als Krankheitsmodell, und wie T Zellen als Treg oder Tconv definiert werden können wenn sie einem Antigen ausgesetzt sind. Material und Methoden Für das Phänotypisieren habe ich Proben von Patienten mit beginnendem T1D (Alter 7-11 Jahre), Autoantikörper positiven Patienten (Aab+) und gesunden Individuen mittels Durchflusszytometrie auf eine Reihe von Treg-assoziierten Markern getestet. Des Weiteren wurden frisch isolierte CD4+CD25+CD127lo Treg und CD+CD25- Tconv für die Transkriptomanalyse (RNAseq) genutzt, welche mit der Gesamt-RNA durchgeführt wurden. Für die funktionelle Analyse von Antigen-spezifischen Genexpressionsmustern habe ich ein Multifarbenproliferationstest entwickelt. Treg (CD4+CD25+CD127lo) und Tconv (CD4+CD25-CD127+/lo) wurden aus isolierten mononukleären Zellen des peripheren Blutes (PBMC) sortiert. Ich habe die sortierten und gefärbten Zellen mit CD4- Zellen zusammengefügt, um einen Gesamt-PBMC-Test zu simulieren und habe die Zellen mit Tetanus-, Influenza- oder Auto-antigen (GAD65, Proinsulin) stimuliert. Die Zellen wurden für 5 Tage inkubiert und die Antigen-reagierenden und -proliferierenden Zellen sowie die nicht-reagierenden Zellen Einzelzell sortiert und mittels Multiplex qPCR analysiert. Um therapeutische Ansätze zum Expandieren oder Generieren von Treg zu untersuchen, habe ich in vitro Ansätze für die de novo Induktion von Treg durch die Nutzung von tolerisierenden dendritischen Zellen (tDCs) untersucht. Die tDCs wurden von Monozyten in Anwesenheit von 1α,25-OH(2)Vitamin D3 und/oder Dexamethason differenziert und mit Lipoploysaccharid maturiert. Naïve T Zellen wurden in einem Mehrschrittverfahren mit DCs inkubiert. Die resultierenden T Zellen wurden auf DNA, Protein und funktioneller Ebene analysiert. Ergebnisse Substantielle phänotypische Heterogenität von peripheren Blut CD4+ T Zellen wurde in drei Hauptpopulationen in gesunden Individuen beobachtet und dokumentiert: ruhende Tconv (CD25-CD127+/lo), aktivierte Tconv (CD25+CD127+) und Treg (CD25+CD127lo). Weiterführend ergab der phänotypische Vergleich von Patienten mit beginnender T1D, Aab+ Patienten und gesunden Individuen keine Unterschiede in den Treg Subpopulationen. Außerdem zeigten sich keine Unterschiede in den durch RNAseq gemessenen Treg Transkriptomen von T1D Patienten und gesunden Individuen. Jedoch wurde ein kleine Gruppe von differentiell exprimierten Genen in Tconv entdeckt, welche eine mögliche Rolle von Neutrophilen in T1D andeuten. Heterogenität von Antigen-spezifischen Tconv und Treg Antworten wurde durch Genexpressionsanalysen identifiziert. Ich konnte Treg- sowie Aktivierungs-spezifische Muster definieren und verschiedene Expressionsprofile finden, wenn T Zellen durch Fremd- oder Autoantigen aktiviert wurden und ob sie die reagierenden Zellen Treg oder Tconv sind. Folgende Gene waren hauptsächlich in die Profilbildung involviert: FOXP3, CD127, mehrere Zytokine, Transkriptionsfaktoren und Aktivierungsmarker. Die Manipulation von naïven CD4+CD25- T Zellen durch tDCs führte zu einem instabilen CD25+CD127loFOXP3+ Phänotyp der generierten Zellen. Jedoch konnte keiner der weiterführenden funktionellen Analysen unterscheiden, ob die resultierenden Zellen iTreg oder aktivierte erschöpfte T Zellen waren. Insbesondere war der Methylierungsstatus der Treg-spezifisch demethylierten Region (TSDR) nicht konsistent mit einen stabilen Treg Phänotyp, was darauf hinweist, dass sogenannte tolerisiernde Protokolle nicht zu einem langlebigen Treg Phänotyp führen. Schlussfolgerungen CD4+CD25+ T Zellen sind heterogen. Ich habe Markerkombinationen definiert die helfen werden Treg von ex vivo und in vitro aktivierten Tconv Zellen zu unterscheiden. Mit diesen Mitteln war ich in der Lage zu zeigen, dass gesunde Individuen und Patienten mit Typ 1 Diabetes nicht anhand ihres Treg Phänotyps unterschieden werden können. Umfassende Einzelzell-Analysen von Antigen aktivierten T Zellen lieferten den vielversprechendsten Ansatz für die Identifizierung von Antigen-spezifischen Treg und eröffnen neue Möglichkeiten um immuntherapeutische Ansätze zu analysieren, insbesondere wenn Treg Expansion das therapeutische Ziel ist. Diese Erkenntnisse werden zukünftig für das Monitoring von Kindern, mit einem hohen T1D Risiko, genutzt die an Antigen-basierten Präventionsstudien teilnehmen.

Zusammenfassung Thure Adler Der Streptozotozin-induzierte Diabetes in der transgenen CD4/DR17-Maus Aus dem Institut für Immunologie der Veterinärmedizinischen Fakultät und dem Institut für Klinische Immunologie und Transfusionsmedizin der Medizinischen Fakultät der Universität Leipzig, 80 Seiten, 24 Abbildungen, 20 Tabellen, 217 Literaturangaben Die Verwendung transgener Tiere, die humane Moleküle exprimieren, gewinnt zunehmend an Bedeutung bei der Erforschung der Funktionen solcher Moleküle in Krankheitsprozessen und bei der experimentellen Erprobung neuartiger Therapieverfahren, in denen solche Moleküle die Zielstrukturen darstellen. In der vorliegenden Arbeit wurde die CD4/DR17-Maus, welche das humane CD4- und das DR17-Molekül exprimiert, im MLD-STZ-induzierten Diabetes, einem Tiermodell für den Typ 1 Diabetes, eingesetzt. Die funktionelle Beteiligung der Transgene wurde durch einen Vergleich mit Segreganten untersucht, denen die Transgene teilweise fehlen. Als klinische Parameter sind Blutglukose und Glukosetoleranz erfaßt worden, histopathologisch wurden Insulitis und Insulingehalt der Inselzellen bestimmt. Ferner wurde getestet, ob sich durch Verabreichung von monoklonalen Antikörpern, die gegen das transgene hCD4- oder gegen das CD8-Molekül gerichtet sind, dieser STZ-induzierte Diabetes beeinflussen läßt. Mit Hilfe der durchflußzytometrischen Immunfluoreszenzanalyse von Blutzellen wurde zusätzlich überprüft, ob Veränderungen auf T-Zellen hinsichtlich der Expression der Aktivierungsmarker CD25, CD69 und CD71 während des STZ-induzierten Diabetes auftreten. Es wurde gezeigt, dass die CD4/DR17-transgene Maus nach der Behandlung mit mehrfachen subdiabetogenen Dosen von Streptozotozin eine transiente Hyperglykämie entwickelt, die mit einer verringerten Glukosetoleranz sowie Insulitiden und einem Rückgang des Insulingehaltes in den Langerhans’schen Inseln einhergeht. Vergleiche mit Segreganten zeigen, dass die Expression beider transgener Merkmale zur maximalen Ausprägung einer schwergradigen Insulitis beiträgt. Die Anwendung von monoklonalen Antikörpern gegen das transgene hCD4-Molekül nach Beginn der STZ-Behandlung hat den Diabetes nicht wirkungsvoll verzögert. Dagegen milderte eine Behandlung mit Antikörpern, die gegen das CD8-Molekül gerichtet sind, den Diabetesverlauf. Während des STZ-Diabetes veränderte sich die Expression von Aktivierungsmarkern auf Lymphozyten des peripheren Blutes nicht signifikant. Die Arbeit belegt, dass die CD4/DR17-Maus suszeptibel gegenüber der Induktion eines experimentellen Diabetes mit mehrfachen subdiabetogenen Dosen von Streptozotozin ist. Die transgenen Moleküle hCD4 und DR17 sind dabei am Krankheitsprozeß beteiligt. / Summary Thure Adler The streptozotocin-induced diabetes in the transgenic CD4/DR17 mouse From the Institute of Immunology, Faculty of Veterinary Medicine and the Institute of Clinical Immunology and Transfusion Medicine, Faculty of Medicine, University of Leipzig 80 pages, 24 figures, 20 tables, 217 references Today, transgenic animals that express human molecules are getting important tools in functional studies and experimental, therapeutical attempts, that target these molecules. In this study, the CD4/DR17 mouse expressing the human CD4 and the human DR17 molecules and with a defective murine CD4 gene, was used in the multiple low-dose streptozotocin-induced (MLD-STZ) diabetes model, a model for type 1 diabetes. The functional involvement of the transgenic molecules in the development of the MLD-STZ-diabetes was analysed by comparing CD4/DR17 mice and segregants that lack one or more of the transgenes. The described parameters included the measurement of blood glucose levels and oral glucose tolerance tests, histopathologically grading of insulitis and determination of the content of insulin in pancreatic islets by immunohistological methods. In addition, the model was used to test the potential therapeutic effect of the administration of monoclonal antibodies against hCD4 or CD8. Furthermore, alterations of the expression of the activation markers CD25, CD69 and CD71 during the experimentally induced diabetes has been measured by FACS analysis. The study shows, that CD4/DR17 mice develop a transient hyperglycemia after MLD-STZ treatment, accompanied by a reduced tolerance to oral glucose, insulitis and the reduction of the content of insulin in the pancreatic islets. The full incidence of insulitis requires the expression of both transgenes. The treatment performed with monoclonal antibodies against the transgenic hCD4 after STZ-treatment could not meliorate the diabetic course, while the treatment with anti CD8 antibodies moderated the diabetic process. After STZ-treatment the expression of activation marker of peripheral T-cells did not alter significantly. Thus, the CD4/DR17 mouse is shown to be susceptible to the induction of experimental diabetes with MLD-STZ. The transgenic molecules CD4 and DR17 are involved in the pathogenesis of the disease.