Children diagnosed with Type 1 diabetes face lifetime issues that will affect their health-related quality of life (HRQoL). These challenges require varied coping skills to manage the disease and a commitment to find ways to increase HRQoL. It was proposed that children’s general coping styles would be mediators in both the relation of family environment and children’s health-related quality of life and the relation of parental perceived social support and children’s health-related quality of life in children aged 8-16 with Type 1 diabetes. Age was also proposed to be a moderator in the relation of children’s coping to their health-related quality of life. Children aged 8 to 16 and their primary caregivers (N = 56) were recruited to participate in the study at a university hospital tertiary care clinic. Children completed the Pediatric Quality of Life Inventory 3.0 Diabetes Module for children and adolescents (PedsQL 3.0) and the Children’s Coping Strategies Checklist-Revision 1. Primary caregivers completed the PedsQL 3.0 for parents, the Family Environment Scale and the Multidimensional Scale of Perceived Social Support. Regression analyses were used to identify a model that explained the contribution of each factor to predict HRQoL. It was hypothesized that children’s active, distraction, and support-seeking general coping strategies would be mediators in the relation of family environment and parental perceived social support to children’s health-related quality of life and that children’s general avoidant coping strategies would not mediate either the relation of family environment or parental perceived social support to children’s health-related quality of life. Although children’s active, distraction, and support-seeking coping strategies were not found to mediate the relation of family environment to children’s health-related quality of life or the relation of parental perceive social support to health-related quality of life, children’s avoidant coping strategies were found to be a mediator in the relation of family environment to children’s health-related quality of life and in the relation of parental perceived social support to health-related quality of life. It was also hypothesized that children’s age would moderate the relation of children’s active, distraction, and support-seeking coping strategies to children’s health-related quality of life. Age moderated the relation of avoidant coping to HRQoL. Avoidant coping was negatively associated with HRQoL for the older children but the association was not significant for younger children. To facilitate a better health-related quality of life for children with Type 1 diabetes, therapists and healthcare professionals should identify ways to help parents feel more supported as they care for and create a more cohesive and low conflict family environment, which contributes to their children’s health-related quality of life. Additionally, therapists should work with children and their parents to increase children’s use of active, distraction, and support-seeking coping strategies, which are related to more positive outcomes compared to children’s use of avoidant coping strategies, which are related to less positive outcomes. / Ph. D. / This research study explored social and emotional climate in families, perception of parents’ social support, and children’s coping as factors that contribute to the health-related quality of life (HRQoL) in children aged 8 to 16 with Type 1 diabetes. One of the main goals of treatment for children diagnosed with Type 1 diabetes is preventing nerve, heart, and blood vessel damage from occurring in adulthood. When children are diagnosed with Type 1 diabetes, they face a lifetime issues that will affect their HRQoL. These challenges require children to develop skills to help them process both the expected and unexpected emotions and thoughts that occur while managing the disease and a commitment to find ways to increase HRQoL over the span of their lives. It was hypothesized that children with better social and emotional family climates or environments and more parental perceived social support would be able to more effectively cope and that better coping would be associated with more health-related quality of life. Effective forms of coping included three different strategies: active (e. g., use of positive restructuring of thoughts), distraction (e. g., use of physical release of emotion), and support-seeking (e. g., seeking support for managing feelings). Avoidant coping was also examined and included use of actions such as wishful thinking. Of note, the children’s coping measure used identified use general coping strategies and was not diabetes specific. Children with connected, expressive, and low conflict family climates and with parents who perceived themselves being supported more were lower in avoidant coping, which was related to more HRQoL for the children. How coping was associated with HRQoL was also predicted to be different when looking at older versus younger children. As children aged, their use of avoidant coping strategies increased and more avoidant coping was related to less HRQoL for older children but not for younger children. To facilitate a better health-related quality of life for children with Type 1 diabetes, therapists and healthcare professionals should identify ways to help parents feel more supported as they care for and create a more cohesive and low conflict family environment, which can contribute to their children’s health-related quality of life. Additionally, therapists should work with children and their parents to decrease children’s use of avoidant coping strategies, which are related to less positive outcomes.

The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file. Title from PDF of title page (University of Missouri--Columbia, viewed on April 1, 2010). Vita. Thesis advisor: Habib Zaghouani. "May 2008" Includes bibliographical references.

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by the immune-mediated destruction of insulin-producing beta-cells of pancreatic islets, culminating in critical insulin deficiency. Both genetic and environmental factors likely orchestrate an immune-mediated functional loss of beta cell mass, leading to the clinical manifestation of disease and lifelong dependence on insulin therapy. Additional evidence suggests the role of innate and adaptive immune mechanisms leading to inflammation in beta cells mediated by proinflammatory cytokines and chemokines, activation of beta-cell-reactive T cells,and failure of immune tolerance. Viral infections have been proposed as causal determinants or initiating triggers for T1D but remain unproven. Understanding the relationship between viral infections and the development of T1D is essential for T1D prevention. Importantly, virus-induced innate immune responses, particularly type I interferon (IFN-I, IFN-a/b), have been implicated in the initiation of islet autoimmunity and development of T1D. The goal of my thesis project is to investigate how the IFN-I signaling pathway affects the development of T1D using the LEW.1WR1 rat model of autoimmune diabetes. My hypothesis is that disrupting IFN-Isignaling via functional deficiency of the IFN-I interferon receptor (IFNAR) prevents or delays the development of virus-induced diabetes.For this purpose, I generated IFNAR subunit 1(IFNAR1)-deficient LEW.1WR1 rats using CRISPR-Cas9 genome editing and confirmed the functional disruption of IFNAR1. The absence of IFNAR1 results in a significant delay in onset and frequency of diabetes following poly I:C challenge and reduces the incidence of insulitis after poly I:C treatment. The frequency of diabetes induced by Kilham rat virus (KRV) is also reduced in IFNAR1-deficient LEW.1WR1 rats. Furthermore, I observe a decrease in CD8+T cells in spleens from KRV-infected IFNAR1-deficient rats relative to that in KRV-infected wild-type rats. While splenic regulatory T cells are depleted in WT rats during KRV-infection, no such decrease is observed in KRV-infected IFNAR1-deficient rats. A comprehensive bulk RNA-seq analysis reveals a decrease of interferon-stimulated genes and inflammatory gene expression in IFNAR1-deficient rats relative to wild-type rats following KRV challenge. Collectively, the results from these studies provided mechanistic insights into the essential role of virus-induced, IFN-I-initiated innate immune responses in the early phase of autoimmune diabetes pathogenesis.

Bakgrund: Att leva med en kronisk sjukdom som diabetes typ 1 kräver daglig kontroll av sin livsföring. Som ung vuxen inträffar många förändringar i livet och det kan vara en utmaning att samtidigt vara drabbad av en kronisk sjukdom och lära sig att leva med denna och de känslor som sjukdomen framkallar. Syfte: Syftet med denna litteraturöversikt är att beskriva unga vuxnas upplevelser av att leva med diabetes typ 1. Metod: Litteraturöversikt med 13 kvalitativa artiklar av olika design. Systematisk sökning av studier i databaserna Pubmed, Cinahl och PsycINFO. Resultat: I de granskade studierna framkom att leva med diabetes och samtidigt växa upp och bli vuxen upplevdes många gånger svårt. Rädsla för att vara annorlunda jämfört med andra jämnåriga, känslor av att tappa kontrollen samt rädslor inför framtid och för komplikationer var vanligt. Den unga vuxna kände sig ofta begränsad och hade svårt att integrera rutiner kring egenvården i det dagliga livet. Familj och vänner hade ofta en viktig roll för den unga vuxna men det fanns även en känsla av kluvenhet gentemot anhörigas delaktighet och sitt eget ansvar för sin sjukdom och hälsa. I kontakten med hälso- och sjukvården upplevdes en del brister och missnöje. Slutsats: Många unga vuxna upplever negativa känslor kring sin sjukdom och har svårigheter att få vardagslivet att fungera. Genom att få kännedom om hur unga vuxna med diabetes upplever sin sjukdom och livssituation kan sjuksköterskans stödjande roll utvecklas. / Background: Living with a chronic disease like type 1 diabetes requires a daily control of the lifestyle. As a young adult, several changes in life occurs. During this time of life, it might be a challenge to also have a chronic disease and learn to live with the disease and the feelings who may emerge from it. Aim: The aim of this study is to describe the experiences of young adults living with type 1 diabetes. Method: A literature review based of 13 qualitative studies with different designs. A systematic search in the databases Pubmed, Cinahl and PsycINFO was conducted. Result: The reviewed studies showed that living with diabetes while growing up and becoming an adult, many times felt difficult. Fear of being different from other peers, feelings of losing control and fears for the future and for complications was common. The young adult often felt limited and had difficulties with integrating routines for self-management in daily life. Family and friends often had an important role for the young adult. However, the young adults could feel ambivalent in family and friend’s participation in self-management and their own responsibility for their health and illness. In contact with the health services, young adult experienced some shortages and discontent. Conclusion: Many young adults experience negative feelings about their illness and have difficulties in everyday life. By gaining knowledge about how young adults with diabetes experience their disease and life situation the supporting role from the nurse can develop.

Islet transplantation is a possible curative treatment for type 1 diabetes (T1D). Currently the liver dominates as implantation site, despite the many challenges encountered at this site. Acute hypoxia in islets transplanted to muscle and omentum, two possible alternative sites, was prevailing. However, it was rapidly reversed at both implantation sites, in contrast to when islets were transplanted intraportally. At the intramuscular site hypoxia was further relieved by co-transplantation of an oxygen carrier, polymerized hemoglobin, which also improved the functional outcome. The complement system was activated after islet transplantation to muscle, but did not hamper graft function. Both mouse and human islets transplanted to omentum become well re-vascularized and have a functional blood flow and oxygenation comparable with that of endogenous islets. Animals transplanted with islets to the omentum had a superior graft function compared with animals receiving intraportal islet grafts. Alloxan-diabetic animals were cured with a low number of islets both when the islets were implanted in the omentum and muscle. The islet grafts responded adequately to both glucose and insulin and displayed a favorable mRNA gene expression profile. A challenge in diabetes research and in islet transplantation is that there are no established techniques for quantifying beta-cell mass in vivo. By using radiolabeled Exendin-4, a GLP-1 receptor agonist, beta-cell mass after transplantation to muscle of mice was quantified. The results may well be translated to the clinical setting. By comparing the pancreatic accumulation of [11C]5-hydroxy tryptophan ([11C]5-HTP) as detected by positron emission tomography (PET) in T1D patients with that of healthy controls, a 66% decrease was observed. This may in fact represent the loss of beta-cells, taking into account that other cells within the islets of Langerhans are largely unaffected in T1D.  In conclusion, the data presented support the use of alternative implantation sites for islet transplantation. In addition to improving the functional outcome this may enable more transplantations since the number of transplanted islets may be reduced. The techniques investigated for quantifying transplanted and endogenous beta-cell mass may greatly improve our knowledge of the pathophysiology of T1D and become a valuable tool for evaluation of beta-cell mass.

Mental health problems are increasing in Swedish adolescents and mortality rates are higher in this age group than among younger. 10-20% of all adolescents suffer from a chronic medical condition (CC). Few protective factors (PF) and clustering of health-risk behaviours (HRB) are frequent among adolescents with CCs. One of the most common CC in Swedish adolescents is type 1 diabetes mellitus (T1DM). Metabolic control often deteriorates during adolescence, especially in girls. Poor metabolic control is associated with increased risk for long-term complications, of which cognitive problems are common. However, the implication of cognitive/executive problems in patients with T1DM has not been sufficiently studied. Neither has the impact of neurodevelopmental problems (NDP), such as ADHD, on HRB in adolescents with CCs been analysed. Methods: In paper I and II the questionnaire ”Life and Health in Youth” was distributed to all students in year nine and year two of the upper secondary school in the county of Sörmland, 2008 (n=5771) and 2011 (n=5550). Adolescents with CCs were compared to healthy peers with regard to PFs and HRBs. In paper III, the ”Five to Fifteen” questionnaire was used in 175 paediatric patients with T1DM. Patients with indications of NDPs were compared with patients without such problems with regard to metabolic control. In paper IV, the BRIEF questionnaire and the ADHD Rating Scale as well as data from the Swedish Childhood Diabetes Registry was used in 241 adolescents with T1DM. Patients with indications of executive problems were compared with patients without such problems with regard to diabetes control. Results: CCs were associated with few PFs and clustered HRBs. The combination of CCs and low numbers of PFs was found to be associated with an increased risk of clustered HRBs. In the presence of coexisting ADHD the pattern of few PFs and clustering of HRBs was aggravated. ADHD was more common among adolescents with other CCs. Definite memory and learning problems as well as mild executive problems were associated with poor metabolic control, especially among adolescents. Executive problems were also associated with many outpatient visits and low physical activity. Girls with T1DM tended to self-report executive problems to a larger extent than boys, while parents more often reported these problems in boys. Conclusion: Knowledge about factors influencing treatment adherence and life in general is essential in the work with chronically ill adolescents. Focus must be put on enhancing PFs in order to avoid HRBs. Identification of coexisting NDPs, such as ADHD, is crucial, since such problems can adversely influence treatment adherence, HRBs and school achievements

Aims: The Childhood Diabetes Registry in Saxony, Germany, examined the incidence and metabolic characteristics of childhood diabetes. Methods: In the federal state of Saxony, newly diagnosed cases of diabetes in children and adolescents aged less than 15 years were registered continuously from 1999 until 2008. Family history, date of diagnosis, clinical and laboratory parameters were obtained. Reported cases were ascertained by public health departments as an independent data source and verified using the capture- recapture method. Results: A total of 865 children and adolescents with newly diagnosed diabetes were registered in Saxony. About 96% of them were classified as having type 1 diabetes, 0.6% had type 2 diabetes, 2.4% had maturity-onset diabetes of the young (MODY), and 1.4% had other types of diabetes. The age-standardized incidence rate of type 1 diabetes was estimated at 17.5 per 100,000 children per year. Completeness of ascertainment as calculated by the capture-recapture method amounted to 93.6%. At the time of diagnosis, 27.1% of children with type 1 diabetes had ketoacidosis, 1.5% had a blood pH <7.0, and 1.1% were unconscious. Conclusion: The registry provided data about the incidence rates and clinical presentation of childhood diabetes in a defined German population. We observed higher incidence rates compared to previous surveys. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Les patients atteints de diabète de type 1 (DbT1) semblent sur-traiter leurs hypoglycémies par rapport aux recommandations des Lignes directrices Canadiennes en diabète. Objectifs : 1) Décrire les habitudes des patients DbT1 pour le traitement des hypoglycémies et estimer les impacts sur le profil de risque cardio-métabolique et 2) explorer les excursions glycémiques suite à un traitement d’hypoglycémie qui respecte les recommandations. Méthodologie (analyses secondaires) : Objectif 1 : 121 patients DbT1 ont complété un journal alimentaire et de glycémies de 48 h. Des variables cardio-métaboliques ont été mesurées et un questionnaire sur la peur des hypoglycémies a été complété. Objectif 2 : 57 patients DbT1 ont complété les bras contrôles de notre programme sur le pancréas artificiel (traitement des hypoglycémies standardisé). Les valeurs de glycémie étaient disponibles aux 5 minutes. Résultats : Projet 1 : Les patients ont fait en moyenne 1,45 hypoglycémies/jour et 73% sur-traitaient avec une consommation moyenne de glucides de 32 ± 24 g. Ce sur-traitement est associé avec un plus jeune âge et une peur des hypoglycémies plus importante, mais pas avec un profil de risque cardio-métabolique plus défavorable. Projet 2 : Dans 20% des cas, traiter une hypoglycémie avec 15 g de glucides était efficace pour ramener la glycémie ≥ 4,0 mmol/L en 15 minutes, le temps moyen étant de 24 ± 12 minutes. La proportion d’insuline basale, le temps depuis le dernier repas et la pratique d’activité physique sont les éléments qui semblent avoir le plus d’impact sur l’efficacité du traitement. Conclusion : L’éducation entourant le traitement des hypoglycémies a besoin d’être renforcée et d’autres études sont nécessaires afin de valider les recommandations. / Patients with type 1 diabetes mellitus (TIDM) seem to be overtreating their hypoglycemia, compared to the Canadian Clinical practice guidelines in diabetes. Objectives: 1) Describe T1DM patients’ habits of nutritional treatment of hypoglycaemia and observe the impact on cardio-metabolic risk profile, and 2) explore glycemic excursions following hypoglycemic treatment performed according to guidelines. Methods (secondary analysis): Objective 1: 121 T1DM patients completed a 48-hour food and glycemic record. Metabolic variables were measured and a self-administered questionnaire on fear of hypoglycemia was completed. Objective 2: 57 T1DM patients completed the control arm from our artificial pancreas program (standardized hypoglycemia treatment). Glycemia levels at a 5-minute interval were available. Results: Project 1: The daily mean of hypoglycemia events was 1.45/day, and 73% of patients over-treated with a mean carbohydrate daily intake of 32 ± 24 g. Overtreatment was associated with a younger age and a higher fear of hypoglycemia, but not with a worsen cardio-metabolic risk profile. Project 2: Rising glycemia to ≥ 4,0 mmol/L within 15 minutes using a treatment of 15g of carbohydrates was efficient in only 20% of the cases. Mean time of hypoglycemia recuperation was 24 ± 12 minutes. Basal insulin, elapsed time since the last meal, and physical activity seemed to have the most impact on hypoglycemia treatment efficiency. Conclusion: Education on treatment of hypoglycemia needs to be increased. Further studies validating recommendations are warranted.

Background: Type 1 diabetes mellitus is a multifactorial disease caused by beta cell destruction of Langerhans pancreatic islets. From the genetic aspect the main predisposition lays on HLA class II genes (40 - 50%), molecules of which present exogenous peptides to CD4+ T lymphocytes. Enviromental factors play a crucial role in the etiopathogenesis of T1DM. Through epigenetic regulation (e.g. DNA methylation) the genetic and enviromental factors communicate. The level of methylation in the regulatory regions can significantly affect expression of these genes. Aims: The aim of the diploma thesis was to define methylation profile of HLA DQB1 alleles in type 1 diabetes mellitus patients and determine their expression. Methods: The genotyping of HLA class II genes (HLA-DRB1, HLA-DQA1, HLA-DQB1) was performed using sequence specific primers. DNA was treated with sodium bisulfite, regulatory region of HLA DQB1 was amplified and cloned into E.coli, strain DH5α/XL1-Blue. Positive clones were sent for sequencing and results analyzed. RNA was transcribed to cDNA by reverse transcription and the level of expression was analyzed by quantitative PCR. Results: Statistically significant differences were found in total methylation of DQB1*0201 and *0302 alleles in the B section of DQB1 gene. Difference in...

INTRODUÇÃO: A atividade física faz parte do tratamento do portador de diabetes mellitus tipo 1 (DM1), devendo ser encorajada pelas mesmas razões que é em não portadores. Os portadores de DM1, como evidenciam os estudos, apresentam póstreino: redução dos fatores de risco para o desenvolvimento de doenças cardiovasculares, melhora do condicionamento físico, da sensibilidade à ação da insulina e do bem-estar. Mas é fundamental realizar a monitorização glicêmica, adequar alimentação e dose de insulina para a prática de exercícios, a fim de evitar hipo ou hiperglicemias antes, durante ou após as sessões, e consequentemente, obter melhora ou manutenção do controle glicêmico. Além disso, o nível de atividade física relaciona-se inversamente ao aparecimento de complicações do diabetes e risco de mortalidade em portadores de DM1. Porém, poucos estudos demonstram o comportamento da glicemia destes pacientes em diferentes tipos de exercícios. O conhecimento da variação glicêmica durante o exercício é fundamental para a conduta terapêutica do médico, para a prescrição e orientação segura de exercícios pelos professores de educação física. OBJETIVOS: Analisar a variação da glicose de DM1, submetidos às sessões de exercício aeróbio, exercícios resistidos e teste ergoespirométrico, utilizando o Sistema de Monitorização Contínua da Glicose (CGMS) e o glicosímetro portátil para monitorização da glicemia capilar. E como objetivo secundário, analisar a acurácia do CGMS e as respostas agudas e crônicas às sessões de exercícios aeróbio, resistidos e teste ergoespirométrico por portadores de DM 1. CASUÍSTICA E MÉTODOS: Dez portadores de DM1, de ambos os sexos, com idade entre 16 e 45 anos, sem complicações da doença. Os pacientes foram submetidos ao teste ergoespirométrico máximo (TE) e a 40 sessões de exercícios aeróbios (A) ou resistidos (R). As sessões foram realizadas no período pós-prandial do almoço e nestes dias, os pacientes foram orientados pela equipe médica a reduzir: 1U (se dose <20U) ou 2U (se dose >20U) da insulina basal (NPH) da manhã e 50 a 75% da insulina pré-prandial ultra-rápida (UR) do almoço; não houve redução para o TE. Os pacientes mediam a glicemia capilar antes, durante (se, necessário) e após as sessões. RESULTADOS: Os exercícios aeróbios promoveram uma queda maior na GC (67 mg/dL), quando comparada a queda causada pelos exercícios resistidos (37mg/dL) (p=0,047). A correlação entre os dados obtidos pelo CGMS e pelo glicosímetro durante o exercício é significativa (p<0,001), positiva e direta (r=+0,925). A freqüência cardíaca e a pressão arterial sistólica apresentaram aumento durante A (p<0,001), não apresentando diferença para R. A pressão arterial diastólica não mostrou diferença em nenhum dos dois grupos. A freqüência média de consumo [(A=19,8) e (R=16,7)] e a quantidade de gel [(A=28,2) e (R=21,3)] utilizada durante o período de treinamento foram similares em ambos os grupos. A freqüência de hipoglicemias foi igual em ambos os grupos [(A=1,5) e (R=1,5)] durante o treinamento, não apresentando diferenças em relação às reduções de dose de insulina UR ou período de treinamento. As respostas crônicas foram obtidas ao final do período de treinamento (40 sessões): o controle glicêmico (HbA1c), o perfil lipídico (colesterol total, triglicérides, HDL, LDL, VLDL) e os parâmetros antropométricos não foram influenciados pelo treinamento. Os níveis médios de microalbuminúria em repouso não modificaram, mas os níveis médios de microalbuminúria induzida pelo exercício praticamente dobraram. CONCLUSÕES: O grupo A apresentou maior declínio da glicose quando comparado ao grupo R. O CGMS pode ser considerado um método acurado para a sua utilização durante o exercício. O comportamento da freqüência cardíaca e pressão arterial foram similares aos não portadores de diabetes. O protocolo de redução de insulina se mostrou efetivo durante o período de treinamento. Houve mudanças na composição corporal detectadas pelo DEXA / Background and Aims: For type 1 diabetes patients is essential self monitoring of blood glucose and adjustment of carbohydrate intake and insulin dose for exercise practice. The aim of this study was to assess glucose variability during: spiroergometric test (ST) and aerobic (A) and resistance exercises(R). Materials and Methods: 10 DM1 patients performed ST, and 40 A and R bouts and they reduced their insulin dose in A and R exercise days. Results: Glycemia variation groups were: A=67mg/dL and R=37mg/dL. Heart rate and systolic blood pressure increased during A. Diastolic blood pressure was not modified. Glycemic control, lipids and body measurements were not influenced by training. Conclusions: Aerobic and resistance exercise produced glycemia reduction but glycemia fall was higher during aerobic exercise bouts when compared with resistance exercise bouts