Individual day-to-day management and effective control of type 1 diabetes (T1D) is ultimately driven by decisions made by the individual. Individuals with attention deficit hyperactivity disorder (ADHD) have a higher tendency to be inattentive, impulsive, and hyperactive. Attention deficits and impulsivity among adolescents and adults with T1D could result in poor diabetes management through infrequent self-monitoring of blood glucose and inadequate insulin dosing – key components of achieving optimal glycemic control. This study included 7,380 adolescents and young adults, ages 13-25 years, participating in the T1D Exchange clinic registry (median age 17.4 years, duration 7.7 yrs, 50% female, 81% white). Participants were classified into 3 groups for the primary analyses using participant reported diagnosis and medication use: 1) No ADHD; 2) ADHD with current medication; 3) ADHD without current medication. Groups were compared in logistic and linear regression models for: self-monitoring of blood glucose (SMBG) /day, missed insulin dose ≥1 time/week, HbA1c, and at least 1 diabetic ketoacidosis (DKA) and severe hypoglycemic (SH) event in the past 3 months. Overall, 774 (10%) participants reported a diagnosis of ADHD of whom 371 currently took medication. Mean SMBG/day was 4.7, 5.0, and 4.9 in the ADHD w/o meds, ADHD with meds, and no ADHD groups, respectively. ADHD patients w/o meds (36%, P=0.02) or with meds (39%, P=0.003) were more likely to report missing insulin doses compared with no ADHD pts (30%). Mean HbA1c was higher in ADHD w/o meds (9.0%, P<0.001) and ADHD with meds (8.9%, P=0.002) compared with no ADHD pts (8.6%). The odds of having at least one DKA event in the past 3 months was 1.8 and 1.5 times higher in the ADHD w/o meds (P<0.001) and ADHD with meds (P=0.01) group compared with no ADHD. The ADHD w/o meds group was significantly more likely to have had a SH event (OR 1.7 95% CI 1.2-2.3; P<0.001) compared with the no ADHD group but the occurrence of SH in the ADHD with meds group was similar to the no ADHD. Results of this study supported the working hypothesis that ADHD without treatment with medication has a negative impact on aspects of diabetes management and glycemic control. Participants with ADHD with and without medication were more likely to miss insulin doses, less likely to use an insulin pump, more likely to have high HbA1c levels, and had a higher frequency of DKA and SH. These results have important public health implications for adolescents and young adults with T1D who are already at risk for poor glycemic control. Since ADHD has a meaningful impact on glycemic outcomes it is important for providers of adolescents and young adults with T1D to review history and signs of an ADHD diagnosis along with diagnosis of other psychosocial disorders with their patients and consider recommending psychosocial services.

Despite considerable effort considerable cost in both time and money, as many as two out of three persons with type 1 diabetes are not in control of their disease. As a result, 40% of these individuals will go on to develop at least one serious complication including retinopathy, nephropathy, neuropathy and cardiomyopathy. It is further estimated that as much as $4 billion could be saved annually if all persons with type 1 diabetes in the US were properly controlled. Adequate treatment of type 1 diabetes is predicated on the estimation of three clinical insulin therapy parameters: the basal dose, the insulin sensitivity factor and the insulin-to-carbohydrate ratio. Currently, these therapy parameters are determined by iterative titration procedures based on expert opinion. Unfortunately, there is evidence suggesting that for the majority of individuals, these titration protocols do not provide good results. In this work we develop an alternative to traditional insulin titration protocols that allows clinical insulin therapy parameters to be estimated directly from a set of easily acquired measurements. First, a simple model of type 1 diabetes is used to derive a series of equations connecting the model's parameters to the clinically important insulin therapy parameters of insulin sensitivity factor, insulin-to-carbohydrate ratio and basal insulin dose. The simplifying assumptions used to derive these equations are tested and shown to be valid and the Fisher Information Matrix is used to demonstrate parameter identifiability. Parameter estimation is then performed on two cohorts of virtual subjects, as well as two segments of real continuous glucose monitoring data from a person with type 1 diabetes. Identification of the true insulin therapy parameters is successful under most conditions for both cohorts of virtual subjects. Parameter estimation for one of the two segments of real continuous glucose monitoring data is also successful. Finally, because continuous glucose monitors are instrumental to successful implementation of our insulin therapy framework, the physiological environment in which continuous glucose monitoring takes place is modeled and a fundamental limitation on measurement precision is shown to exist. An examination of physiological variability in the parameters indicates that many of the challenges observed in real world continuous glucose monitoring may have a relationship to changes in capillary bed perfusion. A rationale for anecdotally reported sensor faults is also proposed based on the physical mechanisms explored. / text

En dramatisk ökning kan ses av antalet barn som insjuknar i diabetes typ 1 i Sverige. Diabetes typ 1 är en allvarlig livslång sjukdom, insjuknandet sker plötsligt och sjukdomen inträder oftast i unga åldrar. Syftet var att belysa föräldrarnas omvårdnadsbehov i samband med att deras barn diagnostiserades med diabetes typ 1. Metoden som valdes var en litteraturstudie och det gjordes systematiska sökningar av vetenskapliga artiklar i utvalda databaser. Nio artiklar valdes ut till resultatet vilka speglade föräldrars perspektiv. En dataanalys gjordes som mynnade ut i två teman: Föräldrars behov av bekräftelse och föräldrars behov av kunskap. I resultatet framkom att föräldrar uppskattade sjuksköterskors närvaro under sjukhusvistelsen vilket gav föräldrarna trygghet. De hade ett behov av samtal och uttryckte även ett behov av kunskap, anpassad information och att praktiskt få träna på omvårdnadsmoment. Det behöver göras mer forskning inom omvårdnad i samband med att barn diagnostiserats med diabetes typ 1 för att kunna utforma en ändamålsenlig omvårdnad för hela familjen. Denna studie kan användas i utbildning av blivande sjuksköterskor och även för att sprida kunskap bland dem som är i klinisk verksamhet. / A dramatic increase can be seen in the number of children who come down with type 1 diabetes in Sweden. Type 1 diabetes is a severe life-long disease, onset occurs suddenly, and the disease often occurs at a young age. The aim was to highlight parents' nursing needs associated with their child’s diagnosed with diabetes type 1. The method chosen was a literature study and it was made through systematic searches of research articles in selected databases. Nine articles were selected to the result which reflected the parents' perspective. A data analysis was done which culminated in two themes: Parents need of confirmation and parents need of knowledge. The result showed that parents appreciated the nurses' presence during hospitalization giving the parents some peace of mind. They had a need to talk and also expressed a need for knowledge, tailored information and to practically get to train in nursing. There needs to be more research to devise an appropriate care for the whole family. This study can be used in the training of future nurses and also to spread knowledge among those in clinical practice.

No description available.

I Sverige finns idag cirka 7000 barn och ungdomar med den kroniska sjukdomen diabetes. Ungdomar med diabetes typ 1 har ibland tendens att experimentera och ta risker genom att testa gränser för att utveckla sin kunskap. Risktagandet vid en kronisk sjukdom kan innebära medicinska konsekvenser för ungdomarna. En god vård är därför av betydande vikt. En systematisk litteraturstudie med deduktiv ansats genomfördes där syftet var att beskriva skolsköterskans stödjande insatser ungdomar med diabetes typ 1, utifrån Orems teori omstödjande och undervisande omvårdnadssystem. De vetenskapliga artiklarna eftersöks i databaserna Cinahl och Pubmed och sammanlagt hittas 16 artiklar som svarade mot syftet. Databearbetningen utfördes i form av temaanalys. Resultatet visade fyra kategorier av stödjande insatser som ungdomar med diabetes typ 1 är i behov av från skolsköterskan. Utifrån Orems teori om stödjande och undervisande omvårdnadssystem delas de in i: stöd – fysiskt och psykiskt, vägledning, undervisning och skapa en utvecklande miljö. Det fysiska stödet bestod av att ha en fysiskt närvarande skolsköterska som befann sig på plats och gav stöd åt ungdomarna när diabetesrelaterade problem uppkom. Det psykiska stödet bestod av att ha en god lyssnare som en som förstod ungdomarnas livssituation och deras känslor. Det vägledande stödet bestod i att ha en skriftlig vårdplan för att kunna hantera ungdomarnas diabetes i skolan. Stöd i form av undervisning till ungdomarna med diabetes, lärarna och övrig skolpersonal ansågs viktigt. För att ungdomar med diabetes ska kunna hantera sin sjukdom och egenvård krävdes en anpassad miljö. I en stödjande miljö fanns behov, tid och tillgänglighet av mat. Det var viktigt för att fler personal på skolan skulle ha kunskap och handlingsberedskap vid eventuella akuta situationer som kunde uppstå. Kunskapen som framkommit är viktig i skolsköterskans kliniska arbete, för att kunna ge ungdomar med diabetes typ 1 en trygg tillvaro under sin skoltid. Vidare kvalitativ forskning behövs för att förbättra skolsköterskans stödjande insatser till ungdomar med kronisk sjukdom. Metoder för att skapa en anpassad och säker miljö för ungdomar med kroniska sjukdomar behöver utarbetas. / In Sweden there are currently 7000 children and young people with the chronic disease diabetes. Young people with type 1 diabetes have sometimes tended to experiment and take risks by testing limits to develop their knowledge. Risk-taking in a chronic disease may involve medical consequences for young people. A good health care is therefore of considerable importance. A systematic literature search with a deductive approach carried out where the purpose was to describe the school nurse support to young people with diabetes type1, based on Orem´s theory of supportive and educational care system. The research articles were searched for in database Cinahl and Pubmed and 16 articles were found who answered the purpose. Dataprocessing was carried out in the form of thematic analysis. The result showed 4 categories of support that young people with diabetes type 1 is in need of. Based on Orems theory of supportive and educational caresystem divided into: support -physically and mentally, guidance, education and create a developed environment. The physical support consisted of having a present school nurse who was situated at school and gave support to young people with diabetes related problems when they needed help. The mental support consisted of having a good listener who understood young people's life situation and feelings. The guidance support consisted in having a written care plan for young people to be able to manage diabetes in school. Educational support for young people with diabetes their teachers and other school staff was considered important. Young people with diabetes should be able to manage their disease and care required a developed environment. A supportive environment was necessary also time and availability of food. It was important that more staff at the school would have knowledge and preparedness in the event of any emergency situations that could arise. The knowledge that was found is important in a school nurse clinical work, to be able to give adolescents with diabetes type 1 safe environment during school time. Further qualitative research is needed to improve the school nurse´s supportive service for young people with chronic illness. Methods to create a customized and secure environment for young people with chronic illnesses need to be developed.

Background and aims: The overall aim of this thesis was to increase knowledge regarding the occurrence of childhood onset T1D and T2D in Sweden and in relation to that describe and elucidate important aspects on two grave complications to diabetes; end-stage renal disease (ESRD) and mortality. The two first studies included in this thesis aimed to describe and analyze the cumulative incidence of childhood onset T1D in Sweden and to assess the occurrence of undetected T2D in Swedish children. The aim with the third study was to describe the cumulative incidence of ESRD, and to analyze how ESRD risk differs with age at-onset and sex. The aim of the fourth study was to show how parental socioeconomic status (SES) affects all cause mortality in Swedish patients with childhood onset T1D. Study populations: The foundation for the studies on T1D was data from the Swedish Childhood Diabetes Registry (SCDR). When studying ESRD we also included adult onset T1D cases from the Diabetes Incidence Study in Sweden (DISS). The study on T2D was a population-based screening study where BMI was measured in 5528 school-children and hemoglobin A1c was measured in children with overweight according to international age and sex specific BMI cut-offs. To study ESRD and mortality, we linked the SCDR to various nationwide registers containing individual information on SES, mortality and ESRD. Results: The incidence rates of childhood onset T1D has continued to increase in Sweden 1977–2007. Age- and sex-specific incidence rates varied from 21.6 (95% CI 19.4–23.9) during 1978–1980 to 43.9 (95% CI 40.7– 47.3) during 2005–2007. Cumulative incidence by birth-cohorts has shifted to a younger age at-onset over the first 22 years of incidence registration. From the year 2000 there was a significant reverse in this trend (p&lt;0.01). In contrast to the increase of T1D, we found no evidence of undetected T2D among Swedish school children. Despite a relatively high incidence in T1D in Sweden there is low cumulative incidence of ESRD, 3.3% at maximum 30 years of duration. We found difference between the sexes regarding long-term risk of developing ESRD that was dependent on the age at onset of T1D. When analyzing how socioeconomic status affects mortality in different age at death groups, we found that having parents that received income support increased mortality up to three times in those who died after 18 years of age. Conclusion: The incidence of childhood onset T1D continued to increase in Sweden 1978-2007. Between the years 1978-1999 there was a shift to a younger age at-onset, but from the year 2000 there is a change in this shift indicating a possible trend break. The prevalence of T2D among Swedish children up to 12 years of age is probably very low. There is still a low cumulative incidence of T1D associated ESRD in Sweden. The risk of developing ESRD depends on age at-onset of T1D, and there is a clear difference in risk between men and woman. Excess mortality among subjects with childhood onset T1D still exists, and low parental socioeconomic status additionally increased mortality in this group.

The incidence of Type 1 diabetes is growing yearly. Worryingly, the aetiology of the disease is inconclusive. What is known is that the total number of affected individuals, as well as the severity and number of associated complications are growing for this chronic disease. With increasing complications due to severity, length of exposure, and poor control, the disease is beginning to consume an increasingly major portion of healthcare costs to the extent that it poses major economic risks in several nations. Research has shown that intensive insulin therapy aimed at certain minimum glycosylated haemoglobin threshold levels reduces the incidence of complications by up to 76% compared to conventional insulin therapy. Moreover, the effects of such intensive therapy regimes over a 6.5y duration persists for at least 10y after, a so called metabolic memory. Thus, early intervention can slow the momentum of complications far more easily than later intervention. Early, safe, intensive therapy protocols offer potential solutions to the growing social and economic effects of diabetes. Since the 1970s, the artificial endocrine pancreas has been heralded as just this type of solution. However, no commercial product currently exists, and ongoing limitations in sensors and pumps have resulted in, at best, modest clinical advantages over conventional methods of insulin administration or multiple daily injection. With high upfront costs, high costs of consumables, significant complexity, and the extensive infrastructure and support required, these systems and devices are only used by 2-15% of individuals with Type 1 diabetes. Clearly, there is an urgent need to address the large majority of the Type 1 diabetes population using conventional glucose measurement and insulin administration. For these individuals, current conventional or intensive therapies are failing to deliver recommended levels of glycaemic control. This research develops an understanding of clinical glycaemic control using conventional insulin administration and glucose measurement techniques in Type 1 diabetes based on a clinically validated in silico virtual patient simulation. Based on this understanding, a control protocol for Type 1 diabetes that is relatively simple and clinically practical is developed. The protocol design incorporates physiological modelling and engineering techniques to adapt to individual patient clinical requirements. By doing so, it produces accurate, patient-specific recommendations for insulin interventions. Initially, a simple, physiological compartmental model for the pharmacokinetics of subcutaneously injected insulin is developed. While the absorption process itself is subject to significant potential variability, such models enable a real-time estimation of plasma insulin concentration. This information would otherwise be lacking in the clinical environment of outpatient Type 1 diabetes treatment due to the inconvenience, cost, and laboratory turnaround for plasma insulin measurements. Hence, this validated model offers significant opportunity to optimise therapy selection. An in silico virtual patient simulation tool is also developed. A virtual patient cohort is developed on patient data from a representative cohort of the broad diabetes population. The simulation tool is used to develop a robust, adaptive protocol for prandial insulin dosing against a conventional intensive insulin therapy, as well as a controls group representative of the general diabetes population. The effect on glycaemic control of suboptimal and optimal, prandial and basal insulin therapies is also investigated, with results matching clinical expectations. To gauge the robustness of the developed adaptive protocol, a Monte Carlo analysis is performed, incorporating realistic and physiological errors and variability. Due to the relatively infrequent glucose measurement in outpatient Type 1 diabetes, a method for identifying the diurnal cycle in effective insulin sensitivity and modelling it in retrospective patient data is also presented. The method consists of identifying deterministic and stochastic components in the patient effective insulin sensitivity profile. Circadian rhythmicity and sleep-wake phases have profound effects on effective insulin sensitivity. Identification and prediction of this rhythm is of utmost clinical relevance, with the potential for safer and more effective glycaemic control, with less frequent measurement. It is thus a means of further enhancing any robust protocol and making it more clinically practical to implement. Finally, this research presents an entire framework for the realistic, and rapid development and testing of clinical glycaemic control protocols for outpatient Type 1 diabetes. The models and methods developed within this framework allow rapid and physiological identification of time-variant, patient-specific, effective insulin sensitivity profiles. These profiles form the responses of the virtual patient and can be used to develop and robustly test clinical glycaemic control protocols in a broad range of patients. These effective insulin sensitivity profiles are also rich in dynamics, specifically those circadian in nature which can be identified, and used to provide more accurate glycaemic prediction with the potential for safer and more effective control.

The dorsal vagal complex (DVC), containing the nucleus of the solitary tract (NTS) and the dorsal motor nucleus of the vagus nerve (DMV), plays a pivotal role in autonomic regulation. Afferent fibers from peripheral organs and higher brain centers synapse in the NTS, which integrates these synaptic connections as well as information from systemically circulating hormones and metabolites. The integrated information is relayed to the dorsal motor nucleus of the vagus nerve (DMV), which in turn, projects motor fibers to elicit parasympathetic control of digestive and other viscera. Physiological functions mediated by the DVC are disrupted in diabetic patients and synaptic plasticity within the DVC has been linked to these complications. N-methyl-D-aspartic acid (NMDA) receptors have been extensively studied for their involvement in synaptic plasticity in a variety of central nervous system disorders; and their activation in the DVC modulates hepatic glucose production and feeding behavior. Although chronic disease can alter NMDA function, changes in DVC expression and/or sensitivity of NMDA receptors in diabetic states has not been addressed. Using whole cell electrophysiology, functional properties of the nuclei in the DVC were investigated in normoglycemic and type 1 diabetic mice. Preterminal NMDA (preNMDA) receptors were discovered to tonically modulate excitatory neurotransmission on terminals contacting DMV neurons. While these preNMDA receptors were not found to differentially modulate tonic excitatory neurotranmission, soma-dendritic NMDA receptor responses of NTS neurons were augmented in type 1 diabetic mice. Through the use single-cell PCR, increased NMDA receptor responses could be correlated to neurons that mediate excitatory neurotransmission and would argue that augmented NMDA receptor responses increase vagal output. In general, enhancing vagal output decreases activity of connected peripheral organs. Molecular approaches were employed to corroborate the observed functional NMDA receptors changes to their protein and mRNA expression levels. Overall, results argue that NMDA receptors are involved in synaptic plasticity in DVC of type 1 diabetic mice to enhance excitatory neurotransmission. This modulation may potentially serve as a physiological counter regulatory mechanism to control pathological disturbances of gastrointestinal homeostatic reflex responses.

Bakgrund: I Sverige insjuknar årligen 800 barn i typ 1 diabetes. Sjukdomen är kronisk och kännetecknas av stor urinmängd, överdriven törst, viktminskning och trötthet. Behandlingen är livslång vilket leder till livsstilsförändringar för barnet. Sjukdomen påverkar samtidigt hela familjen känslomässigt och en stor omställning krävs för att få livet att gå ihop. Omhändertagandet av hela familjen är viktigt då det påverkar dem i hur de ser på sjukdomen och klarar av att gå vidare i livet. Syfte: Att belysa hur familjer till barn med typ 1 diabetes upplever sin situation. Metod: En litteraturöversikt baserad på elva studier med kvalitativ ansats. Resultat: Resultatet i denna studie sammanfattas med två huvudteman och nio underkategorier: Förändringar i det dagliga livet – Anpassning, Delaktighet och engagemang, Egenvård, Gå vidare i livet; Känslomässiga upplevelser – Oro och rädsla, Förnekelse, Utanförskap, Sorg och förlust, Betydelse av kunskap. Slutsats: Familjer till barn med typ 1 diabetes drabbas av olika känslor vid diagnos och hanteringen av sjukdomen kräver stor förändring i livet för barnet och dennes familj. Kunskap, engagemang och delaktighet är viktiga faktorer för att främja hälsa hos familjen. Klinisk betydelse: Studien har betydelse och klinisk relevans för att öka kunskapen bland de som berörs så att omvårdnaden och bemötandet kan bli bättre i framtiden för de familjer med barn som drabbas av typ 1 diabetes. / Background: Every year 800 children in Sweden get the diagnosis type 1 diabetes. The disease is chronic and is characterized by a large amount of urine, excessive thirst, weight loss and fatigue. Treatment is life long, which leads to lifestyle changes for the child. At the same time the disease affects the whole family emotionally, and they need to change their life in order to make ends meet. It is important to take care of the entire family as it affects them in the way they look at the disease and are able to move on in life. Aim: To illuminate how families of children with type 1 diabetes experiences their situation. Method: A literature review based on eleven studies involving qualitative approach. Results: The results in this study are summarized in two themes and nine subthemes: Changes in daily life – Adaptation, Participation and commitment, Self-care, Move on after diagnosis; Emotional experiences – Anxiety and fear, Denial, Exclusion, Grief and loss, Importance of knowledge. Conclusion: At diagnosis families of children with type 1 diabetes suffer from mixed emotions and the management of the disease requires great change in the life of the child and their family. Knowledge, commitment and involvement are important factors to promote health of the family. Clinical implications: The study has significance and clinical relevance to increase knowledge among those who are affected so that the care and treatment can be improved in the future for those families with children who suffer from type 1 diabetes.

Bakgrund: Barn och ungdomar med typ 1diabetes har en kronisk sjukdom. En överförflyttning från barn-och ungdomsvård till vuxenvård är därmed oundviklig. Övergången emellan vårdorganisationerna tar vid under en ömtålig period i livet när ytterligare förändringar sker för de unga personerna, exempelvis inträdandet in i vuxenlivet. Syfte: Syftet var att beskriva unga personers erfarenheter av överförflyttningen från barn- och ungdomsvård till vuxenvård. Metod: Uppsatsen baseras på en litteraturöversikt av tio artiklar. Kvantitativa samt kvalitativa artiklar inhämtades från databaserna Cinahl och Medline. Resultat: Via analysen av artiklarna uppkom tre teman. Det första temat ”Ett möte   med två världar” skildrar de unga personernas erfarenheter av barn- och ungdomsvårdens samt vuxenvårdens varierande miljöer och de olika vårdorganisationernas strukturer. Det andra temat ”Ett ökat egenansvar” beskriver hur vårdnadshavarnas avsaknad och nya rutiner inom vuxenvården påverkar de unga personerna. Det tredje temat ”Ett sökande efter information” visar på att informationsbrist inför och om överförflyttningen förekommer. Det leder till att de unga   personerna känner sig vilsna och svikna inom vårdorganisationen. Diskussion: För unga personer med typ 1 diabetes kan det vara mycket svårt att balansera vardagen med arbete/studier och ta ansvar för sin egenvård. Efter övergången till vuxenvården förväntas den unga personen ta fullt ansvar för sin sjukdom och är personen inte förberedd på förändringen kan resultatet leda till utebliven närvaro. Sjuksköterskan kan stödja den unga personen med aktuell kunskap om sjukdomen och informera tidigt om vad överförflyttningen innebär. Resultatdiskussionen har Afaf Meleis omvårdnadsteori om transition som grund. / Background: Children and adolescents with type 1 diabetes, have a chronic disease. A transfer from the child and youth to adult care is therefore inevitable. The transition between healthcare organizations take place during a delicate period of life when further changes occur to the young people, such as the transition into adulthood. Aim: The aim was to describe young people's experiences of transition from child and youth to adult care. Methods: The essay is based on a literature review of ten articles. Quantitative and qualitative articles were obtained from the databases Cinahl and Medline. Results: Via the analysis of the articles emerged three themes. The first theme "A meeting of two worlds" describes the young people’s experiences of the child and youth care and adult care different environments, and the various healthcare organizations' structures. The second theme "An increasing responsibility" describes how guardian’s absence and procedures in adult care affects young people’s transition. The third theme "A search for information" indicates that the lack of information for and about the transfer occurs. The result is that the young people feel lost and deceived within the healthcare organization. Discussions: For young people with type 1 diabetes it may be very difficult to balance everyday life with work / study and take responsibility for their own self-care. After the transition to adult care the young person is expected to take full responsibility for the disease, and if the person is not prepared for the change the result may lead to loss of presence. The nurse can support the young person with current knowledge of the disease and inform early about what the transfer means. The result discussion has Afaf Meleis nursing theory of transition as a basis.