Bakgrund: Diabetes typ 1 är en kronisk sjukdom som ofta drabbar barn. För att kunna leva ett normalt liv krävs en livslång behandling med insulin. Föräldrar som står barnet nära tar över ansvaret för behandlingen. Detta innebär en påverkan på föräldrarnas livskvalité. Sjukvården är ansvarig att i mötet med familjen fokusera på föräldrarnas och barnets upplevelse, reducera lidandet och främja hälsan. Det är viktigt att vårdpersonalen inkluderar närståendes perspektiv i patientens vårdande. Syfte: Studiens syfte är att beskriva föräldrars upplevelse av att leva med barn som har diabetes typ 1. Metod: En kvalitativ studie med induktiv ansats baserad på fem självbiografier skrivna av föräldrar vars barn har drabbats av diabetes typ 1. Detta analyserades med manifest innehållsanalys. Resultat: I resultatet framkommer tre huvudkategorier: Det första tiden efter beskedet, Anpassning till den nya verkligheten, Erfarenheter av stöd. Slutsats: Utifrån resultatet framkom att sjuksköterskan ska ta hänsyn till föräldrarnas lidande och veta hur barnets sjukdom påverkar deras liv. Genom att ge anpassad information och ha en god kommunikation med föräldrarna kan sjuksköterskan öka både barnets och föräldrarnas livskvalitet, minska lidandet samt bidra till en säker och trygg vård.

Aims: Thiazolidinediones have been advocated as second or third line insulin sensitizing agents in the management of type 2 diabetes (T2DM). Their widespread use has been hampered by concerns about their cardiovascular safety, including fluid retention. Metformin is established as first-line glucose-lowering pharmacotherapy in T2DM. It has also been suggested that it may have benefits in alleviating insulin resistance in type 1 diabetes (T1DM). This thesis examined: (i) cardiovascular, renal and metabolic differences between individuals with T2DM ‘tolerant’ or ‘intolerant’ of TZDs; (ii) risk factors for TZD-associated oedema in T2DM; and (iii) the potential for metformin as adjunct therapy in T1DM. Methods: (i) A small clinical study characterising TZD tolerant and intolerant individuals with T2DM; (ii) A population-based epidemiological study of TZD induced oedema in individuals with T2DM in Tayside, Scotland (using incident loop diuretic prescription as a surrogate); (iii) A systematic review and meta-analysis of published studies of adjunct metformin in T1DM. Results (i) During a five-day high sodium diet, two known TZD-intolerant individuals with T2DM had reductions in haematocrit, aldosterone, and diastolic BP and increases in ANP and central and peripheral augmentation indices which were outwith reference ranges derived from nine TZD-tolerant individuals; (ii) Predictors of time to loop diuretic prescription included age, body mass index, systolic BP, haematocrit, ALT and macrovascular disease but rates of this outcome did not differ by therapy: 4.3% (TZDs) vs 4.7% (other agents) [unadjusted OR 0.909 (95% CI 0.690, 1.196); p = 0.493]; (iii) In meta-analysis of nine small studies in T1DM (192.8 patient-years of follow-up), metformin was associated with a reduction in total daily insulin dose (6.6 units/day; p < 0.001) but no studies examined cardiovascular surrogates or outcomes. Conclusions: Hypotheses were generated for several potential biomarkers predictive of TZD-induced oedema but the clinical importance of TZDs as a risk factor for oedema in individuals with T2DM was questioned. As there is some evidence for the safety of metformin as an adjunct therapy in T1DM but little evidence of efficacy, larger studies are warranted.

O presente trabalho refere-se ao estudo do papel dos microRNAs no controle pós-transcricional das células T de camundongos Non Obese Diabetic (NOD) modelo que reproduz o diabetes mellitus do tipo 1 (DM-1). Durante o desenvolvimento do trabalho, procurou-se esclarecer a hipótese de que os microRNAs controlam os níveis de determinados RNAs mensageiros (mRNAs) das células T durante a indução ou perda de tolerância imunológica. Portanto, a expressão alterada dos microRNAs estaria contribuindo com o processo da autoimunidade. Sendo assim, o objetivo do estudo foi identificar os perfis de expressão e as redes de interação entre um conjunto de microRNAs e seus respectivos mRNAs alvos nos timócitos e nos linfócitos T CD3+ periféricos durante o desenvolvimento do diabetes mellitus do tipo 1 (DM-1) em camundongos NOD. Para avaliar a expressão de genes codificadores de mRNAs, sendo estes possíveis alvos de microRNAs, utilizou-se a tecnologia de microarrays. O uso de programas de análise e para a construção das redes foi imprescindível. Acreditase que fenômenos complexos como a regulação pós-transcricional de células T e seu envolvimento no processo de tolerância imunológica, bem como o surgimento de doenças autoimunes, podem ser melhor compreendidos por meio da genômica funcional. Os resultados encontrados evidenciam uma expressão diferenciada de mRNAs e microRNAs em timócitos e linfócitos T CD3+ periféricos durante o desenvolvimento do diabetes mellitus do tipo 1 (DM-1). As diferenças nos perfis transcricionais encontradas envolvem expressão de genes (mRNAs) relacionados diretamente ao sistema imune, a diferenciação e ativação de linfócitos T e a apoptose, bem como a outros processos relacionados a resposta imune. Além disso, as redes de interação microRNA-mRNA encontradas no presente trabalho evidenciam interações já conhecidas e apresentam novas interações, mostrando a participação de um grupo de microRNAs que estão atuando no controle pós-transcricional do diabetes do tipo 1 em camundongos NOD, contribuindo com a melhor compreensão do controle genético-molecular das doenças autoimunes, principalmente do diabetes do tipo 1. / This study refers to the role played by microRNAs in the post-transcriptional control of T cells from non obese diabetic (NOD) mice model which reproduces the type 1 diabetes (T1D). During the study, it was tried to clarify the hypothesis that microRNAs control certain messenger RNAs (mRNAs) levels of the T cells during the induction or loss of immunological tolerance. Therefore, the altered expression of microRNAs might be contributing to the process of autoimmunity. Thus, the study aim was to identify the expression profiles and interaction networks between a set of microRNAs and their mRNA targets in thymocytes and peripheral CD3+ T lymphocytes during the development of type 1diabetes (T1D) in NOD mice. The microarray technology was used to evaluate the expression of mRNAs as possible targets of microRNAs involved in this process. The use of bioinformatics software to reconstruct the networks was essential. It was realized that complex phenomena as post-transcriptional regulation in T cells and their involvement in the immune tolerance process, as well as the emergence of autoimmune diseases can be better understood only by means of functional genomics. The results show differential expression of mRNAs and microRNAs in thymocytes and peripheral CD3+ T lymphocytes during the development of type 1 diabetes (T1D). The differences found in the transcriptional profiles involve mRNAs related to the immune system, differentiation and activation of T lymphocytes and apoptosis as well as other processes related to immune response. In addition, the microRNA-mRNA interaction networks obtained in this study evidence the predicted interactions as well as new ones, showing the participation of a group of microRNAs that may be acting in post-transcriptional control of type 1 diabetes in NOD mice contributing to a better understanding of the molecular genetic control of autoimmune diseases in specially type 1 diabetes.

Perdas gestacionais, malformações, restrição de crescimento intrauterino (IUGR) são associadas a gestações diabéticas. Para ampliar o conhecimento nesse tema, nosso grupo desenvolveu um modelo de gestação complicada por diabetes tipo 1 em camundongos que, nessa tese, foi utilizado para analisar o ciclo estral, desenvolvimento fetal e organização placentária. O diabetes foi induzido por aloxana e estudado em dois períodos 30-50D (curto prazo) e 90-110D (longo prazo). Placentas e fetos foram coletados, pesados, e submetidos a técnicas moleculares, bioquímicas e morfológicas. Detectaram-se alterações no perfil temporal do ciclo estral. O grupo 30-50D apresentou altas taxas de perdas embrionárias e IUGR, e o 90-110D malformações, mortes fetais, IUGR e aumento no peso placentário. As placentas diabéticas apresentaram aumento e desorganização da zona juncional, redução do labirinto e vasodilatação. A expressão dos colágenos I e III aumentou e a do V diminuiu em 30-50D, porém, a deposição destes aumentou concomitante com a redução da atividade da MMP9. A deposição dos colágenos III e V e a atividade da MMP2 aumentaram em 90-110D. Nossos resultados reiteram a importância do fator temporal nas complicações do diabetes sobre a gestação. / Gestational loss, malformations and intrauterine growth restriction (IUGR) are often associated with pregnancies. To increase the knowledge about this topic, our group has developed a model of pregnancy complicated by type 1 diabetes in mice. In this study, was analyzed the estrous cycle and the fetal and placental development. For this, diabetes was induced by alloxan and studied in two time-periods 30-50D (short term) and 90-110D (long term). Placentas and fetuses were collected, weighed and analyzed by biochemical, morphological and molecular procedures. We detected changes in the temporal profile of the estrous cycle. The 30-50D group showed high rates of embryonic loss and IUGR whereas malformations, fetal death, IUGR and increased placental weight was detected in 90-110D. Increase and disorganization of junctional zone, reducing labirinth and vasodilation characterize diabetic placentas. The expression of collagen I and III was increased whereas collagen V decreased in the 30-50D. The deposition of this collagen, however increased concomitant with the reduction of MMP9 activity. In 90-110D deposition of collagen III and V and the MMP2 activity was increased. Together, our results reinforce the relevance of the time factor in the complications of diabetes on pregnancy.

O adequado manejo do DM Tipo 1 tem se tornado um desafio, principalmente para as próprias crianças, em virtude da presença de comportamentos, habilidades e conhecimentos inadequados que colaboram para a não adesão ao tratamento e para aumento de complicações em longo prazo. Estudos têm demonstrado que compreender as experiências de vida das crianças nos seus diversos espaços, valorizando-as e buscando maior aproximação com as mesmas, pode contribuir para a partilha do conhecimento sobre o manejo do diabetes e para o maior envolvimento da criança no cuidado. O objetivo deste trabalho foi compreender, na perspectiva de crianças com DM Tipo 1, os fatores que interferem no manejo da doença. Trata-se de uma pesquisa qualitativa, de natureza exploratória. Participaram do estudo 19 crianças. Utilizamos a entrevista semiestruturada e, como recurso facilitador da comunicação com a criança, os fantoches. Esses brinquedos foram confeccionados pelas próprias crianças e criou-se, também, um cenário que ilustrou e complementou a utilização dos fantoches no dia da entrevista. A análise dos dados empíricos foi feita por meio da análise de conteúdo. Os resultados evidenciaram a compreensão do que é ser criança com diabetes e dos fatores relacionados à sua existência, como seus sentimentos e percepções. A compreensão da interação da criança com os conhecimentos que possui sobre a sua doença, sua inserção no processo do autocuidado, as habilidades desenvolvidas e os recursos disponíveis para lidar com as demandas da doença constituem fatores que interferem de forma positiva ou negativa no manejo da doença e merecem ser foco de atenção dos profissionais de saúde. Todos esses elementos atuam dinamicamente nos espaços do cotidiano da criança, tais como o familiar, o escolar, o de amizades, o de lazer e o dos serviços de saúde, atuando como fatores que fragilizam ou potencializam o manejo da doença. O apoio de familiares, amigos, professores e profissionais de saúde que compartilham as experiências de ser uma criança com diabetes mostrou-se essencial para o alcance do adequado manejo. Além disso, o conhecimento adquirido por estes atores e pela própria criança interfere diretamente no manejo do DM Tipo 1. Os resultados deste estudo evidenciam ações que visam a fortalecer o trabalho da equipe multidisciplinar no cuidado da criança com diabetes e apontam cenários de atuação que podem ser incrementados pelos profissionais de saúde. O enfermeiro ocupa posição privilegiada para identificar e operacionalizar ações apropriadas ao estágio de desenvolvimento da criança e às suas necessidades, em todos os espaços em que vive, atuando, assim, em consonância com todos os envolvidos em prol do sucesso do manejo da doença. / The adequate handling of Type 1 DM has become a challenge, mainly for the children themselves, due to the presence of inadequate behaviors, skills and knowledge that contribute to non-adherence to treatment and increased complications in the long term. Research has demonstrated that understanding children\'s life experiences in their different spaces, valuing them and seeking greater approximation, can contribute to knowledge sharing on diabetes management and to the children\'s greater involvement in care. This research aimed to understand, from the perspective of children with Type 1 DM, the factors that interfere in the management of this disease. This is a qualitative and exploratory research. Study participants were 19 children. Semi-structured interviews were used and, to facilitate communication with the child, puppets, which the children made themselves. A scenario was also created to illustrate and complement the use of puppets on the day of the interview. Content analysis was used for empirical data analysis. Results evidenced the understanding of what it means to be a child with diabetes and the factors related to his/her existence, such as feelings and perceptions. Understanding of these children\'s interaction with their knowledge about their disease, their insertion in the self-care process, developed skills and resources available to deal with the demands of the disease constitute factors that interfere positively or negatively in disease management and deserve further attention from health professionals. All of these elements act dynamically in the child\'s daily spaces, such as the family, school, friendships, leisure and health services, as factors that weaken or strengthen disease management. Support from relatives, friends, teachers and health professionals who share the experiences of being a child with diabetes showed to be essential to achieve adequate management. Moreover, the knowledge these actors and the children themselves acquire interferes directly in Type 1 DM management. These study results evidence actions aimed at strengthening the work of the multidisciplinary team in care delivery to children with diabetes and indicate activity scenarios which health professionals can build upon. Nurses play a privileged role to identify and put in practice actions that are appropriate for the children\'s development stage and needs, in all spaces they live in. Thus, they act in line with all parties involved with a view to successful disease management.

Physical activity (PA) provides many benefits to adolescents with Type 1 Diabetes (T1D); however, adolescents with T1D tend to have lower fitness and PA levels. One reason adolescents with T1D engage in less PA is due to a fear of hypoglycemia. Most studies examining PA in relation to glycemic control measure PA through self-report, thus introducing bias. The purpose of this study was to objectively monitor PA and glucose in adolescents with T1D to examine the temporal associations between moderate and vigorous intensity physical activity (MVPA) and hypoglycemia. Twenty participants (14 to 19 yr, n=10 females and 10 males) with a T1D diagnosis for at least 1 year were recruited. Participant fitness was evaluated via indirect calorimetry during a maximal treadmill exercise test, and body composition was measured using air displacement plethysmography. An accelerometer (GENEActiv, Activinsights Ltd, Kimbolton, UK) was worn on the wrist continuously for 7 days and the waveform data used to estimate MVPA in min/d. Blood glucose values were simultaneously tracked using continuous glucose monitoring (DexCom SEVEN PLUS, San Diego, CA). After controlling for gender, % body fat (%BF), and fitness, the likelihood of hypoglycemia (¡Ü 70 mg/dl) at nighttime or the next day due to MVPA was examined using logistic regression. Participants were of avg fitness (females: 43.9 ml/kg/min; males: 49.8 ml/kg/min) and fatness (females: 26.2%; males: 19.2%), and 63.2% of participants met the US federal guidelines of accumulating 60 min/d of MVPA. Hypoglycemia was 22% more likely in those who had 30 min/d more MVPA than those with less (95% CI: 1.03, 1.45; p =0.022). The results indicate that participating in MVPA increases the risk of hypoglycemia during the night time and the following day. The relationship is independent of gender, %BF and fitness. While promoting PA as a healthy behavior, it is important to educate adolescents with T1D on prevention of hypoglycemia following PA.

The discovery that cationic lipids can independently stimulate the immune system has generated interest in their potential as vaccine adjuvants. Here, we show that the cationic lipid R-DOTAP can independently stimulate type 1 interferon production in dendritic cells in both primary culture and immortalized cell culture. Levels of type 1 interferon production are cell line-dependent and limited in vitro by lipid-induced cell death. We show that cationic lipids can independently activate TLR-7 and TLR-9, suggesting a mechanism for type 1 interferon induction. This TLR-stimulatory activity is not restricted to R-DOTAP and can be extended to other similar cationic lipids in a lipid-specific and TLR-specific manner.

Poor metabolic control is a major health concern for children and adolescents with type 1 diabetes, particularly for African American youth. The aims of this study were to test the mediating relationship between two variables consistently related to metabolic control, depressive symptoms and adherence, as well as to attempt to explain racial disparities in metabolic control. The study sample consisted of 53 European American youth and 33 African American youth ages 5 to 20 (M = 13.59, SD = 3.49) with type 1 diabetes. Information on depressive symptoms, adherence, and HbA1c was collected during routine outpatient clinic visits. Significant associations were found between depressive symptoms and metabolic control, depressive symptoms and adherence, and adherence and metabolic control. When included together in a regression model, adherence mediated the relationship between depressive symptoms and metabolic control. This mediation pathway did not significantly differ between African American youth and European American youth; however, African American youth had significantly higher HbA1c levels. These findings indicate the importance of considering depressive symptoms during treatment for type 1 diabetes. This study also supports previous research findings of racial disparities in metabolic control among youth with type 1 diabetes. Future studies should further examine mechanisms by which these racial disparities emerge. / acase@tulane.edu

In this dissertation, the posterior probability of linkage (PPL) framework is extended to the analysis of case-control (CC) data and three new linkage disequilibrium (LD) statistics are introduced. These statistics measure the evidence for or against LD, rather than testing the null hypothesis of no LD, and they therefore avoid the need for multiple testing corrections. They are suitable not only for CC designs but also can be used in application to family data, ranging from trios to complex pedigrees, all under the same statistical framework, allowing for the unified analysis of these disparate data structures. They also provide the other core advantages of the PPL framework, including the use of sequential updating to accumulate LD evidence across potentially heterogeneous sets of subsets of data; parameterization in terms of a very general trait likelihood, which simultaneously considers dominant, recessive, and additive models; and a straightforward mechanism for modeling two-locus epistasis. Finally, being implemented within the PPL framework, the new statistics readily allow linkage information obtained from distinct data, to be incorporated into LD analyses in the form of a prior probability distribution. Performance of the proposed LD statistics is examined using simulated data. In addition, the effects of key modeling violations on performance are assessed. These statistics are also applied to a previously published type 1 diabetes (T1D) family dataset with a few candidate genes with previously reported weak associations, and another T1D CC dataset also previously published as a genome-wide association (GWA) study with some strong associations reported. The new LD statistics under the PPLD framework confirm most of the findings in the published work and also find some new SNPs suspected of being associated with T1D. Sequential updating between the family dataset and the CC dataset dramatically increased the association signal strength for a CTLA4 SNP genotyped in both studies. Linkage information gleaned from the family dataset is also combined into the LD analysis of the CC dataset to demonstrate the utility of this unique feature of the PPL framework, and specifically for the new LD statistics.

Protein pK(a)s and metalloprotein reduction potentials are studied with computational methodologies based on an ab initio quantum mechanics (QM) description of the protein and a linearized Poisson-Boltzmann Equation (LPBE) description of the solvent. The practical applicability of the QM/LPBE method is extended to proteins by using a QM description of the ionizable residue and a molecular mechanics (MM) description of the rest of the protein. This QM/MM/LPBE method is used to predict the pKa of Lys55 in the serine protease inhibitor turkey ovomucoid third domain (OMTKY3) and the prediction of 11.0 is in good agreement with the experimental value of 11.1. This is the first time a protein pKa value has been predicted with QM/MM methods. The QM/LPBE method is used to predict and interpret the pKa values of the five carboxyl residues (Asp7, Glu10, Glu19, Asp27, and Glu43) in OMTKY3. All the predicted pKa values are within 0.5 pH units of experiment, with a root mean square deviation of 0.31 pH units. We find that the decreased pKa values observed for some of the residues are primarily due to hydrogen bonds to the carboxyl oxygens. Hydrophobic effects are also shown to be important in raising the pKa. Interactions with charged residues are shown to have relatively little effect on the carboxyl pKa values in this protein, in general agreement with experiment. The relative Cu2+/Cu+ reduction potentials of six type-1 copper sites (cucumber stellacyanin, P. aeruginosa azurin, poplar plastocyanin, C. cinereus laccase, T. ferrooxidans rusticyanin and human ceruloplasmin), which lie in a reduction potential range from 260 mV to over 1000 mV, have been studied with the QM/LPBE method. For the first time, the range and relative orderings of the reduction potentials are reproduced well compared to experimental values. The study suggests that the main interactions determing the relative reduction potentials of blue copper sites are located within 6 Å of the Cu atoms. Further analysis suggests that the reduction potential differences of type-1 copper sites are caused by axial ligand interactions, hydrogen bonding to the S(Cys), and protein constraints on the inner sphere ligand orientations.