Thèse doctorat : Neurosciences : Strasbourg 1 : 2007. Thèse doctorat : Neurosciences : Freiburg - Allemagne : 2007. / Thèse soutenue en co-tutelle. Titre provenant de l'écran-titre. Bibliogr. p. 204-228.

Thèse de doctorat : Psychologie : Angers : 2007. / Bibliogr. p. 257-293.

Thesis (Ph.D.)--University of Alabama at Birmingham, 2008. / Title from PDF title page (viewed on Feb. 4, 2010). Includes bibliographical references.

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.

Bakgrund: Diabetes är en kronisk sjukdom som kan påverka hela människan och dess omgivning. Sjuksköterskans förståelse av patientens upplevelser och erfarenheter kan ha stor betydelse i omvårdnaden. Att vara ung och leva med diabetes kan vara svårt och attityder till sjukdomen kan påverka egenvården. Syfte: Syftet var att beskriva ungdomars upplevelser av att leva med diabetes typ 1. Metod: Denna allmänna litteraturstudie bygger på empiriska studier. Resultat: Analysen resulterade i fyra följande kategorier: Relation till sin diabetes, relation till föräldrar, relation till vänner och relation till sjukvårdspersonalen. Åtta subkategorier bildades: positiva och negativa effekter, stöd, konflikter, bryta sig loss, stöd, att känna sig annorlunda, relation till läkare och relation till sjuksköterskor. Diskussion: Vårdpersonalen kan stödja ungdomar med diabetes genom att ge dem mer ansvar. Genom att förstå ungdomarnas upplevelser kan sjuksköterskan ge dem en förbättrad omvårdnad. Sjuksköterskan kan använda sig av empowermentmodellen, vilket innebär att patienten blir mer delaktig i sin behandling och tilldelas mer ansvar över sin situation. / Background: Diabetes is a chronic illness, which affects the ill person as well as the people in its immediate surroundings. The nurses' understanding of the experiences of the patients is also a vital part of the treatment. Being young and living with diabetes could be difficult and the attitude towards the illness can affect the diabetes self-care. Objectives: The aim of the literature study was to describe the experience of young people living with diabetes type 1. Method: This study is a general literature study that consists of empiric studies. Result: The analysis led to the following four categories: Relationship to diabetes, relationship to parents, relationship to friends and the relationship to the health care personnel. Eight subcategories were formed: Positive and negative effects, support, conflicts, detachment, support, feeling different and the relationship to physicians and nurses. Discussion: Nursing personnel can support youth with diabetes by giving them more responsibility. Understanding the experiences of the youths improves the care taking of the nurses. Nurses can use the empowerment model, which makes the patient more involved in the treatment as well as feeling more responsible about their situation.

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.