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Approximately 5 percent of the Swedish population is diagnosed with either type 1 or type 2 diabetes. A growing treatment method for type 1 patients is to supply the body with insulin using a pump. This thesis investigates if the use of pumps improves the health of the patients using two-way fixed effects regressions on quality register data on Swedish diabetes patients. I find statistically significant results indicating health benefits for type 1 diabetes patients, though smaller than previous studies. For future research, I suggest estimating quality of life changes from using an insulin pump in order for policymakers to make fully informed decisions on insulin treatment.

Type 2 diabetes (T2DM) has reached epidemic levels worldwide during the past two decades. It affects nearly 26 million adults in the U.S. Advances in both the treatments for T2DM and guidelines for its optimal management are extensive. Despite these advances, barely half of type 2 diabetics achieve recommended glycemic targets. Specific Aims: The specific aims were to: Describe the available research on clinical inertia and interventions that have been implemented to reduce it. Analyze various behavioral theories that explain and predict self-care practices in diabetes in order to develop a conceptual model on which to base an investigation of predictors of readiness to initiate insulin therapy in type 2 diabetics. Determine predictors of readiness to initiate insulin therapy in patients with T2DM when oral medications fail to control hyperglycemia using the conceptual model based on Self-Determination Theory (SDT) as a framework. Results: A review of research articles published from 1990 to 2010 concluded that clinical inertia of primary care providers treating T2DM resulted in a majority of patients experiencing unnecessary chronic uncontrolled hyperglycemia. Behavioral theories were analyzed for their ability to predict self-care behaviors in type 2 diabetics. A conceptual model was developed based on the major constructs of SDT in order to guide the design of study to investigate predictors of readiness to begin insulin therapy in T2DM. Finally, a descriptive, correlational study was performed to determine readiness to initiate insulin therapy in patients with T2DM when oral medications fail to control hyperglycemia. Results of the study revealed that participants who had a friend or family using insulin were 5.5 times more likely to rate their readiness to initiate insulin as high than those who had neither (p=.020). In addition, those with greater negative beliefs and attitudes toward insulin therapy were more likely to rate their readiness to initiate insulin as low (p=.012). A majority (58%) of participants rated their readiness to begin insulin therapy as immediate if it would give them better control over their hyperglycemia. The study also confirmed findings from previous studies that clinical inertia was present in this setting.

There is growing evidence that patients with type 2 diabetes mellitus have increased cancer risk. We examined the association between diabetes, cancer, and cancer-related mortality and hypothesized that insulin sensitizers lower cancer-related mortality. Participants in the Diabetes Cardiovascular Risk and Evaluation: Targets and Essential Data for Commitment of Treatment study, a nationwide cross-sectional and prospective epidemiological study, were recruited from German primary care practices. In the cross-sectional study, subjects with type 2 diabetes mellitus had a higher prevalence of malignancies (66/1308, 5.1%) compared to nondiabetic subjects (185/6211, 3.0%) (odds ratio, 1.64; 95% confidence interval, 1.12-2.41) before and after adjustment for age, sex, hemoglobin A1c, smoking status, and body mass index. Patients on metformin had a lower prevalence of malignancies, comparable with that among nondiabetic patients, whereas those on any other oral combination treatment had a 2-fold higher risk for malignancies even after adjusting for possible confounders; inclusion of metformin in these regimens decreased the prevalence of malignancies. In the prospective analyses, diabetic patients in general and diabetic patients treated with insulin (either as monotherapy or in combination with other treatments) had a 2- and 4-fold, respectively, higher mortality rate than nondiabetic patients, even after adjustment for potential confounders (incidence of cancer deaths in patients with type 2 diabetes mellitus [2.6%] vs the incidence of cancer deaths in patients without type 2 diabetes mellitus [1.2%]). Our results suggest that diabetes and medications for diabetes, with the exception of the insulin sensitizer metformin, increase cancer risk and mortality.

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

Very premature infants often experience high blood sugar levels as a result of incomplete metabolic development, illness, and stress. High blood sugar levels have been associated with a range of worsened outcomes and increased mortality, but debate exists as to whether high blood sugar levels are a cause of, or marker for, these worsened outcomes. Insulin can be used to lower blood sugar levels, but there is no standard protocol for its use in neonates, and the few clinical studies of insulin use in neonatal intensive care are relatively small and/or have resulted in high incidence of dangerously low blood sugar levels. Hence, there is a need for a safe and effective protocol for controlling blood sugar levels to a normal range in order that potential clinical benefits can be successfully studied in this clinical cohort. This thesis adapted a glucose-insulin model successfully used in adult intensive care for the unique physiology and situation of the very premature infant. The model aims to reflect known physiology. As such, sources and disposal of glucose and insulin within the body are examined using both published data and unique data sets from a study here in New Zealand. In addition, the absorption of glucose from milk feeds is examined. This glucose-insulin physiological model is then used alongside statistical forecasting to develop a protocol for selecting an appropriate insulin dose based on targeting of likely outcomes to a specified target normal range. The protocol is tested in silico using virtual trials, and then clinically implemented, with results showing improved performance over current clinical practice and other published studies. In particular, ~77% of blood glucose is observed within the specified target range across the cohort, and there has been no incidence of dangerously low blood glucose levels. This protocol is thus safe and effective, accounting for inter- and intra- patient variability, and thus enabling patient-specific care.

Advanced practice providers (APPs), consisting of nurse practitioners and physician assistants, face many challenges in the provision of evidence-based practice in their management of hospitalized adult patients with diabetes. Some of the barriers faced by APPs at a Northeast acute care facility are poor communication between disciplines, lack of confidence in initiating insulin, limited understanding of the management of insulin and the insulin pump, and insufficient treatment of the hospitalized patient with diabetes that aligns with current clinical guidelines for the management of inpatient hyperglycemia. This quality improvement project focused on the development of an evidence-based theory supported educational intervention to improve APPs' knowledge regarding glycemic management. An interdisciplinary team created the educational intervention using the analyze, design, develop, implement, and evaluate (ADDIE) instructional model. A 10-member expert panel validated the program utilizing both a formative and summative evaluation. The results from the formative evaluation was discussed with the interdisciplinary team, corrections were made, and was returned to the expert panel. Once the changes were made to the satisfaction of the expert panel, the program was then validated and submitted to the institution as a completed project to be used by the institution for APPs. This project addresses social change by increasing awareness in the management of inpatients with diabetes therefore decreasing fragmented care delivered by the APPs which will improve quality of care and patient safety.

Bakgrund: Diabetes Mellitus typ 2 är en av vår tids största sjukdomar och ett växande folkhälsoproblem. Mer än 75 % av personer med Diabetes Mellitus typ 2 som befinner sig i övergången till insulinbehandling upplever det som en svår utmaning.Syftet: Var att beskriva upplevelser hos personer med Diabetes Mellitus typ 2 vid transition till insulinbehandlingMetod: Litteraturöversikt med kvalitativ ansats, 14 artiklar analyserades.Resultat: Presenteras under tre huvudkategorier och sju underkategorier. Vid övergång till insulinbehandling upplevdes rädsla för smärta och biverkningar. Oro i samband med injektionsgivning och okunskap gällande biverkningar och insulinets påverkan på kroppen samt skuldkänslor gällande misskötsel av sjukdomen beskrevs. Sociala och praktiska förändringar i vardagen så som oro inför egenvård och minskad flexibilitet upplevdes. Förväntad positiv effekt av insulin gällande förbättrad hälsa bidrog till att transitionen underlättades.Slutsats: För att underlätta transition krävdes individanpassad utbildning för både patienten och dennes anhörig om sjukdomens progression, behandling och påverkan på kroppen i ett tidigt skede av sjukdomen. Förhoppningsvis kan resultatet leda till en ökad förståelse hos vårdpersonal för hur personer med Diabetes Mellitus Typ 2 upplever transition till insulinbehandling, för att på så vis ge adekvat stöd till dessa personer.Nyckelord: Diabetes Mellitus typ 2, insulinbehandling, psykologisk insulinresistens,upplevelser. / Background: Diabetes type 2 is now one of the world’s diseases and an increasing public health problem. More than 75% of people with diabetes mellitus type 2 who are in transition to insulin therapy experience the transition to a difficult challenge.Aim: Was to describe how people with diabetes mellitus type 2 experience the transition to insulin therapy.Method: Literature review outgoing from articles that had a qualitative design. 14 articles were analyzed.Results: These presented in three main categories and seven subcategories. During the transition to insulin therapy patients experienced worry for potential pain and side effects. Anxiety about transition to insulin therapy because ignorance of insulin´s effect on the body and guilt about their own inability to manage the disease was described. Social and practical changes in everyday life such anxiety about self-care and reduced flexibility was experienced. Anticipated positive effects of insulin for their health contributed to make the transition easier.Conclusions: To facilitate the transition required individualized information to both the patient and his family about disease progression, treatment and the impact on the body in the early stages of the disease. The results are expected to provide greater insight into how people with type 2 diabetes experience transition to insulin therapy, to thus provide adequate support to these people.Keyword: Diabetes Mellitus type 2, insulin therapy, psychological insulin resistance, experiences

This thesis deals with the control of blood glucose levels of critically ill patients in intensive care, focusing on hyperglycemia of the critically ill and possible therapy within the competences of nursing and medical staff. The theoretical part of the thesis deals with the issue of hyperglycemia of critically ill patients from the medical and nursing perspective as well as the issues concerning instrumentation. The first chapter describes briefly the history of insulin, relating to its discovery and introduction into practice. The following chapter describes the concepts of critically ill, intensive medicine, intensive care as well as specific nursing care. Short information about etiology, diagnosis, treatment and complications of diabetes mellitus is described in the third chapter. The following are the chapters, which are more specifically devoted to the issue of hyperglycemia of the critically ill, including chapters on glucose homeostasis of the critically ill, the evolution of blood glucose levels, instrument technique, insulin protocols, insulin therapy, details of insulin therapy in intensive care and on the principles of correct blood collection for the determination of blood glucose levels in the conditions of intensive care. The empirical part of this work contains research on the...