Nursing in a Community With Leprosy at the Center: A Conversation With Remi Kalnime.

Donna Wright, a consultant with Creative Health Care Management who has wide experience in international nursing, interviews Remi Kalnime, a nurse who cares for patients who have had Hansen's Disease, at Foubarka Leprosarium in Cameroon, Africa. They discuss the challenges these patients and their families face in dealing with the residual effects of untreated leprosy and in facing stigmatization and discrimination from their communities, within the socioeconomic context of a developing country.

The Cost-effectiveness of Dulaglutide 1.5mg versus Exenatide QW for the Treatment of Patients with Type 2 Diabetes Mellitus in France.

INTRODUCTION: Dulaglutide is a novel onceweekly administered glucagon-like peptide 1 receptor agonist (GLP-1 RA) for the management of type 2 diabetes mellitus (T2DM). The objective of this analysis was to estimate the cost-effectiveness of dulaglutide 1.5 mg versus exenatide QW for the management of T2DM in France. METHODS: The QuintilesIMS CORE Diabetes Model was used to estimate the expected lifetime direct medical costs and outcomes of T2DM from the perspective of the French National Health Service. In the absence of head-to-head data, relative efficacy was derived from a network meta-analysis. Patient cohort characteristics were derived from the AWARD-2 trial. All patients were assumed to remain on treatment for 2 years before escalating to insulin therapy. Costs included treatment costs and costs associated with long-term complications of T2DM. Utilities were estimated based on a recent systematic review. One-way sensitivity analyses (OWSA) and probabilistic sensitivity analysis (PSA) were conducted. Cost-effectiveness acceptability curves (CEACs) were generated. RESULTS: Dulaglutide 1.5 mg was associated with lower costs (lifetime costs €41,562 vs €43,021) and increased health benefits (lifetime quality-adjusted life years: QALYs 9.804 vs 9.757) versus exenatide QW for the treatment of T2DM in France. OWSA and PSA indicated that results were robust across a range of plausible input parameters. The CEAC indicated a 99.5% probability that dulaglutide would be considered cost-effective at a willingness to pay of €30,000. CONCLUSION: Dulaglutide 1.5 mg reduced expected costs and increased expected QALYs when compared against exenatide QW for the treatment of T2DM in France. Compared with exenatide QW, dulaglutide 1.5 mg can provide additional health benefits for patients with T2DM and may result in cost savings for payers. FUNDING: Eli Lilly.

Radiologist assistant: best fit for medical imaging.

The radiologist assistant (RA) is an emerging mid-level provider who can benefit radiologists, technologists, radiology departments, patients, and the healthcare system in the United States. A review of the peer-reviewed literature published from 2005-2013 revealed a moderate amount of research about these benefits, which was supplemented with research on collaborative relationships and advanced practice registered nurses (APRN). As an advanced practice radiologic technologist, the RA has a strong technically based, patient-centered background and is the ideal mid-level provider in an imaging-centered clinical environment.

Reducing blood stream infections during catheter insertion.

BACKGROUND: Registered radiologist assistants (R.R.A.s) and other health care providers frequently are responsible for placing peripherally inserted central catheter (PICC) lines. Postprocedure blood stream infections are a potentially costly and medically serious complication. PURPOSE: To determine the most effective methods for R.R.A.s and other health professionals to reduce blood stream infections related to PICC line insertion and management. METHODS: Using specific inclusion criteria, the authors searched for scholarly reviewed articles related to PICC lines, infection, and adulthood. RESULTS: The search produced 2237 articles, from which the authors selected 35 for review, in addition to 6 articles identified in the reference lists of articles not selected. The authors investigated 6 topics related to infection control in PICCs among nonimmunocompromised adults: securement devices, staff education, needleless systems, site preparation, maximum sterile barriers, and antimicrobial patches. CONCLUSION: In the long run, proactive continuing education is less expensive than the cost of complications caused by postprocedure infections. Although further research is needed, specific strategies reported in the literature included prepping the skin using chlorhexidine and antimicrobial patches to reduce the microorganisms in the area. These steps should be followed by maximum sterile barriers. Needleless connectors and positive-pressure valves were found to be more effective than the alternatives, and proper securement with self-adhesive anchoring devices was found to be more effective than suturing for reducing blood stream infections.

Modeling the lifetime costs of insulin glargine and insulin detemir in type 1 and type 2 diabetes patients in Canada: a meta-analysis and a cost-minimization analysis.

BACKGROUND: Two basal insulin analogues, insulin glargine once daily and insulin detemir once or twice daily, are marketed in Canada. OBJECTIVE: To estimate the long-term costs of insulin glargine once daily (QD) versus insulin detemir once or twice daily (QD or BID) for type 1 (T1DM) and type 2 (T2DM) diabetes mellitus from a Canadian provincial government's perspective. METHODS: A cost-minimization analysis comparing insulin glargine (IGlarg) to insulin detemir (IDet) was conducted using a validated computer simulation model, the CORE Diabetes Model. Lifetime direct medical costs including costs of insulin treatment and diabetes complications were projected. T1DM and T2DM patients' daily insulin dose (T1DM: IGlarg QD 26.2 IU; IDet BID 33.6 IU; T2DM: IGlarg QD 47.2 IU; IDet QD 65.7 IU or IDet BID 80.4 IU) was derived from a meta-analysis of randomized trials. All patients were assumed to stay on the same treatment for life. Costs were discounted at 5% per annum and reported in 2010 Canadian Dollars. RESULTS: The meta-analysis showed T1DM and T2DM patients had similar HbA(1c) change from baseline when receiving IGlarg compared to IDet (T1DM: 0.002%-points; p = 0.97; T2DM: -0.05%-points; p = 0.28). Treatment of T1DM patients with IGlarg versus IDet BID resulted in lifetime cost savings of $4231 per patient. Treatment of T2DM patients with IGlarg resulted in lifetime cost savings of $4659 per patient versus IDet QD and cost savings of $8709 per patient versus IDet BID. CONCLUSIONS: Similar HbA(1c) change from baseline can be achieved with a lower IGlarg than IDet dose. From the perspective of a Canadian provincial government, treatment of T1DM and T2DM patients with IGlarg instead of IDet can generate long-term cost savings. Main limitations include trial data were derived from multi-country studies rather than the Canadian population and self-monitoring blood glucose costs were not included.

A meta-analysis of placebo-controlled clinical trials assessing the efficacy and safety of incretin-based medications in patients with type 2 diabetes.

AIMS: A systematic review of the literature, in combination with a meta-analysis of randomized controlled trials comparing treatments with placebo, was conducted to provide an update on the clinical efficacy and safety of incretin-based medications in adult patients with type 2 diabetes. METHODS: A literature search (2000-2009) identified 38 placebo-controlled trials (phase II or later - parallel design) comparing exenatide (n = 8), liraglutide (n = 7), vildagliptin (n = 11) and sitagliptin (n = 12) with placebo. Outcomes were change from baseline in HbA(1c) and in weight, and the number of patient-reported hypoglycemic episodes. HbA(1c) and weight outcomes were analyzed as weighted mean differences (WMD), and the number of hypoglycemic episodes as relative risks (RR). RESULTS: Patients receiving liraglutide showed greater reduction in HbA(1c) in comparison to placebo (WMD = -1.03, 95% confidence interval, CI = -1.16 to -0.90, p < 0.001) than those on sitagliptin (WMD = -0.79, 95% CI = -0.93 to -0.65, p < 0.001), exenatide (WMD = -0.75, 95% CI = -0.83 to -0.67, p < 0.001) or vildagliptin (WMD = -0.67, 95% CI = -0.83 to -0.52, p < 0.001). Weight was statistically significantly negatively associated with exenatide (WMD = -1.10, 95% CI = -1.32 to -0.87, p < 0.001) and positively associated with sitagliptin (WMD = 0.60, 95% CI = 0.33-0.87, p < 0.001) and vildagliptin (WMD = 0.56, 95% CI = 0.27-0.84, p < 0.001). The number of patient-reported hypoglycemic episodes was statistically significantly associated with the use of sitagliptin (RR = 2.56, 95% CI = 1.23-5.33, p = 0.01) and exenatide (RR = 2.40, 95% CI = 1.30-4.11, p = 0.002). CONCLUSION: Incretin-based therapies are effective in glycemic control and also offer other advantages such as weight loss (exenatide and liraglutide). This may have an important impact on patient adherence to medication.

Radiation biology and protection.

To protect themselves, their patients and their coworkers, radiologic technologists should regularly refresh and reinforce their understanding of key radiation biology and protection principles. This article reviews the concepts of radiation physics, human biology and radiation protection strategies, with emphasis on how historical events and developing research affect radiation protection understanding and practice.

Individual unmet needs for care: are they sensitive as outcome criterion for the effectiveness of mental health services interventions?

BACKGROUND: Mental health interventions should demonstrate an effect on patients' functioning as well as his/her needs, in particular on unmet needs whose assessment depends on the perspective of either the patient or the clinician. However, individual met and unmet needs appear to change over time, qualitatively and quantitatively, raising questions about their sensitivity to change and about the association between level of needs and treatment. METHODS: Data on baseline and follow-up need assessment in community mental health services in four European countries in the context of a cluster randomised trial on a novel mental health service intervention were used, which involved 102 clinicians with key worker roles and 320 patients with schizophrenia or related psychotic disorders. Need assessment was performed with the Camberwell assessment of needs short appraisal schedule (CANSAS) among patients as well as clinicians. Focus is the sensitivity to change in unmet needs over time as well as the concordance between patient and clinician ratings and their relationship with treatment condition. RESULTS: At follow-up 294 patients (92%) had a full need assessment, while clinician rated needs were available for 302 patients (94%). Generally, the total number of met needs remained quite stable, but unmet needs decreased significantly over time, according to patients as well as to clinicians. Sensitivity to change of unmet needs is quite high: about two third of all unmet needs made a transition to no or met need, and more than half of all unmet needs at follow-up were new. Agreement between patient and clinician on unmet needs at baseline as well as follow-up was rather low, without any indication of a specific treatment effect. CONCLUSIONS: Individual unmet needs appear to be quite sensitive to change over time but as yet less suitable as outcome criterion of treatment or specific interventions.

Sarcoidosis: a primer.

Sarcoidosis is an enigmatic disease with high variability in its manifestation within the body. Associated granulomas can form in many different parts of the body and can affect multiple organs. Some patients affected by this multiorgan disease never require treatment, while others require comprehensive long-term care and follow-up. Familiarity with the clinical and radiologic features of sarcoidosis is key to understanding how physicians diagnose and manage the disease. Further research is needed to comprehend the relationship between sarcoidosis and malignant neoplasms.

Loss to follow-up in longitudinal psychiatric research.

AIMS: To analyse factors that differentiate patients who attend follow-up assessments versus those who do not, and to identify predictors for drop-out within the context of the European Day Hospital Evaluation Study (EDEN-Study). METHODS: The EDEN-Study, a multi-center RCT comparing acute psychiatric day care with inpatient care, required re-assessment of patients at discharge, 3 and 12 months after discharge. Follow-up rates varied between 54.0% and 99.5%. Socio-demographic and clinical characteristics of patients who did and did not attend follow-up were analysed using uni- and multivariate statistical methods. RESULTS: Univariate analyses showed differences between patients regarding study site, treatment setting, living situation, employment, age, psychopathological symptoms and treatment satisfaction. They were not confirmed in multivariate analyses thus meaningful predictors of drop-out could not be identified. CONCLUSIONS: Results emphasize the general need to compare patients re-assessed and not re-assessed in terms of their most relevant socio-demographic and clinical variables to assess the generalizability of results.

Mental health care institutions in nine European countries, 2002 to 2006.

OBJECTIVE: Although mental health reforms in the 20th century were characterized by deinstitutionalization, previous research suggested a new era of reinstitutionalization in six European countries between 1990 and 2002. This study aimed to establish whether there has been a trend in Europe toward more institutionalized care since 2002. METHODS: Primary data sources were used to collect data on conventional inpatient beds, involuntary hospital admissions, forensic beds, places in residential care and supervised and supported housing, and the prison population in nine countries: Austria, Denmark, England, Germany, Republic of Ireland, Italy, the Netherlands, Spain, and Switzerland. RESULTS: Between 2002 and 2006 the number of conventional psychiatric inpatient beds tended to fall and changes in involuntary admissions were inconsistent. The number of forensic beds, places in supervised and supported housing, and the prison population increased in most, but not all, of the countries studied. CONCLUSIONS: The findings suggest an ongoing although not consistent trend toward increasing provision of institutionalized mental health care across Europe.

Structured patient-clinician communication and 1-year outcome in community mental healthcare: cluster randomised controlled trial.

BACKGROUND: Patient-clinician communication is central to mental healthcare but neglected in research. AIMS: To test a new computer-mediated intervention structuring patient-clinician dialogue (DIALOG) focusing on patients' quality of life and needs for care. METHOD: In a cluster randomised controlled trial, 134 keyworkers in six countries were allocated to DIALOG or treatment as usual; 507 people with schizophrenia or related disorders were included. Every 2 months for 1 year, clinicians asked patients to rate satisfaction with quality of life and treatment, and request additional or different support. Responses were fed back immediately in screen displays, compared with previous ratings and discussed. Primary outcome was subjective quality of life, and secondary outcomes were unmet needs and treatment satisfaction. RESULTS: Of 507 patients, 56 were lost to follow-up and 451 were included in intention-to-treat analyses. Patients receiving the DIALOG intervention had better subjective quality of life, fewer unmet needs and higher treatment satisfaction after 12 months. CONCLUSIONS: Structuring patient-clinician dialogue to focus on patients' views positively influenced quality of life, needs for care and treatment satisfaction.

Leadership theory and motivation of medical imaging employees.

*This literature review explores how transactional, transformational, and charismatic leadership theories might be applied in a typical stressful hypothetical department situation. *Transactional department leaders motivate employees using extrinsic rewards, encouraging them to do what is needed to get the minimal results with no encouragement for higher levels of thinking. *Transformational department leaders motivate employees by transforming their beliefs and values to be more in alignment with the organization's values and goals. This alignment helps create higher levels of intrinsic motivation. *Charismatic leaders exhibit the same behaviors as transformational leaders to motivate employees; however; because of their specific characteristics, their effectiveness can be limited to only times of distress or crisis. The situation in the particular department determines which leadership theory is likely to be most successful.

Rural radiology services in Texas: an assessment in quality.

Health professionals share a common interest in improving the quality of healthcare provided to the notion's underserved citizens, many who live in rural areas. This article examines the quality of radiology services found in rural Texas hospitals as reported by radiology managers through online survey research in terms of staffing, radiologist availability, and quality control measures. A 22 question survey was developed and 72 of 106 possible responses were obtained for a 67.9% response rate representing 45% of the total population. Texas is a licensure state for radiologic technologists. Texas rural counties with fewer than 50 thousand citizens have only 9% of MRTs, 10% of LMRTs, and 12% of NCTs licensed to practice radiology imaging. Licensing all three levels of technologists through the some administrative body could result in more standard educational and training requirements, thereby increasing the quality of care given by these individuals. Patients seen at lower-volume rural facilities benefit from convenient scheduling and lower prices and are beginning to see faster reporting with the prevalence of teleradiology and voice recognition dictation.

Admission requirements for radiography programs.

CONTEXT: Radiography program applicants far outnumber available class capacity in many programs. Educational accountability requires that programs justify their admission practices, work to retain all qualified students and evaluate their attrition rates. Thus, radiography programs are interested in identifying the best candidates for admission. PURPOSE: The purpose of this small survey study was to document admission requirements of entry-level programs in radiography accredited by the Joint Review Committee on Education in Radiologic Technology (JRCERT) in Oklahoma and Texas. METHODS: A 14-question survey was sent to 45 JRCERT-accredited entry-level radiography programs in Oklahoma and Texas. The survey included questions concerning program demographics, admission criteria and admission practices. RESULTS: Cumulative grade point average, interviews, successful completion of math and science courses, and performance on standardized tests were the most commonly used admission criteria, although no criteria were used by all of the programs surveyed. CONCLUSION: The current study is the first step toward identifying the most effective admission criteria for radiography programs. Future research should examine the correlation of specific admission criteria with program success (ie, program retention, program completion and professional certification).