Diabetes mellitus (DM) is a significant public health problem that afflicted approximately 29.1 million Americans in 2012 (CDC, 2014). The estimated cost of diabetes in the United States in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity (ADA, 2013a). To reach a diagnosis of DM, a clinician generally relies on fasting plasma glucose (FPG), the oral glucose tolerance test (OGTT), and/or the Hemoglobin A1c (HbA1c) test (ADA, 2013b). Current noninsulin antidiabetic medications include sulfonylureas, GLP-1 analogues, DPP-4 inhibitors, biguanides, thiazolidinediones, and SGLT2 inhibitors (Kaiser & Oetjen, 2014). Insulin therapies include basal (long-acting insulin analogues), biphasic (premixed insulin analogues), prandial (short-acting insulin analogues), and basal bolus (a combination of long-acting and short-acting insulin analogues) (Esposito et al., 2012). The aim of this study is to review the existing literature on the cost effectiveness of diabetes interventions to develop a standardized protocol for early type 2 diabetes care that can be delivered through primary care providers. The substantial cost effectiveness of preventative measures, including ad campaigns and outreach programs, has already been established (Mendis & Chestnov, 2013). Screening for impaired glucose tolerance early and implementing lifestyle and pharmacological changes at an early stage are also considered cost effective approaches for the long-term management of diabetes mellitus (Gillies et al., 2008). This study utilizes six cost effectiveness analyses on both clinical and non-clinical interventions to determine a standardized protocol for screening, diagnosing, and treating DM. Noninsulin antidiabetic drugs accounted for 78.4% of the 154.4 million prescriptions for antidiabetic drugs filled in 2012 (Hampp et al., 2014). Approximately half of the noninsulin antidiabetic drugs filled in 2012 was for metformin, whereas roughly a quarter of the same category was for sulfonylureas (Hampp et al., 2014). In decreasing order, long-acting human analog insulin and fast-acting human analog insulin were the most popular insulin variants in the insulin antidiabetic drug market (Hampp et al., 2014). Of the noninsulin antidiabetic drugs, the highest proportion of diabetic patients who achieved the HbA1C target of <7% were those taking sustained release exenatide (a GLP-1 analog) (63.2%) (Esposito et al., 2012). Of the insulin varieties, the highest proportion of diabetic patients who achieved the HbA1C target of <7% were those using basal bolus insulin (50.2%) (Esposito et al., 2012). While there are some concerns about the ability of diabetic patients with chronic kidney disease to clear metformin via renal excretion, extensive clinical experience supports its use in diabetic patients with mild to moderate renal impairment (Inzucchi et al., 2014). From the cost effectiveness studies, lifestyle modification (i.e., changes in diet and exercise) beginning at any age was determined to be a cost-effective approach in preventing and treating DM and may be cost saving for adults between the age of 25 to 44 (Herman et al., 2005). Screening for DM beginning at age 45 and repeating every three years if negative provides the best balance of effectiveness and cost effectiveness (Kahn et al., 2010). As a first-line clinical intervention, metformin was established to be cost-effective as well in treating DM (but less so compared to lifestyle modification) (Herman et al., 2005). Bariatric surgery for diabetics with a BMI greater than or equal to 35 kg/m2 has also been established as cost effective (Hoerger et al., 2010). Next, in considering the ideal frequency of clinical consultations, diabetics with a stable condition (assessed as HbA1c ≤7.5%, blood pressure ≤145 mmHg, and total cholesterol ≤201 mg/dL) can safely be seen by a primary care provider every six months compared to every three months with no noticeable decline in long-term health outcomes (Wermeling et al., 2014). For cases of T2D that cannot be simply controlled with metformin, sulfonylurea has shown that it is overall more cost-effective and effective as a second-line therapy when compared to DPP-4 inhibitors and GLP-1 analogs (Zhang et al., 2014). Cost effectiveness analysis of the long-acting analogue insulin detemir across different countries reveals substantially different cost effectiveness for the medication in terms of both nominal and purchasing power terms (Home et al., 2014). The results of these studies were parsed to establish a long-term clinical protocol for primary care providers in screening, diagnosing, and treating type 2 diabetes. Future studies should focus on integrating cost effectiveness and comparative effectiveness research in implementing even more nuanced clinical decisions through a structured protocol. The cost effectiveness of existing and new interventions--both clinical and non-clinical in nature--will also need to be continuously assessed to ensure that the measurements incorporate the most accurate set of assumptions on costs and effectiveness.

Résumé : Introduction : La prise en charge de la douleur aiguë pédiatrique persiste à être sous-optimale. Cette situation est souvent expliquée par la présence de barrières qui nuisent à l’application des connaissances. Depuis plus de 10 ans, un protocole standardisé (algorithme) basé sur une échelle d’auto-évaluation est utilisé au CIUSSS de l’Estrie-CHUS afin de traiter la douleur aiguë chez les enfants hospitalisés âgés entre 5 et 17 ans. Les infirmières pédiatriques ont demandé d’adapter cet algorithme afin de pouvoir l’utiliser chez les enfants plus jeunes. Pour ce faire, nous devions débuter par établir l’état des lieux de la gestion de la douleur pédiatrique. Puisqu’aucune échelle d’hétéro-évaluation de la douleur n’était utilisée au CIUSSS de l’Estrie-CHUS, l’échelle EVENDOL fut implantée. Objectifs : 1. Répertorier les scores de douleur avec l’échelle EVENDOL, les analgésiques prescrits et administrés pour les enfants âgés de 1 à 7 ans hospitalisés pour une condition douloureuse; 2. Évaluer la satisfaction et les changements de pratique des infirmières et infirmières auxiliaires suite à l’implantation de l’échelle EVENDOL. Méthodologie : 1. Une étude de cohorte fut réalisée. Tous les enfants âgés de 1 à 7 ans hospitalisés pour douleur aiguë furent inclus. Les scores de douleur ainsi que l’analgésie prescrite et reçue ont été relevés dans chacun des dossiers des enfants recrutés; 2. Les appréciations des infirmières furent consignées. Résultats : 1. Quarante patients ont participé à l’étude : 24 pour des soins chirurgicaux et 16 pour des soins médicaux. Un total de 260 scores de douleur fut relevé : la moyenne de douleur selon l’échelle EVENDOL fut de 2,3 (ÉT = 3,2) sur 15 (score maximal représentant une douleur sévère). Seulement 12 évaluations de douleur sur un total de 260 relevées furent cotées sévères (≥ 10/15); ces enfants avec douleur sévère ont reçu une analgésie proportionnelle à leur niveau de douleur. L’ensemble des patients a reçu une analgésie multimodale (deux analgésiques ou plus) dans une proportion de 95%. Plus de la moitié des prescriptions PRN (au besoin) ont été administrées sur un horaire régulier par les infirmières; 2. Les infirmières ont trouvé l’échelle simple d’utilisation à 93%. Le score global de satisfaction fut de 6,7/10. Conclusion : Les enfants ont reçu une analgésie multimodale de façon régulière et appropriée selon l’évaluation basée sur l’échelle EVENDOL. De plus, très peu de douleurs sévères furent notées. Nous suggérons que les infirmières ont donc transposé les principes de l’algorithme des 5-17 ans chez les enfants âgés de 1 à 7 ans. Ainsi, le projet subséquent de démontrer l’efficacité d’un algorithme chez les 1-7 ans fut jugé inopportun. L’application des connaissances peut être facilitée en contrant plusieurs barrières nuisant à une prise en charge optimale de la douleur en utilisant un algorithme. / Abstract : Background: Pediatric pain remains sub-optimally controlled. Many existing barriers that prevent knowledge translation (KT) are often mentioned as a reason for this situation. We used an algorithm based on an auto-evaluation scale in the CIUSSS of Estrie-CHUS for over 10 years for the 5 to 17 old hospitalized children. Pediatrics nurses ask to adapt this algorithm for using it with younger children. To do so, we had to dress an inventory of pediatric pain management. Because no hetero-evaluation scale was use in our pediatric ward, the EVENDOL scale had to be implemented. Objective: 1. Describe pain scores from the EVENDOL scale plus the prescribed and administrated analgesia from 1-7 years old hospitalized children with painful condition. 2. To evaluate the satisfaction and practice changes of nurses following the EVENDOL scale implementation. Methods: 1. This study used a cohort design. All children 1 to 7 years old admitted for painful medical or surgical conditions were evaluated using EVENDOL. Pain values and analgesia were noted for each patient by electronic and paper charting. 2. Satisfaction within the nursing staff were also evaluated. Results: 1. Forty children participate at this study: 24 were under surgical care and 16 under medical care. A total of 260 pain measurements were documented. The mean EVENDOL scores were 2.3 (SD 3.2) on 15 (maximal score that represent an intolerable pain). Only 12 of 260 pain assessments were in the severe pain category (≥ 10/15). These children with severe pain received an appropriate and timely analgesia. Overall 95% of this cohort received multimodal analgesia which are two or more types of pain medication. More than 50% of prescribed PRN medications were given on a regular basis. 2. Nurses’ ease of EVENDOL use was rated at 93%. Nurses’ global satisfaction score about the scale was 6.7/10. Conclusions: Children received a multimodal and a regular based analgesia combined to a valuable pain evaluation using the EVENDOL scale. Therefore, a low rate of severe pain was noted. We suggest that nurses spontaneously transposed the pre-existing 5 to 17 years old standardised analgesia protocol and used it in the 1-7-years-old group. Thereby, evaluating experimental group after algorithm implementation was irrelevant. KT can be facilitated to overcome several barriers to PPM by combined the use of an algorithm with several factors.

Ein bezüglich Datenakquisition und Nachverarbeitung optimiertes Visualisie-rungsprotokoll zur dreidimensionalen Darstellung der Hirnnerven V-VIII im Be-reich der basalen Zisternen wird vorgestellt. Auf der Basis von hochauflösen-den MRT Daten und unter Verwendung der Volume-Rendering-Technik entstanden insgesamt 10 Standardansichten der genannten Hirnnerven, die deren vollständige und zeiteffektive intrazisternale Abbildung mit besonderer Beachtung pathophysiologisch relevanter Zonen ermöglichen. Das Protokoll zeigte in der Evaluation an Patienten mit neurovaskulären Konflikten und an-deren neuralen Kompressionssyndromen im Bereich des Kleinhirnbrücken-winkels seine Eignung bezüglich Bildqualität und diagnostischer Wertigkeit. Probleme traten vor allem aufgrund von Pulsations- und Bewegungsartefakten im akquirierten MRT-Datensatz, sowie zu enger Zisternen auf der Höhe der virtuellen Kameraposition auf. Diese ließen sich in den meisten Fällen jedoch durch leichte Parametervariationen beheben. Zur genauen Identifikation der Gefäße und zur Vermeidung der Weitergabe von Fehlzuordnungen war zu-sätzlich zu den Rekonstruktionen die Betrachtung des Originaldatensatzes er-forderlich. Die Nachverfolgung der mit dem beschriebenen Protokoll virtuell zisternoskopisch untersuchten Patienten ergab bei der weit überwiegenden Zahl der verfolgbaren Patienten Konsequenzen hinsichtlich Diagnose und/oder Therapie. Die Korrelation mit intraoperativen Befunden konnte nur bei zwei Patienten mit Akustikusneurinomen erfolgen, wobei hier eine Über-einstimmung festgestellt werden konnte. Ursache für die nur geringe Zahl der zur Verfügung stehenden intraoperativen Befunde ist die lange Latenz zwi-schen Bildgebung und neurochirurgischer Intervention bei neurovaskulären Konflikten. Zusammenfassend lässt sich feststellen dass die virtuelle Zister-noskopie nach dem vorgestellten Protokoll eine komplementäre Bildgebungs-technik ist, die wichtige räumliche Informationen zu neurovaskulären Interakti-onen in den basalen Zisternen liefert. Weitere Untersuchungen, insbesondere die intraoperative Befundkorrelation, sind jedoch erforderlich. / The following thesis presents a protocol for the three-dimensional visualization of the cranial nerves V-VIII within the basal cisterns, being optimized with regard to data acquisition and postprocessing. Based on high resolution MRI datasets and using the volume rendering technique, 10 standardized views of the aforementioned cranial nerves were developed. Thus, the complete and time effective intracisternal depiction was intended to be made possible, focussing on pathophysiological important areas of the nerves. The protocol showed its suitability concerning image quality and diagnostic value in evaluation of patients with neurovascular conflicts or other neural compression syndromes in the cerebello-pontine angle. Problems mainly occurred as a result of pulsation and motion artefacts in the MR dataset and narrow cisterns in the level of the virtual camera position. In most cases they could be solved by slight variations of the postprocessing parameters. To guaranty the correct identification of the vessels and to avoid the risk of giving incorrectly assigned anatomic information to subsequent readers, the additional inspection of original dataset is necessary. In the follow up of the examined patients consequences in diagnosis and/or therapy were found in the most cases. The correlation of the virtual cisternoscopic images with the intraoperative results could only be performed in two patients with acoustic neuromas and was successful. The reason for the small amount of available intraoperative results is the latency between imaging and neurosurgical intervention in neurovascular conflicts. Concluding the virtual cisternoscopy following the introduced protocol is a complementary imaging technique that provides important spatial information about neurovascular interactions within the basal cisterns. Yet further investigations, especially the intraoperative correlation of the results, are necessary.