Patient satisfaction with a pharmacist-led best possible medication discharge plan via tele-robot in a remote and rural community hospital.

INTRODUCTION: Medication reconciliation (MedRec) reduces the risk of preventable medication-related adverse events (ADEs). A best possible medication discharge plan (BPMDP) is a revised list of medications a patient will take when discharged from hospital; a pharmacist review ensures accuracy. For many hospitals, on-site pharmacists are non-existent. Extension of a visual presence via a mobile robotic platform with real-time audiovisual communication by pharmacists to conduct MedRec remains unstudied. This study explored patient perceptions of a pharmacist-led BPMDP using a telepresence robot. Time requirements, unintentional discharge medication discrepancies (UMD), programme inefficiencies/barriers and facilitators involved in pharmacist review of the discharge medication list and patient interviews were also described. METHODS: This prospective cohort study enrolled adult patients admitted to a 12-bed community hospital at high risk of an ADE. Remote pharmacists reviewed the discharge prescription list, identified/resolved UMDs, and interviewed/counselled patients using a telepresence robot. Thereafter, patients completed an anonymous satisfaction questionnaire. Prescriber discharge UMDs were classified, and barriers/inefficiencies and facilitators were documented. RESULTS: Nine patients completed an interview, with a 75% interview agreement rate. All patients were comfortable with the robot and 76% felt their care was better. With a median of 11 discharge medications/patient, the UMD rate was 78%; 71% had omitted medications, 43% involved a cardiovascular medication, 88% were due to a hospital system cause, and 43% were specifically due to an inaccurate best possible admission medication history. Median times for interview preparation, interview and UMD/drug therapy problem resolution were 45, 15 and 10 min, respectively. CONCLUSION: Using a telepresence robot to provide pharmacist-led BPMDPs is acceptable to patients and an innovative, effective solution to identify/resolve UMDs.

Résumé Introduction: Le bilan comparatif des médicaments (BCM) réduit le risque d'événements indésirables liés aux médicaments pouvant être évités. Le meilleur schéma thérapeutique possible (MSTP) désigne une liste révisée de la médication qu'un patient devra prendre au congé de l'hôpital; l'examen du pharmacien en assure l'exactitude. Malheureusement, de nombreux hôpitaux n'ont pas de pharmacien sur place. Aucune étude n'a porté sur l'expansion d'une présence visuelle par plateforme robotique mobile avec communication audiovisuelle en temps réel des pharmaciens pour réaliser le BCM. Cette étude a porté sur la perception des patients à l'égard d'un MSTP dirigé par un pharmacien par l'entremise d'un robot de téléprésence. L'étude s'est aussi penchée sur le temps nécessaire, les erreurs liées aux médicaments, les inefficacités ou obstacles du programme et les modérateurs qui sont intervenus dans le BCM et les entrevues auprès des patients. Méthodes: Cette étude de cohorte prospective a inscrit des adultes à risque élevé d'événement indésirable lié aux médicaments ayant été admis dans un hôpital communautaire de 12 lits. Des pharmaciens ont révisé à distance la liste des ordonnances au congé, relevé et résolu les erreurs liées aux médicaments et ont interviewé/renseigné les patients à l'aide d'un robot de téléprésence. Les patients ont ensuite répondu anonymement à un questionnaire de satisfaction. Les erreurs liées aux médicaments ont été classifiées, et les obstacles ou inefficacités et les modérateurs ont été identifiés. Résultats: Neuf patients SE sont soumis à l'entrevue, avec un taux d'acceptation de l'entrevue de 75%. Tous les patients étaient à l'aise avec le robot, et 76% étaient d'avis qu'ils avaient reçu de meilleurs soins. Avec une médiane de 11 médicaments/patient au congé, le taux d'erreurs liées aux médicaments était de 78%; 71% avaient oublié des médicaments, 43% touchaient un médicament cardiovasculaire, 88% étaient causées par le système de l'hôpital et 43% étaient causées précisément par un MSTP inexact. Les délais médians pour la préparation de l'entrevue, l'entrevue, et la résolution des erreurs liées aux médicaments/problèmes de pharmacothérapie étaient respectivement de 45, 15 et 10 min. Conclusion: Un robot de téléprésence pour réaliser le MSTP dirigé par un pharmacien est acceptable pour les patients et est une solution innovante et efficace pour relever et résoudre les erreurs liées aux médicaments. Mots-clés: Rural, pharmacien, bilan comparatif des médicaments, télémédecine, hôpital, robot.

Pharmacy Distribution, Clinical, and Management Services: A Survey of Small Hospitals in Canada Supported by Telepharmacy Services.

BACKGROUND: The Canadian Society of Hospital Pharmacists' Hospital Pharmacy in Canada Report presents data from pharmacy departments that service hospitals with at least 50 acute care beds. This report provides valuable data on pharmacy distribution, clinical, and management services in relation to hospital size, type, and geographic region. Pharmacy and hospital leadership use these extensive data in identifying baseline, benchmarking current, and planning enhanced pharmacy services. However, for most of Canada's small hospitals, such data remain unknown, and leadership remains uninformed. OBJECTIVE: To gather and analyze data about current pharmacy distribution, clinical, and management services in hospitals with fewer than 50 acute care beds receiving third-party remote pharmacy (telepharmacy) services. METHODS: In April 2019, pharmacy administrators of hospitals in Ontario, Quebec, and Saskatchewan that had fewer than 50 acute care beds and were using third-party telepharmacy services were invited to complete a comprehensive survey addressing concepts similar to those in the Hospital Pharmacy in Canada Survey. The following data on clinical pharmacy practice were collected: models of care, assignments to patient care programs, pharmacists' activities, performance indicators, and professional evaluation. The description of pharmacy distribution services comprised type of system, technology, location, hours of operation, method of medication order entry and verification, and medication administration records. Details on facilities' parenteral admixture infrastructure, policy for and provision of sterile compounding, and pharmacy department human resources, including composition and staffing ratios, were also collected. RESULTS: Of the 27 hospitals in Ontario, Quebec, and Saskatchewan that were invited to participate, 24 (89%) completed the survey. The median facility size was 19 acute care beds. CONCLUSIONS: Previously unavailable in Canada, these quantitative data from small hospitals supported by telepharmacy services provide facts about pharmacy distribution, clinical, and management services to inform hospital and pharmacy leaders. Creation of a survey unique to small hospitals, whether or not they use telepharmacy services, could provide a valuable resource to assist in the benchmarking, planning, and enhancement of pharmacy services in remote and rural communities.

CONTEXTE: Le Rapport sur les pharmacies hospitalières canadiennes de la Société canadienne des pharmaciens d'hôpitaux expose les données provenant des services de pharmacie qui appuient les hôpitaux comptant au moins 50 lits de soins aigus. Il offre de précieuses données sur les services de distribution des médicaments, les services cliniques et de gestion en relation avec la taille, le type et la région géographique des hôpitaux. Les équipes de direction des pharmacies et des hôpitaux utilisent ces données exhaustives pour déterminer une base de référence, évaluer les services de pharmacie actuels et planifier l'amélioration des services. Cependant, la plupart des petits hôpitaux du Canada ne disposent pas de ce type de données, et les équipes de direction n'en sont pas informées. OBJECTIF: Réunir et analyser des données sur la distribution de médicaments, les services cliniques et la gestion des services pharmaceutiques actuels dans les hôpitaux comptant moins de 50 lits de soins aigus, qui reçoivent des services de pharmacie à distance (services de télépharmacie) fournis par des tiers. MÉTHODE: En avril 2019, les administrateurs de pharmacie d'hôpitaux en Ontario, au Québec et en Saskatchewan remplissant ces critères ont été invités à répondre à une enquête exhaustive abordant des concepts similaires à ceux de Sondage sur les pharmacies hospitalières canadiennes. Les données suivantes sur la pratique de la pharmacie clinique ont été recueillies: modèles de soins, affectation des pharmaciens à des programmes particuliers de soins des patients, activités des pharmaciens, indicateurs de performance et évaluation professionnelle. La description des systèmes de distribution des médicaments par les pharmacies comprenait: le type de système, la technologie, le lieu, les heures de service, le mode de saisie et de vérification des ordonnances de médicaments ainsi que les dossiers d'administration. Les détails concernant l'infrastructure pour l'administration de solutions parentérales, la politique relative aux composés stériles et à leur distribution ainsi que les ressources humaines des services de pharmacie, y compris la composition et les ratios en personnel, ont également été recueillis. RÉSULTATS: Sur les 27 hôpitaux en Ontario, au Québec et en Saskatchewan invités à participer à l'enquête, 24 (89 %) y ont répondu. La taille moyenne des installations était de 19 lits de soins aigus. CONCLUSIONS: Autrefois indisponibles au Canada, ces données quantitatives provenant de petits hôpitaux soutenus par des services de télépharmacie livrent des faits concernant le système de distribution des médicaments au sein des pharmacies, les services cliniques et de gestion, qui permettent de guider les cadres des hôpitaux et de la pharmacie. La création d'une enquête unique destinée aux petits hôpitaux, utilisant ou non des services de télépharmacie, pourrait constituer une précieuse ressource pour aider à évaluer, à planifier et à améliorer les services pharmaceutiques dans les communautés rurales et éloignées.

Diagnostic Value of Galectin-3 in Distinguishing Invasive Encapsulated Carcinoma from Noninvasive Follicular Thyroid Neoplasms with Papillary-Like Nuclear Features (NIFTP).

Background: non-invasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP), which is considered as low-risk cancer, should be distinguished from the malignant invasive encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC). Improved discrimination of NIFTPs from invasive EFVPTCs using a molecular biomarker test could provide useful insights into pre- and post-surgical management of the indeterminate thyroid nodule. Galectin-3 (Gal-3), a ß-galactosyl-binding molecule in the lectin group, is involved in different biological functions in well differentiated thyroid carcinomas. The aim of this study was to determine whether Gal-3 expression as a diagnostic marker could distinguish indolent NIFTP from invasive EFVPTC on tissue specimens from surgical thyroid nodules. Methods: immunohistochemical (IHC) analysis of cytoplasmic and nuclear Gal-3 expression was performed in formalin-fixed paraffin-embedded (FFPE) surgical tissues in four specific diagnostic subgroups- benign nodules, NIFTPs, EFVPTCs and lymphocytic/Hashimoto's thyroiditis (LTs). Results: cytoplasmic Gal-3 expression (mean ± SD) was significantly increased in invasive EFVPTCs (4.80 ± 1.60) compared to NIFTPs (2.75 ± 1.58, p < 0.001) and benign neoplasms (2.09 ± 1.19, p < 0.001) with no significant difference between NIFTPs and benign lesions (p = 0.064). The presence of LT enhanced cytoplasmic Gal-3 expression (3.80 ± 1.32) compared to NIFTPs (p = 0.016) and benign nodules (p < 0.001). Nuclear Gal-3 expression in invasive EFVPTCs (1.84 ± 1.30) was significantly higher than in NIFTPs (1.00 ± 0.72, p = 0.001), but similar to benign nodules (1.44 ± 1.77, p = 0.215), thereby obviating its potential clinical application. Conclusions: our observations have indicated that increased cytoplasmic Gal-3 expression shows diagnostic potential in distinguishing NIFTP among encapsulated follicular variant nodules thereby serving as a possible ancillary test to H&E histopathological diagnostic criteria when LT interference is absent, to assist in the detection of the invasive EFVPTC among such nodules.

Programmed death-ligand 1 expression by digital image analysis advances thyroid cancer diagnosis among encapsulated follicular lesions.

Recognition of noninvasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP) that distinguishes them from invasive malignant encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) can prevent overtreatment of NIFTP patients. We and others have previously reported that programmed death-ligand 1 (PD-L1) is a useful biomarker in thyroid tumors; however, all reports to date have relied on manual scoring that is time consuming as well as subject to individual bias. Consequently, we developed a digital image analysis (DIA) protocol for cytoplasmic and membranous stain quantitation (ThyApp) and evaluated three tumor sampling methods [Systemic Uniform Random Sampling, hotspot nucleus, and hotspot nucleus/3,3'-Diaminobenzidine (DAB)]. A patient cohort of 153 cases consisting of 48 NIFTP, 44 EFVPTC, 26 benign nodules and 35 encapsulated follicular lesions/neoplasms with lymphocytic thyroiditis (LT) was studied. ThyApp quantitation of PD-L1 expression revealed a significant difference between invasive EFVPTC and NIFTP; but none between NIFTP and benign nodules. ThyApp integrated with hotspot nucleus tumor sampling method demonstrated to be most clinically relevant, consumed least processing time, and eliminated interobserver variance. In conclusion, the fully automatic DIA algorithm developed using a histomorphological approach objectively quantitated PD-L1 expression in encapsulated thyroid neoplasms and outperformed manual scoring in reproducibility and higher efficiency.

Programmed Death - Ligand 1 Expression Distinguishes Invasive Encapsulated Follicular Variant of Papillary Thyroid Carcinoma from Noninvasive Follicular Thyroid Neoplasm with Papillary-like Nuclear Features.

BACKGROUND: The noninvasive Encapsulated follicular variant of papillary thyroid cancer (EFVPTC) has been reclassified as Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) without a significant risk for malignant behavior. However the evaluation remains a challenge for clinicians. We sought to determine whether programmed death-ligand 1 (PD-L1) expression may serve as a biomarker to predict invasiveness of EFVPTC and assist to distinguish these neoplasms from NIFTP. METHODS: Immunohistochemical staining of PD-L1 expression was performed in sections of 174 Formalin-fixed paraffin-embedded (FFPE) tissue blocks from surgery removed thyroid nodules. RESULTS: Cytoplasmic PD-L1 expression was significantly increased in invasive EFVPTC (4.76±1.49) as compared to NIFTP (3.06±2.16, p<0.001). Increased cytoplasmic PD-L1 expression was associated with invasiveness in EFVPTC (p<0.001); PD-L1 positive EFVPTC cases were at 3.16 folds higher risk in developing invasion than the PD-L1 negative cases. No significant difference in cytoplasmic PD-L1 expression was observed between NIFTP and benign nodules. CONCLUSION: PD-L1 expression may serve as a useful biomarker in predicting invasiveness of EFVPTC and distinguishing NIFTP from invasive EFVPTC. To our knowledge this is the first report suggesting the application of a protein biomarker to confirm NIFTP as benign indolent neoplasms.

Programmed death-ligand 1 overexpression is a prognostic marker for aggressive papillary thyroid cancer and its variants.

Programmed death-ligand 1(PD-L1) expression on tumor cells is emerging as a potential predictive biomarker in anti-PD-L1 directed cancer immunotherapy. We analyzed PD-L1 expression in papillary thyroid carcinoma (PTC) and its variants and determined its prognostic potential to predict clinical outcome in these patients. This study was conducted at an academic oncology hospital which is a prime referral centre for thyroid diseases. Immunohistochemical subcellular localization (IHC) analyses of PD-L1 protein was retrospectively performed on 251 archived formalin fixed and paraffin embedded (FFPE) surgical tissues (66 benign thyroid nodules and 185 PTCs) using a rabbit monoclonal anti-PD-L1 antibody (E1L3N, Cell Signaling Technology) and detected using VECTASTAIN rapid protocol with diaminobenzidine (DAB) as the chromogen. The clinical-pathological factors and disease outcome over 190 months were assessed; immunohistochemical subcellular localization of PD-L1 was correlated with disease free survival (DFS) using Kaplan Meier survival and Cox multivariate regression analysis. Increased PD-L1 immunostaining was predominantly localized in cytoplasm and occasionally in plasma membrane of tumor cells. Among all combined stages of PTC, patients with increased PD-L1 membrane or cytoplasmic positivity had significantly shorter median DFS (36 months and 49 months respectively) as compared to those with PD-L1 negative tumors (DFS, both 186 months with p < 0.001 and p < 0.01 respectively). Comparison of PD-L1+ and PD-L1- patients with matched staging showed increased cytoplasmic positivity in all four stages of PTC that correlated with a greater risk of recurrence and a poor prognosis, but increased membrane positivity significantly correlated with a greater risk of metastasis or death only in Stage IV patients. In conclusion, PD-L1 positive expression in PTC correlates with a greater risk of recurrence and shortened disease free survival supporting its potential application as a prognostic marker for PTC.