Answering Hospital Caregivers' Questions at Any Time: Proof-of-Concept Study of an Artificial Intelligence-Based Chatbot in a French Hospital.

BACKGROUND: Access to accurate information in health care is a key point for caregivers to avoid medication errors, especially with the reorganization of staff and drug circuits during health crises such as the COVID­19 pandemic. It is, therefore, the role of the hospital pharmacy to answer caregivers' questions. Some may require the expertise of a pharmacist, some should be answered by pharmacy technicians, but others are simple and redundant, and automated responses may be provided. OBJECTIVE: We aimed at developing and implementing a chatbot to answer questions from hospital caregivers about drugs and pharmacy organization 24 hours a day and to evaluate this tool. METHODS: The ADDIE (Analysis, Design, Development, Implementation, and Evaluation) model was used by a multiprofessional team composed of 3 hospital pharmacists, 2 members of the Innovation and Transformation Department, and the IT service provider. Based on an analysis of the caregivers' needs about drugs and pharmacy organization, we designed and developed a chatbot. The tool was then evaluated before its implementation into the hospital intranet. Its relevance and conversations with testers were monitored via the IT provider's back office. RESULTS: Needs analysis with 5 hospital pharmacists and 33 caregivers from 5 health services allowed us to identify 7 themes about drugs and pharmacy organization (such as opening hours and specific prescriptions). After a year of chatbot design and development, the test version obtained good evaluation scores: its speed was rated 8.2 out of 10, usability 8.1 out of 10, and appearance 7.5 out of 10. Testers were generally satisfied (70%) and were hoping for the content to be enhanced. CONCLUSIONS: The chatbot seems to be a relevant tool for hospital caregivers, helping them obtain reliable and verified information they need on drugs and pharmacy organization. In the context of significant mobility of nursing staff during the health crisis due to the COVID-19 pandemic, the chatbot could be a suitable tool for transmitting relevant information related to drug circuits or specific procedures. To our knowledge, this is the first time that such a tool has been designed for caregivers. Its development further continued by means of tests conducted with other users such as pharmacy technicians and via the integration of additional data before the implementation on the 2 hospital sites.

Specifics of chronic fatigue syndrome coping strategies identified in a French flash survey during the COVID-19 containment.

The COVID-19 pandemic has focused health systems on supporting patients affected by this virus. Meanwhile in the community, many other contained patients could only use self-care strategies, especially in countries that have set up a long and strict containment such as France. The study aimed to compare coping strategies deployed by patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS; a poorly recognised syndrome) to those with better known and referenced chronic conditions. An online flash survey was conducted during the containment period in partnership with French Patients Organizations including ME/CFS national association. Therefore, 'Brief COPE' version of Lazarus and Folkman's Ways of Coping Check List has been adapted to the specificity of the containment. The survey was e-distributed in France from 15 April to 11 May 2020. Differences of coping strategies were analyzed using Wilcoxon-Mann-Withney test. Amongst 637 responses, 192 were complete, presenting a wide variety of diseases, including 93 ME/CFS. The latter have significantly different coping strategies than recognised diagnosed diseases patients: similar uses of emotion focused coping but less uses of seek social support and problem-focused copings. In conclusion, coping strategies are different for those who deal with the daily experience of ME/CFS, highly disabling chronic condition with diagnostic ambiguity, low degree of medical and social recognition and without treatment. Better understanding of those strategies is needed to provide the means for health promotion researchers, managers and clinicians, to accompany those patients.

Efficacy of next treatment received after nivolumab progression in patients with advanced nonsmall cell lung cancer.

Nivolumab for the treatment of advanced nonsmall cell lung cancer (NSCLC) evaluated in phase III trials showed 50% progression at first evaluation, but better overall survival (OS), suggesting regained efficacy of treatments given thereafter. We aimed to evaluate the efficacy of nivolumab and of next treatment received after nivolumab progression in patients with advanced NSCLC. Our multicentre retrospective study included all patients receiving nivolumab between January and December 2015. The primary end-point was progression-free survival (PFS) of treatment given after nivolumab. The 303 patients had the following characteristics: median age 63 years, 69% males, 92% smokers, 67% performance status 0-1 and 61% adenocarcinoma. Nivolumab was given as second-line treatment in 40% of patients. With 13.7 months of median follow-up, nivolumab PFS and OS were 2.6 and 11.3 months, respectively. At the cut-off analysis 18% were controlled under nivolumab, 14% were deceased and 5% were lost to follow-up under nivolumab. Among the 191 (63%) patients eligible for post-nivolumab (PN) treatment, 115 (38%) received further treatment and were characterised by better performance status (p=0.028) and by receiving more injections of nivolumab (p=0.001). Global PN-OS and PN-PFS were 5.2 and 2.8 months, respectively. Drugs most frequently used after nivolumab were gemcitabine (23%), docetaxel (22%) and erlotinib (16%), with median PFS of 2.8, 2.7 and 2.0 months, respectively. Nivolumab produced similar efficacy as in phase III trials, although patients received nivolumab later and had worse performance status. 38% received treatment after nivolumab progression with efficacy comparable to historical second-line trials.

[Care pathways of cancer patients: Modeling and risks analysis induced by oral anticancer drugs]. / Parcours de soins : modélisation et analyse des risques induits par les anticancéreux oraux.

The care pathway of cancer patients is complex and therefore difficult to define. The oral anticancers (AKPO) have shown their benefits to patients and health professionals, however, the risks induced on the care pathway remain unknown. The objective of the study is to define, quantify the risks from AKPO and their effects on the care pathway (breakdown [Ds], rupture [Rt]). From the proposed care pathway model, FMEA method is used to analyze risks. For the 3 identified processes (1 monotherapy, 2 bitherapies: 2 AKPO or 1 AKPO/1 AKIV), analysis revealed an average of 91 risks, 173 Ds, 147 Rt, increased for 1 AKPO/1 AKIV therapy. The administration and delivery are the most risky steps. The lack of training and information of patients and healthcare professionals generates 80% of Ds and Rt. This model confirms the complexity, variability of the care pathway. The development of actions to improve town-hospital coordination and exchange of information is required to optimize and secure the route, confirming the objectives of "Plan Cancer 3".

Development of an Experimental Model to Study the Relationship Between Day-to-Day Variability in Blood Pressure and Aortic Stiffness.

We aimed to develop an animal model of long-term blood pressure variability (BPV) and to investigate its consequences on aortic damage. We hypothesized that day-to-day BPV produced by discontinuous treatment of spontaneously hypertensive rats (SHR) by valsartan may increase arterial stiffness. For that purpose, rats were discontinuously treated, 2 days a week, or continuously treated by valsartan (30 mg/kg/d in chow) or placebo. Telemetered BP was recorded during 2 min every 15 min, 3 days a week during 8 weeks to cover the full BP variations in response to the treatment schedule. Pulse wave velocity (PWV) and aortic structure evaluated by immunohistochemistry were investigated in a second set of rats treated under the same conditions. Continuous treatment with valsartan reduced systolic BP (SBP) and reversed the aortic structural alterations observed in placebo treated SHR (decrease of medial cross-sectional area). Discontinuous treatment with valsartan decreased SBP to a similar extent but increased the day-to-day BPV, short term BPV, diastolic blood pressure (DBP), and PWV as compared with continuous treatment. Despite no modifications in the elastin/collagen ratio and aortic thickness, an increase in PWV was observed following discontinuous treatment and was associated with a specific accumulation of fibronectin and its αv-integrin receptor compared with both groups of rats. Taken together the present results indicate that a discontinuous treatment with valsartan is able to induce a significant increase in day-to-day BPV coupled to an aortic phenotype close to that observed in hypertension. This experimental model should pave the way for future experimental and clinical studies aimed at assessing how long-term BPV increases aortic stiffness.

Extreme bradycardia after first doses of sofosbuvir and daclatasvir in patients receiving amiodarone: 2 cases including a rechallenge.

Sofosbuvir and daclatasvir are direct-acting antiviral drugs used to treat chronic hepatitis C virus infection. In 2015, the Food and Drug Administration and European Medical Agency warned that bradycardia could occur when amiodarone was administered in combination with sofosbuvir, but no case reports had been published. We report extreme bradycardia within 2 hrs after intake of sofosbuvir and daclatasvir by 2 patients receiving amiodarone. The first patient had a cardiac asystole 30 min after receiving sofosbuvir and daclatasvir. Amiodarone, sofosbuvir, and daclatasvir treatment were stopped; after 10 days, the cardiac evaluation was normal and patient was discharged. The second patient was taking amiodarone and propranolol; 2 hrs after receiving sofosbuvir and daclatasvir, he had an extreme sinus node dysfunction (heart rate of 27beats/min). Amiodarone and propranolol were stopped, but the patient continued receiving sofosbuvir and daclatasvir for 3 days and sinus bradycardia was recorded each day, 2 hrs after intake of these drugs. When he stopped taking the drugs, no bradycardia was observed. Administration of sofosbuvir and daclatasvir on day 13 induced bradycardia 2 hrs after intake. However, no bradycardia occurred following a rechallenge 8 weeks after the patient stopped taking amiodarone. These observations indicate that patients treated with amiodarone should be continuously monitored within the first 48 hrs following the initiation of sofosbuvir and daclatasvir.

Diseases of abnormal sensitivity to cold in children on psychostimulant drugs.

BACKGROUND: Oral psychostimulant (PS) drugs, the pharmacologic treatment of choice for attention-deficit/hyperactivity disorder (ADHD), have been associated with diseases of abnormal sensitivity to cold (DASC) such as Raynaud phenomenon and acrocyanosis. OBJECTIVES: In a cohort of pediatric patients with DASC, we sought to identify prevalence and clinical features of patients on PS drugs. METHODS: A 6-year retrospective chart review (2005-2011) of Ste-Justine University Hospital Center DASC patients with and without exposure to PS drugs was performed. Clinical data were analyzed with descriptive statistical methods. RESULTS: Of 43 patients with DASC, 11 (25%) were exposed to PS drugs. In this group males were overrepresented, there was no evidence of collagen vascular diseases, serologic findings were not significant and the mean duration of PS intake was of 2.5 years. DASC age of onset was similar in both exposed and nonexposed patients. The incidence of more than one DASC type was greater in teenager patients with a positive family history of autoimmune and/or collagen vascular diseases. LIMITATIONS: This study is limited by its small population size, short follow-up period and its retrospective nature. CONCLUSION: Physicians should be aware of PS drugs as possible triggers for DASC.

Diseases of abnormal sensitivity to cold in children on psychostimulant drugs.

BACKGROUND: Oral psychostimulant (PS) drugs, the pharmacologic treatment of choice for attention-deficit/hyperactivity disorder (ADHD), have been associated with diseases of abnormal sensitivity to cold (DASC) such as Raynaud phenomenon and acrocyanosis. OBJECTIVES: In a cohort of pediatric patients with DASC, we sought to identify prevalence and clinical features of patients on PS drugs. METHODS: A 6-year retrospective chart review (2005-2011) of Ste-Justine University Hospital Center DASC patients with and without exposure to PS drugs was performed. Clinical data were analyzed with descriptive statistical methods. RESULTS: Of 43 patients with DASC, 11 (25%) were exposed to PS drugs. In this group males were overrepresented, there was no evidence of collagen vascular diseases, serologic findings were not significant and the mean duration of PS intake was of 2.5 years. DASC age of onset was similar in both exposed and nonexposed patients. The incidence of more than one DASC type was greater in teenager patients with a positive family history of autoimmune and/or collagen vascular diseases. LIMITATIONS: This study is limited by its small population size, short follow-up period and its retrospective nature. CONCLUSION: Physicians should be aware of PS drugs as possible triggers for DASC.

Pilot Study on the Impact of Evidence-Based Data on Oncology Pharmacists' Perceptions.

OBJECTIVES: The main objective was to evaluate whether the level of agreement of oncology hospital pharmacists with statements on their impact is influenced by the presence or absence of evidence-based data. The secondary objective was to evaluate the relative importance of evidence-based data among factors that may have contributed to oncology pharmacy practice evolution. METHODS: Oncology pharmacists' answered a Web questionnaire to measure their level of agreement with statements regarding their impact. Respondents answered the questionnaire before (pre) and after (post) being informed whether supporting evidence was available for each statement. Respondents were also asked to rank all of the factors in order of their perceived contribution to oncology pharmacy practice evolution. RESULTS: A total of 64 questionnaires were obtained. Respondents reported a high level of agreement with statements regarding their impact on oncology pharmacy practice (mean agreement of 95.9% pre vs 93.8% post). A statistically significant diminution in the level of agreement was observed for 3 statements after respondents were informed that no supporting evidence was available for these statements. Respondents assigned a high importance to factors related to the perception of positive outcomes of pharmaceutical activities on patient safety, health care costs, and clinical results but a low importance to the use of evidence-based data.

Increase in transaminase levels following the use of raltegravir in a woman with a high HIV viral load at 35 weeks of pregnancy.

BACKGROUND: Despite the efficacy of raltegravir in reducing viral load in HIV-infected patients, evidence for its safety in late pregnancy is lacking. A high rate of placental transfer was recently demonstrated. CASE: A treatment-naïve 34-year-old HIV-1-positive woman of African origin began treatment with zidovudine/lamivudine, lopinavir/ritonavir, and raltegravir at 35 weeks of pregnancy. After 11 days of treatment with raltegravir, a substantial reduction in viral load was achieved. Concurrently, she had a 23-fold increase in serum alanine aminotransferase and a 10-fold increase in serum aspartate aminotransferase, both of which returned to normal when raltegravir treatment was discontinued. A healthy boy was delivered at term. The infant's tests for HIV were negative at five months, and he had no health problems at eight months. CONCLUSION: This is the first case report, to our knowledge, of increased maternal serum transaminase levels following the use of raltegravir in a woman at a late stage of pregnancy.

Prioritizing pharmaceutical activities: a simulation by pharmacy residents.

OBJECTIVES: The primary objective was to examine the consistency of prioritization decisions made by pharmacy residents in a simulated environment where the available resources are constrained. Secondary objectives were to rank the factors that influenced their prioritization and to compare the residents' results with those of Canadian pharmacy leaders. METHODS: We have developed a prioritization exercise that aims at evaluating how pharmaceutical activities are prioritized. The simulation was conducted with hospital pharmacy residents in 2 Quebec universities in 2011. RESULTS: Residents covered a similar number of activities in the prioritization simulation (mean 27 of 32). Teams tended to favor a broad range of services delivered less comprehensively. Participants ranked "perception of the favorable impact of the activity on health outcomes" higher than "conclusive evidence available to support the decisions." The relative weight attributed per domain was similar between pharmacy residents and pharmacy leaders, but their ranking of factors that influenced their decisions was different. CONCLUSIONS: Pharmacy residents opted to provide a wide range of services, but at a low level of comprehensiveness. The high variation between each team's coverage per activity in this simulation supports the observation that pharmacy residents do not agree on a core set of pharmaceutical activities that should be prioritized.