Needs Assessment for Pharmacy Program Creation Designed to Serve Minority Francophone Populations in Canada.

OBJECTIVES: Current literature provides little insight into the need for French-language pharmaceutical services in Francophone minority settings in Canada. This study aims to understand the pharmaceutical care and services offered in French in Canada. It also aims to conduct a needs assessment in the context of curriculum development, by validating whether pharmaceutical needs are being met in Francophone minority settings in Canada. METHODS: An online survey was sent to community members and health care professionals. Respondents were asked to identify the perceived importance of pharmaceutical needs and the degree to which they perceive these to be fulfilled in French and English in their communities. RESULTS: A total of 113 community members and 109 health care professionals completed the survey. Most respondents were from Ontario (64.84%), Quebec (10.50%), or Atlantic Provinces (10.05%). In total, > 95% of survey respondents identified that pharmaceutical needs assessed were of very high importance. The rate of pharmaceutical need fulfillment was lower in French than English across all pharmaceutical needs assessed. The greatest difference in rate of pharmaceutical need fulfillment was seen with "Having safe access to required medication". The perception of pharmaceutical needs being met was congruent between community members and health care professionals. CONCLUSION: These results confirm a lack of pharmaceutical needs being met in French in Canadian Francophone minority communities. There is a lack of French-language services that limit the ability to receive care in one's own language. Pharmacy education in French may be an effective approach to improve pharmaceutical care services received in French in Francophone minority communities.

Emotional Impact of Medication-Related Patient Safety Incidents on Canadian Hospital Pharmacists: A Mixed-Methods Study.

Background: Patient safety incidents are the third leading cause of death in Canada. These occurrences have negative effects on patients and on the well-being of health care professionals. They also lead to financial burdens on the health care system. Several organizations focus on minimizing patient safety incidents; however, an area requiring additional research is evaluating the emotional impact of medication-related patient safety incidents (MRPSIs) on Canadian hospital pharmacists. An MRPSI is a preventable, unintended outcome resulting from medication management rather than an underlying disease. The consequences may be no harm, temporary harm, prolonged hospital stay, disability, or death. Objectives: To describe the psychological burden on pharmacists after occurrence of an MRPSI and to identify supportive strategies. Methods: This mixed-methods study involved a voluntary survey of hospital pharmacists and structured individual interviews. Survey respondents scored their emotional distress on the Impact of Event Scale (IES), a validated self-reporting tool used to assess the impact of traumatic life events. Interviewees' responses were analyzed qualitatively. Results: Of the 128 pharmacists who had experienced an MRPSI and submitted a complete survey response, 105 (82%) had a score above 8 on the IES, indicating that the MRPSI had an important impact. Commonly reported factors contributing to MRPSIs were heavy workload, interruptions, and inexperience. The most desired support strategies included talking to a colleague, compassionate notification of the event through management, and involvement in team debriefs. Conclusions: The emotional impact of MRPSIs as reported by Canadian hospital pharmacists is significant. Most participants felt that increased support is needed to overcome emotional burdens related to MRPSIs.

Contexte: Les incidents liés à la sécurité des patients sont la troisième cause de décès au Canada. Ces événements ont des effets négatifs sur les patients et sur le bien-être des professionnels de la santé. Ils entraînent en outre des charges financières pour le système de santé. Plusieurs organismes se concentrent sur la réduction de ces incidents; cependant, l'évaluation de l'effet émotionnel des incidents liés à la sécurité des patients découlant des médicaments (ci-après « les incidents ¼) sur les pharmaciens hospitaliers canadiens est un domaine qui nécessite des recherches supplémentaires. Un incident est un résultat évitable et imprévu résultant de la gestion des médicaments plutôt que d'une maladie sous-jacente. Les conséquences peuvent être l'absence de préjudice, un préjudice temporaire, un séjour prolongé à l'hôpital, une invalidité ou la mort. Objectifs: Décrire le fardeau psychologique des pharmaciens dans un contexte où un incident s'est produit et identifier des stratégies d'accompagnement. Méthodes: Cette étude à méthodes mixtes comportait une enquête volontaire auprès des pharmaciens hospitaliers et des entretiens individuels structurés. Les répondants au sondage ont noté leur détresse émotionnelle sur l'échelle de l'effet des événements (IES [Impact of Event Scale]), un outil d'auto-déclaration validé utilisé pour évaluer l'impact des événements traumatisants de la vie. Les réponses des personnes interrogées ont été analysées qualitativement. Résultats: Sur les 128 pharmaciens qui avaient fait l'expérience d'un incident et qui avaient soumis une réponse complète à l'enquête, 105 (82 %) avaient un score supérieur à 8 sur l'IES. Ce score indique que l'incident avait eu un impact important. Les facteurs couramment signalés contribuant aux incidents étaient la lourde charge de travail, les interruptions et l'inexpérience. Les stratégies de soutien les plus recherchées comprenaient : la discussion avec un collègue; la notification compatissante de l'événement par l'intermédiaire de la direction; et la participation aux comptes rendus de l'équipe. Conclusions: L'impact émotionnel des incidents, tel que rapporté par les pharmaciens hospitaliers canadiens, est important. La plupart des participants ont estimé qu'un soutien accru est nécessaire pour surmonter le fardeau émotionnel associé.

Multiple endocrine neoplasia 1: a broad overview.

This review article discusses the diagnoses and treatment of patients with multiple endocrine neoplasia type 1 (MEN 1). The most common tumors associated with MEN 1 are located in the pancreas, pituitary, and parathyroid glands. Less common tumors include neuroendocrine tumors of the lung and thymus, adrenal tumors, and cutaneous lesions. This article describes the diagnosis, clinical manifestations, treatment, and surveillance of tumors associated with patients who are diagnosed with MEN 1.

Factors contributing to unintentional parathyroidectomy during thyroid surgery.

Unintentional parathyroidectomy during thyroid surgery has an incidence ranging between 1% and 31% across institutions. Many studies have identified malignancy and central neck dissection as risk factors for losing parathyroid glands, but few studies have evaluated the impact of other factors such as lymphocytic thyroiditis, hyperthyroidism, or concomitant primary hyperparathyroidism. The purpose of this study was to investigate which factors contribute to parathyroid loss during thyroid surgery. Charts of 269 patients undergoing thyroid surgery at a tertiary care medical center from 2010 to 2013 were retrospectively reviewed. Sixty-six patients (24.5%) experienced unintentional parathyroidectomy. Bivariate analysis showed no significant differences in patient characteristics. Patients with unintentional parathyroid removal had a significantly smaller largest thyroid nodule size (P = 0.002), higher rate of central neck dissection (30.3% vs 7.9%, P < 0.0001), and higher rate of malignancy (50% vs 36.0%, P = 0.04). Multivariable analysis showed that the strongest risk factor for unintentional parathyroidectomy was central neck dissection (P = 0.0008; odds ratio 4.72, confidence interval 1.91-11.71). In conclusion, central neck dissection for thyroid malignancy is the strongest risk factor for unintentional thyroidectomy. The presence of concomitant primary hyperparathyroidism, lymphocytic thyroiditis, or hyperthyroidism did not appear to increase the risk of unintentional parathyroidectomy.

Biochemical prognostic indicators for pancreatic neuroendocrine tumors and small bowel neuroendocrine tumors.

Pancreatic neuroendocrine tumors (PNETs) and small bowel neuroendocrine tumors (SBNETs) are rare tumors that are frequently diagnosed late in the course of the disease. Several biomarkers have been proposed in the literature as prognostic factors for patients with these tumors. This article discusses a recent publication in Annals of Surgical Oncology from the University of Iowa analyzing the effect of different biomarkers on survival in patients with PNETs and SBNETs.

Resection of at-risk mesenteric lymph nodes is associated with improved survival in patients with small bowel neuroendocrine tumors.

BACKGROUND: Neuroendocrine tumors of the small intestine commonly metastasize to regional lymph nodes (LNs). Single-institution reports suggest that removal of LNs improves outcome, but comprehensive data are lacking. We hypothesized that the extent of lymphadenectomy reported in a large administrative database would be associated with overall survival for jejunal and ileal neuroendocrine tumors. METHODS: A search of the Surveillance Epidemiology and End Results database was performed for patients with jejunal and ileal neuroendocrine tumors from 1977 to 2004. Descriptive patient characteristics were collected to include age at diagnosis, sex, race, grade, primary tumor size, LN status, number of LNs resected, presence of distant metastasis, and the type of operation. Statistical analyses were limited to patients with only one primary tumor to exclude patients with other malignancies. Univariate and multivariate analyses were performed to analyze the number of LNs resected and the LN ratio (number of positive LNs/total number of LNs removed) to determine the effect on cancer-specific survival. RESULTS: Altogether, 1,364 patients were included in this analysis. Removal of any LNs was associated with improved cancer-specific survival when compared to patients with no LN removal reported (p = 0.0027) on univariate analysis. Among those who had any LNs removed, a median of eight LNs were identified in resection specimens with a median LN ratio of 0.29 (range 0-1). On multivariate analysis (adjusting for age and tumor size), patients with >7 LNs removed experienced better cancer-specific survival than those with ≤ 7 LNs removed (median survival not reached vs. 140 months): hazard ratio and 95 % confidence interval were 0.573 (0.402, 0.817) (p = 0.002). CONCLUSIONS: This review of a large number of surgical patients demonstrates that regional mesenteric lymphadenectomy in conjunction with resection of the primary tumor is associated with improved survival of patients with small bowel neuroendocrine tumors.

Greater than age-predicted functional deficits in older patients with primary hyperparathyroidism.

OBJECTIVE: To compare the functional capacity of "asymptomatic" patients with primary hyperparathyroidism (PHPT) with normative values of healthy age-matched subjects. METHODS: Eighteen asymptomatic patients with PHPT met the study inclusion criteria: age >55 years, serum calcium concentration elevated ≤1 mg/dL above normal, inappropriate elevation of parathyroid hormone (PTH) level, and no objective symptoms of PHPT. Functional capacity was assessed by (1) a 6-minute walk test, (2) time to complete 2 sit-to-stand maneuvers, (3) gait velocity, and (4) forward reach. Serum calcium, 25-hydroxyvitamin D, and PTH levels were measured by standard laboratory assays. Functional outcomes of the study patients were compared with age-matched normative values (unpaired t test) and correlated with these biomarkers. Because these patients often have weakness, fatigue, and malaise, we hypothesized that their functional capacity would be compromised relative to that of healthy, age-matched persons. RESULTS: The mean age of the patients was 65.6 years, and the mean serum calcium, PTH, and 25-hydroxyvitamin D levels (and standard deviations) were 10.36 ± 0.37 mg/dL, 122.22 ± 39.54 pg/mL, and 44.4 ± 14.27 ng/mL, respectively. Relative to normative values of healthy, age-matched subjects, these patients had comparable 6-minute walk distances but required a 37% longer time to complete a repeated sit-to-stand maneuver (P<.05), demonstrated a 52% slower gait speed (P<.001), and had a greater forward reach (P=.05). CONCLUSION: Our findings suggest that older asymptomatic patients with PHPT may have significant functional deficits that can affect their safety and quality of life. Therefore, their functional capacity should be routinely evaluated, and identified deficits should be treated with appropriate interventions.

Predictable criteria for selective, rather than routine, calcium supplementation following thyroidectomy.

OBJECTIVES: To identify patients at risk for symptomatic hypocalcemia and to make recommendations for safe, selective calcium supplementation. DESIGN: Retrospective review of consecutive patients undergoing thyroidectomy. Patients were divided into 2 groups. Group 1 (the "high-risk/calcium-yes" group) included patients who were found to have (1) postoperative symptoms of hypocalcemia (ie, tingling and numbness), (2) any postoperative serum calcium level of less than 7 mg/dL, or (3) a parathyroid hormone level of less than 3 pg/mL on postoperative day 1. Group 2 (the "low-risk/calcium-no" group) included all other patients. Demographic, operative, biochemical, and pathologic data, as well as postoperative calcium supplementation data, were recorded. Trends in serum calcium level and parathyroid hormone level were analyzed during the immediate postoperative period to identify specific factors unique to group 1. PATIENTS: A total of 156 patients who underwent a thyroidectomy. SETTING: Tertiary care center. RESULTS: Of the 156 patients reviewed, 78% were female, 70% had a malignant disease, and the median age at operation was 50 years. Thirty-four patients (22%) were in group 1, and 122 patients (78%) were in group 2. Twenty-nine (19%) patients had a parathyroid hormone level of less than 3 pg/mL within 24 hours after a thyroidectomy. Patients who underwent a central neck dissection (P = .001), had malignant disease (P = .01), or had a documented removal of the parathyroid gland (with or without autotransplantation) at operation (P = .013) were most likely to be classified into group 1. Forty-two percent of patients in group 2 had either a parathyroid hormone level of less than 6 pg/mL or a serum calcium level of less than 8 mg/dL on postoperative day 1, but all patients in group 1 who were symptomatic met these parameters. CONCLUSION: Limiting supplementation to patients with a parathyroid hormone level of less than 6 pg/mL or a serum calcium level of less than 8 mg/dL on postoperative day 1 may eliminate unnecessary calcium/vitamin D intake, phlebotomy, and follow-up assessments in up to 58% of patients undergoing thyroidectomy. Validation is required in a prospective setting.

Robot-assisted transaxillary thyroid surgery in the United States: is it comparable to open thyroid lobectomy?

BACKGROUND: The purpose of this study was to compare the outcome of robot-assisted transaxillary thyroid surgery (RATS) to the standard open technique for thyroid lobectomy in the U.S. population. METHODS: Comparison was made between 25 consecutive patients who underwent thyroid lobectomy via RATS and 25 patients who underwent open thyroid lobectomy. All patients met predetermined criteria for RATS. Clinical characteristics of patients and operative data were compared between groups using the Fisher exact or the Kruskal-Wallis test. RESULTS: The RATS and open groups were similar in gender (92% vs 84% female), median body mass index (BMI) (25 vs 26), preoperative cytology (P=.71), and postoperative diagnosis (P=.91). Operative time for the RATS group was longer than the open group [median 121 minutes (range 74-199 minutes) vs 68 minutes (41-112 minutes), P<.0001]. Estimated blood loss was greater in the RATS group [median 10 cc (0-150 cc) vs 0 cc (0-25 cc), P=.0042]. Unlike the open group, postoperative complications in the RATS group included 2 patients with neurological deficits in the brachial plexus distribution. The postoperative incidence of temporary hoarseness, bleeding, infection, seroma, numbness, and length of hospital stay did not differ significantly between groups. CONCLUSIONS: In a select group of patients, RATS is comparable to open thyroid lobectomy in terms of postoperative complications and hospital stay. Patients should be counseled that RATS is associated with a longer operative time, a potential for brachial plexus neurological deficits, and larger (although still low) blood loss. A prospective trial further evaluating cost, quality of life, and patient-reported satisfaction is warranted.

Vitamin D receptors and parathyroid glands.

OBJECTIVE: To describe the function and metabolism of the vitamin D hormone and the role of the vitamin D receptor and the calcium-sensing receptor in the secretion of parathyroid hormone. METHODS: A review of the literature was undertaken regarding the function and metabolism of vitamin D; the role of the vitamin D receptor and calcium-sensing receptor in the secretion of parathyroid hormone; and the contemporary research regarding the interaction of vitamin D and parathyroid hormone in patients with vitamin D deficiency, primary hyperparathyroidism, and secondary hyperparathyroidism. RESULTS: Over the last several years, great interest has been generated about the interaction of vitamin D and the parathyroid glands, gastrointestinal tract, kidney, and bone in relation to calcium and parathyroid hormone levels. Vitamin D has an important role in calcium and parathyroid hormone metabolism. Likewise, the vitamin D axis appears to be involved with the development of both primary and secondary hyperparathyroidism. The specific mechanism by which vitamin D interacts with the parathyroid gland to bring about observed effects is not yet fully understood. CONCLUSION: Future studies investigating the relationship of the vitamin D receptor, calcium-sensing receptor, and parathyroid glands are needed to enhance our knowledge of vitamin D deficiency and primary and secondary vitamin D deficiency.

Cystic lymph nodes in the lateral neck as indicators of metastatic papillary thyroid cancer.

OBJECTIVE: To determine whether radiographic findings portend to metastatic disease in patients with papillary thyroid carcinoma (PTC) and whether cystic lymph node metastasis can be recognized by preoperative, ultrasound-guided fine-needle aspiration (FNA). METHODS: We performed a retrospective review of patients with cystic lymph nodes in the lateral neck identified on preoperative ultrasonography between March 1996 and December 2009. Factors examined included demographic information; stage; cytologic and final pathologic findings; and imaging characteristics including location, size, and presence of vascularity and calcifications. Time of cystic node identification in relationship to initial diagnosis was also recorded. RESULTS: Thirty patients had cystic lymph nodes in the lateral neck on cervical ultrasonography during the study period. Among this group, 28 (93%) had PTC, 1 (3%) had papillary serous carcinoma of the ovary, and 1 (3%) had poorly differentiated thyroid cancer. Median age at initial cancer diagnosis was 41 years (range, 16-64 years). Twenty-one patients (70%) were women, and median lymph node size was 1.8 cm (range, 0.6-4.8 cm). Twenty-three patients (77%) had a solitary cystic lymph node, and the remainder had more than 1 cystic lymph node. Cystic lymph nodes were identified at initial presentation in 11 patients (37%), while cystic lymph nodes were discovered in 19 patients (63%) after the initial operation. FNA was performed on the cystic lymph nodes of 23 patients (77%). Cytologic findings were positive for metastatic disease in 18 of 23 patients (78%). Among the 5 of 23 patients with negative cytologic findings, thyroglobulin aspirate was obtained in 1 patient, confirming metastatic PTC. Final pathologic review after surgical resection of cystic lymph nodes with negative cytologic findings from FNA was consistent with metastatic disease in 4 of 5 patients (80%). CONCLUSIONS: In patients with PTC, the presence of a cystic lymph node by ultrasonographic examination is highly suggestive of locally metastatic disease. Confirmation of metastatic PTC may sometimes be achieved with thyroglobulin aspirate from cystic lymph nodes when cytologic findings are negative. Clinicians should strongly consider surgical lymph node resection of cystic lymph nodes regardless of the preoperative cytologic findings by FNA.

Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands.

BACKGROUND: Robotic assisted transaxillary surgery (RATS) is a minimally invasive approach for the removal of the thyroid and/or parathyroid glands through the axilla. This anatomically directed technique, popularized by Chung, eliminates a visible scar and affords excellent high definition optics of the cervical anatomy. We report an initial series of single access RATS in the U.S. METHODS: The prospective endocrine surgery database at a tertiary care center was used to capture all patients who underwent RATS between October 2009 and March 2010. All procedures were performed using a single transaxillary incision. RESULTS: Fourteen operations were performed on 13 patients. Indications for RATS were indeterminate thyroid nodules in 11 patients, the need for completion thyroidectomy in 1 patient, and primary hyperparathyroidism in 2 patients. For patients who underwent robotic assisted thyroid lobectomy, the median thyroid nodule size was 2.1 cm (range, 0.8-2.8 cm), and the median body mass index was 25.33 (range, 21.3-34.4). Mean and median total operative times for robotic assisted thyroid lobectomies were 142 minutes and 137 minutes respectively (range, 113-192 minutes). Operative time for the 2 patients who underwent robotic assisted parathyroidectomy was 115 and 102 minutes. Minor complications occurred in 4 patients (28.5%), with no significant perioperative morbidity or mortality. CONCLUSION: RATS is feasible. We believe that further study of the RATS technique for removing thyroid lobes and parathyroid glands is warranted. This initial series suggests that careful, continued investigation is necessary prior to routine implementation into clinical practice across the U.S.

Bilateral robotic-assisted transaxillary surgery.

HYPOTHESIS: Robotic-assisted transaxillary surgery (RATS) for the removal of thyroid glands is feasible by surgeons in the United States. DESIGN: Case report. SETTING: Academic research. Patient A 53-year-old woman. INTERVENTION: Total thyroidectomy via the transaxillary approach. MAIN OUTCOME MEASURE: Successful completion thyroidectomy using bilateral RATS. RESULTS: Right thyroid lobectomy was performed via RATS to remove a 2.2-cm Hurthle cell neoplasm of the thyroid gland per cytologic analysis. Final pathologic analysis was consistent with minimally invasive follicular thyroid carcinoma. The patient then underwent completion thyroidectomy via left-sided RATS. There were no complications. CONCLUSIONS: Bilateral RATS to perform total thyroidectomy is a feasible option in properly selected patients. To our knowledge, this is the first reported use of this technique in the United States.

Surgical management of nonmultiple endocrine neoplasia endocrinopathies: state-of-the-art review.

The development of genetic testing has given patients with familial endocrine diseases the opportunity to be identified earlier in life. The importance of this technological advancement cannot be underestimated, as some of these heritable diseases have significant potential for malignancy. This article focuses on the identification and surgical management of familial endocrinopathies of the thyroid, parathyroid, adrenal glands, and pancreas. Familial endocrinopathies discussed include hereditary nonmedullary carcinoma of the thyroid, Cowden disease, familial adenomatous polyposis, Carney complex, Werner syndrome, familial medullary thyroid carcinoma, Pendred syndrome, hereditary hyperparathyroidism jaw-tumor syndrome, familial isolated hyperparathyroidism, Beckwith- Wiedemann syndrome, Li-Fraumeni syndrome, neurofibromatosis I, von Hippel-Lindau disease, and tuberous sclerosis.

A proposed staging system for gastric carcinoid tumors based on an analysis of 1,543 patients.

The lack of a clinically relevant staging system for gastric carcinoid tumors creates a persistent challenge for clinicians trying to provide patients with meaningful prognostic information. The purpose of this study was to identify the clinicopathologic factors that affect survival for patients diagnosed with gastric carcinoid, and use this information to create a staging system. A search of 15,983 patients with carcinoid tumors from the Surveillance Epidemiology and End Results (SEER) database identified 1,543 patients with gastric carcinoid tumors from 1973 to 2004. Patients were analyzed according to various clinicopathologic factors, and a tumor (T1, T2, T3), lymph node (N0, N1), and metastasis (M0, M1) staging system was created according to these parameters. Gastric carcinoid was the only primary malignancy in 74% of patients; 24% presented with one additional primary malignancy, and 2.7% had two or more additional malignancies. On multivariate analysis, age and depth of invasion were significant for patients with one tumor. Four stages were created according to statistically significant prognostic factors: 60% of patients were classified into stage I, 7.6% into stage II, 6.5% into stage III, and 26% into stage IV. Five-year survival rates were 82, 63, 21, and 5.5% for stages I-IV, respectively. We conclude that this tumor-node-metastasis (TNM) staging system accurately discriminates prognosis for all types of gastric carcinoid tumors, with size, depth of invasion, lymph node involvement, and distant metastasis having the greatest impact on survival. Incorporation of this staging system into clinical practice will allow better study of outcomes and development of stage-specific treatment recommendations.

Preoperative chemotherapy does not increase morbidity or mortality of hepatic resection for colorectal cancer metastases.

Hepatic metastasis from colorectal cancer (mCRC) is best treated with a multidisciplinary approach. Conflicting data exist regarding the impact of preoperative chemotherapy on morbidity and mortality after hepatectomy. We hypothesized that preoperative chemotherapy does not adversely impact complications or mortality associated with hepatectomy. A retrospective analysis was performed and included patients with mCRC who underwent hepatectomy from 1996 to 2006. Patients were separated into two groups: those who received preoperative chemotherapy and those who did not. Univariate and multivariate analyses were performed to determine the factors associated with morbidity and mortality. Kaplan-Meier analyses were performed to determine disease-free survival (DFS) and overall survival (OS). One hundred eighty-six patients were analyzed: 112 (60%) received preoperative chemotherapy for a median of 4.2 months. Eighty patients (43%) underwent major hepatectomy. When comparing the two groups, there were no differences in hepatic tumor size (median 3 cm; p = 0.35), type of resection (p = 0.62), stage (p = 0.44) or location (p = 0.10) of the primary tumor, preoperative carcinoembryonic antigen (CEA) level (p = 0.80), or number of nodes in lymphadenectomy (p = 0.62). Only number of positive nodes after colectomy (p = 0.02), age (p < or = 0.0001), and combined resection/radiofrequency ablation (RFA) (p = 0.004) were statistically different between the two groups. There was no difference in rates of morbidity (p = 0.81), mortality (p = 0.29), DFS (p = 0.25) or OS (p = 0.30). We conclude that the use of preoperative chemotherapy did not increase the risk of complications or death for patients undergoing hepatectomy for metastatic colorectal cancer. Pre-hepatectomy chemotherapy appears to be safe and is an important part of the multidisciplinary approach for this disease.