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Objectives The aim of this study was to assess the public’s and healthcare professionals’ awareness and perception on rare diseases and orphan drugs, and to identify challenges faced by both populations. Methods Two questionnaires, one for healthcare professionals and one for the public including rare disease patients, were developed, validated and disseminated. The experience and awareness of the public and healthcare professionals with regard to rare diseases and orphan medicines were analysed. Key findings The questionnaires were completed by 228 members of the public and 73 healthcare professionals. Thirty-seven percent of the public knew or were related to someone with a rare disease. Public participants consisted of those who knew or were related to someone with a rare disease (37%) and rare disease patients (12%). Nineteen percent of rare disease patients had encountered problems while trying to obtain an orphan drug. Seventy-three healthcare professionals completed the questionnaire. Fifty-five percent had diagnosed, encountered or examined a rare disease patient at a point in their career, while 32% had dispensed or tried to dispense an orphan drug. Twenty-seven percent of healthcare professionals had encountered various problems while trying to obtain an orphan drug for patients. Conclusions The elucidation of public’s perception on rare diseases can offer better guidelines for healthcare professionals to support rare disease patients better.

Background: The fast tracking of the production of COVID-19 vaccines gave rise to aspects of general concern regarding their safety. The vigilance aspect of adverse drug reaction (ADR) reporting is a means to build up the science behind the safety aspects. The aim was to develop, validate and apply learning activities for healthcare professionals (HCPs) to educate and support them on ADR reporting. Methods: Two educational webinars were developed, validated, applied and evaluated by pharmacists, medical doctors, dentists and nurses. Results: Evaluation forms about the webinars were completed by 103 out of 132 HCPs (first webinar), and 73 out of 90 HCPs (second webinar). Conclusion: HCPs agreed that the educational webinars made them more aware of the importance of ADR reporting and the webinars helped them overcome barriers to ADR reporting.

Objectives The aim of this study was to assess the prevalence of inappropriate prescribing (IP) in an acute care hospital and to identify medication classes that are inappropriately prescribed. IP occurs in patients with poor renal function in hospital and in outpatient settings. The extent of IP among patients with impaired renal function varies between countries and medical specialties. Methods The retrospective descriptive study included patients aged 18 years and older who were admitted to hospital for more than 24 h with documented estimated glomerular filtration rate (eGFR) Key findings The study included 399 patients (63% female; 37% male) with an average age of 79 years (range 42–99). At least one inappropriate prescription was prescribed to 236 (59.1%) patients and 90 patients (38.1%) received ≥3 inappropriately prescribed medications. The prevalence of IP was 32.0% (n = 790), 29.2% (n = 568) and 30.6% (n = 596) when eGFR, absGFR and eCrCl values were used, respectively. Anticoagulants (n = 261, 43.6%) were the most inappropriately prescribed class of medication followed by analgesics (n = 85, 33.9%) and antidiabetic agents (n = 55, 39.6%). Conclusions Results of the study show that dosage adjustment of medication in renal impairment to avoid IP needs to be addressed. Choice of renal function estimate did not significantly affect the overall prevalence of IP among the study population.

Objective: The purpose of this work was to develop and validate a high-performance liquid chromatography (HPLC) with ultra-violet (UV) detection method for the determination of ∆9-tetrahydrocannabinol (THC) in oil. Methods: HPLC analysis was carried out using an Agilent 1260 Infinity Series® II liquid chromatography system with ultra-violet detection. The stationary phase consisted of an ACE 5 μm C18 column 5 μm (250×4.6 mm) at a temperature of 40°C. The mobile phase consisted of acetonitrile and phosphate buffer (pH=2.5) (70:30, v/v) at a flow rate of 2 mL/min. The injection volume was 20 μL. The UV detector was set at 220 nm. Separation of THC from oil was carried outusing solvent extraction: 0.6 mL of methanol, 0.3 mL of THC in oil and two drops of internal standard were placed in a centrifuge tube, vortex mixed for 30 s, sonicated for 20 min, and centrifuged at 6000 rpm for 15 min. The organic layer was separated, stored at −20°C for 2 h, and centrifuged at 6000 rpm for 15 min. The organic layer was separated again, passed through syringe filters of 0.45 μm, and analyzed. Results: The method was found to be linear in the range of 0.039–5.000 μg/mL, with acceptable inter- and intra-assay precision, accuracy, and stability. The limit of detection was 0.019 μg/mL and the limit of quantification was 0.039 μg/mL. Conclusion: The developed method is quick and easy to use and can determine THC in oil with good peak shape and resolution. Application of the analytical method will help in the determination of THC in CBD oil for medicinal use., peer-reviewed

Objectives To assess the perception of pharmacists and physicians towards pharmacogenetic testing. Methods A self-administered questionnaire was developed, validated, tested for reliability and disseminated to pharmacists and physicians in Malta. Key findings The study population consisted of 292 participants; 61% pharmacists (64% female, 38% practicing >10 years) and 39% physicians (50% female, 54% practicing >10 years). Pharmacists and physicians felt they lack sufficient competence in the area (95.0% and 97.4%, respectively; P > 0.05) and agreed that further training is required (92.7% and 91.2%, respectively; P > 0.05). Conclusions The need for further training was identified by the participants to support competency development and sustain confidence on the topic, hence facilitating the clinical implementation of pharmacogenetic testing.

Objectives Affordability and availability of medicinal products depend on governmental policies, healthcare budgets and pricing. Pharmaceutical price regulation can improve the accessibility and affordability of essential medicinal products. In Europe, medicinal product prices are assigned individually by each country. The study aimed to compare prices of medicinal products indicated for cardiovascular (n = 18) and respiratory disease (n = 9) available for retail in community pharmacies in five European countries., Methods Unit dose medicinal product prices in North Macedonia, Malta, Slovenia, Greece and the UK were compared., Key findings Malta had the highest unit dose prices for the majority (n = 11) of medicinal products used for cardiovascular disease and the majority (n = 8) of the medicinal products indicated for respiratory disease., Conclusion Variation in prices of commonly dispensed medicinal products exists. Having a more thorough knowledge about the prices of medicines in different countries can contribute to making policies that will ultimately make medicines more affordable and accessible to patients., peer-reviewed

Objectives The cytochrome P450 2C19*2 (CYP2C19*2) genetic polymorphism is associated with reduced clopidogrel bioactivation, increasing the risk of atherothrombotic complications after percutaneous coronary intervention (PCI). In-stent restenosis (ISR) is a complication that limits the long-term prognosis of PCI. The aim was to investigate the association between presence of the CYP2C19*2 allele and ISR within one-year after PCI in patients prescribed dual antiplatelet therapy with aspirin and clopidogrel. Methods Sixty patients with angiographically-confirmed drug eluting stent (DES)-ISR within 12 months post-PCI when on DAPT with aspirin and clopidogrel were retrospectively identified (Cases). Another 60 patients with no documented ISR post-PCI in the study period (Controls) were case-matched for age, gender, ethnicity, diabetes mellitus and estimated glomerular filtration rate value, and were invited for CYP2C19*2 genotyping. The association between presence of the CYP2C19*2 allele and ISR was analysed using the Fisher’s exact test and binary logistic regression. Results Twenty-six (43.3%) cases and 5 (8.3%) controls were carriers of one or two CYP2C19*2 alleles. As to non-carrier status of the CYP2C19*2 allele, 34 (56.7%) cases and 55 (91.7%) controls were identified. The association between CYP2C19*2 carrier status and DES-ISR within one-year post-PCI was statistically significant (p Conclusions The proportion of patients who were carriers of one or two CYP2C19*2 alleles who presented with DES-ISR within one-year post-PCI while on clopidogrel was significantly higher compared to patients with no documented ISR.

The COVID-19 pandemic, which was globally declared during the first quarter of the year 2020, led to the transition of teaching activities from the traditional classroom setting to online platforms. This study evaluated preparedness and perception towards online learning and its impact among pharmacy academics and students by using two self-administered questionnaires. Fifteen academics and 60 students answered the questionnaire. Participants had the required technology for online learning (academics n=14, 93%; students n=56, 93%) and believed that the transition to online learning was easy (academics n=12, 80%; students n=41, 68%). Most participants (academics n=12, 80%; students n=46, 77%) stated that online learning allowed more flexibility even though they preferred classroom-based approach. A minority of students stated that the shift to online learning during the pandemic made them feel alone (n=11, 18%), anxious (n=7, 12%) and depressed (n=9, 15%). Given the option, participants would prefer a hybrid learning approach, whereby some teaching activities are switched to online platforms.

The educator and career development team of the academic section of the International Pharmaceutical Federation (FIP) is working on one of the five goals of the strategic plan. The team are initiating a needs assessment to determine how many pharmacists have a desire to expand their careers into the academic setting. Additionally, the team want to discover what types of training they feel would be useful in entering this field. This article describes the process used to develop the instrument to gather this important information.

Introduction A paediatric cancer ward is a setting where pharmacists participate in direct patient care, acting as coordinators between the patient, caregivers and healthcare professionals. The aim of the study was to develop a Gap Finding Tool to support the setting up of a pharmaceutical care model at a Paediatric-Adolescent Cancer Ward. Methods The Standards of Practice for Clinical Pharmacy Services by the Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Clinical Pharmacy (2013), the American College of Clinical Pharmacy (2014) and the European Association of Hospital Pharmacists (2014) were used to compile the Gap Finding Tool. The developed Tool was tested for content validity by a panel of experts and subsequently implemented over 2 months. Results The Gap Finding Tool comprised of nine sections with an average of eight statements each about pharmacy services that should be provided at ward level. For each statement, the rater indicates whether these contributions are provided. When the Tool was implemented at the Paediatric-Adolescent Cancer Ward, four major gaps were identified, namely, absence of a clinical pharmacist, lack of medicines information, vetting of chemotherapy prescriptions by pharmacist with limited access to patient data and lack of pharmacist-input on medicines availability. Processes requiring optimisation included discharge medication advice and documentation processes. Conclusion The developed Gap Finding Tool is an innovative tool which is versatile and can be used in ward or ambulatory clinical settings to identify gaps in pharmaceutical processes and services and compare national or regional practices to international standards.

Introduction: Interprofessional Education (IPE) activities are a first experience of real-world patient care practice for students, where collaboration with different professions is appreciated. Methods and timing of inclusion of IPE are not well-defined, and it is interesting to assess students’ perception on IPE activities., Objective: To assess changes in pharmacy students’ perception of IPE before (t0) and after (t1) an IPE activity., Methods: The ‘Student Perceptions of Interprofessional Clinical Education–Revised 2’ (SPICE-R2) tool was adopted to assess perception of IPE activities in third year pharmacy students, final year pharmacy students and in postgraduate Doctorate in Pharmacy (PharmD) students at t0 and t1., Results: The SPICE-R2 tool was completed at t0 and t1 by 61 students: 12 third year pharmacy students, 13 final year students and 36 PharmD students. A significant improvement between t0 and t1 (P < .05) was measured in the three groups of students for all three subscales of the tool. The largest improvement was observed in the ‘Roles/Responsibilities for Collaborative Practice’ subscale in all three groups of students., Conclusion: Perception of IPE was positively increased in all three student groups. The results could be useful to support the design of IPE activities within pharmacy programmes., peer-reviewed

Background Effective communication strategies in health care help to enhance patient empowerment and improve clinical outcomes. Objective Adapt the original Communication Assessment (CAT) instrument for the pharmacist profession (CAT-Pharm) and to test its validity and reliability in two different settings. Setting Five hospital pharmacies in Italy and five community pharmacies in Malta. Method Pilot study involving a standardized multi-step process adhering to internationally accepted and recommended guidelines. Corrections and adjustments to the translation addressed linguistic factors and cultural components. CAT-Pharm, compared to the original CAT, maintained 10 out of the 14 items: one was slightly modified; three were changed to better fit the pharmacist role; one was added. Main outcome measures CAT-Pharm development and testing its practicality to assess patient perceptions of pharmacists’ interpersonal and communication skills. Results CAT-Pharm was tested on 97 patients in the Italian setting and 150 patients in the Maltese setting to assess the practicality of the tool and its usefulness in investigating gaps and priorities for improving pharmacist-patient communication. Results Show reliability and internal validity of the CAT-Pharm tool. The analysis of patient perceptions of communication with the pharmacist in Italy indicated differences from that in Malta. The different settings provided insight into the utility of CAT-Pharm. Conclusion This study provided a valid and reliable tool that could be applied to assess patient perception of the pharmacist's communication abilities.

Background: The cytochrome P450 2C19 *2 ( CYP2C19*2 ) genetic polymorphism is associated with reduced clopidogrel bioactivation, increasing the risk of atherothrombotic complications after percutaneous coronary intervention (PCI). In-stent restenosis (ISR) is a complication that limits the long-term prognosis of PCI. Objective: To investigate the association between CYP2C19*2 and ISR within one-year after PCI in patients prescribed dual antiplatelet therapy (DAPT) with aspirin and clopidogrel Setting: Acute general hospital, Malta Main outcome measure: Association between CYP2C19*2 and drug-eluting stent (DES)-ISR within one-year post-PCI in patients on DAPT with aspirin and clopidogrel Method: Sixty patients with angiographically-confirmed DES-ISR within one year when on DAPT with aspirin and clopidogrel were retrospectively identified (cases) and 60 patients with no documented ISR post-PCI in the study period (controls) were case-matched for age, gender, diabetes and estimated glomerular filtration rate value. Cases and controls were invited by cardiologists for CYP2C19*2 genotyping. The association between CYP2C19*2 and ISR was analysed using the Fisher’s Exact test and binary logistic regression. Results: Twenty-six (43.3%) cases and 5 (8.3%) controls were carriers of CYP2C19*2 , while 34 (56.7%) cases and 55 (91.7%) controls were non-carriers of CYP2C19*2 . The association between CYP2C19*2 carrier status and DES-ISR within one-year post-PCI was statistically significant (p

Background A three-year post-graduate international Doctorate in Pharmacy collaborative course, was launched by the Department of Pharmacy, University of Malta in collaboration with the College of Pharmacy, University of Illinois at Chicago., Aim and rationale To demonstrate that the professional Doctorate in Pharmacy (i) fits the requirements of a Level 8 degree according to the Bologna process, (ii) helps graduates develop competencies and attributes in proficiency in clinical and professional aspects, (iii) has a research component that provides the right level of abilities to participate in research initiatives and to interpret research outcomes, (iv) enables graduates to obtain leadership characteristics., Approach The unique characteristics of the course were evaluated through an outcomes result-oriented measurement. Leadership aspects were measured through policies and strategies presented by students and graduates., Outcomes i) course is in line with the Bologna declaration, ii) research work shown in the dissertation satisfied competencies required iii) research abilities have been examined through a third party and found to be compliant with acquiring of concepts in the design, carrying out, assessment of outcomes and interpretation of results of the research study carried out by each student, and iv) leadership characteristics were shown by the positions taken up by the graduates and early outcomes from these positions., Conclusion Learning activities enable development of professionals able to merge scientific and practice aspects in the evaluation of innovative therapies, the use of medicines and patient monitoring, and in pharmaceutical policy development and regulation. Leadership positions taken up by graduates point to the acquisition of leadership skills by graduates., Next Steps The authors are happy to extend collaboration for this model to be adapted by other institutions for the curricular development entailed in this programme to enhance and improve an innovative aspect in the evolvement of the pharmacy profession on the international scenario., peer-reviewed

Objectives To investigate the perception of Maltese pharmacists to prescribe a selected number of antibiotics. Methods A self-administered questionnaire entitled ‘Antibiotic Prescribing by Pharmacists’ was developed to study pharmacist perception to prescribing a selected number of antibacterial agents. The questionnaire was validated by a two-round Delphi technique and disseminated to all practising pharmacists (N = 930) during a 3-month period. Key findings Two hundred and nine pharmacists answered the questionnaire. The majority of pharmacists (77%) were in agreement with pharmacists prescribing a selected number of antibacterials. Reasons given are that pharmacist prescribing would increase recognition of the participation of pharmacists within patient care and as members of the healthcare team. Protocol-based prescribing was the preferred model for prescribing by 60% of pharmacists. Half of the respondents (50%) feel competent to prescribe, 34% have no opinion and 16% do not feel competent at all. Co-amoxiclav for an uncomplicated upper respiratory tract infection was the antibacterial that most pharmacists (51%) feel confident prescribing. When pharmacists were asked whether they feel comfortable prescribing other medications rather than antibacterials, 93% answered positively, with 83% feeling mostly comfortable prescribing lactulose solution. Conclusion Pharmacists in Malta are in agreement with prescribing selected antibiotics for minor ailments. A collaborative approach between medical practitioners and pharmacists should be evaluated as a possible national structure towards achieving better antibiotic prescribing whilst giving patient access to the use of antibacterials as necessary.

In 2008, we published the first set of guidelines for standardizing research in autophagy. Since then, this topic has received increasing attention, and many scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Thus, it is important to formulate on a regular basis updated guidelines for monitoring autophagy in different organisms. Despite numerous reviews, there continues to be confusion regarding acceptable methods to evaluate autophagy, especially in multicellular eukaryotes. Here, we present a set of guidelines for investigators to select and interpret methods to examine autophagy and related processes, and for reviewers to provide realistic and reasonable critiques of reports that are focused on these processes. These guidelines are not meant to be a dogmatic set of rules, because the appropriateness of any assay largely depends on the question being asked and the system being used. Moreover, no individual assay is perfect for every situation, calling for the use of multiple techniques to properly monitor autophagy in each experimental setting. Finally, several core components of the autophagy machinery have been implicated in distinct autophagic processes (canonical and noncanonical autophagy), implying that genetic approaches to block autophagy should rely on targeting two or more autophagy-related genes that ideally participate in distinct steps of the pathway. Along similar lines, because multiple proteins involved in autophagy also regulate other cellular pathways including apoptosis, not all of them can be used as a specific marker for bona fide autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field.

Objective: During reversed-phase high-performance liquid chromatography (HPLC) analyses, optimization of separation can be achieved by selecting appropriate chromatographic conditions. The retention time, peak shape, and peak size of chromatographic peaks are dependent on amount of organic modifier in the mobile phase and buffer pH. The aim of this study was to investigate the effects of varying pH, acetonitrile composition and flow rate of the mobile phase, and temperature of the stationary phase and wavelength in the development of a method to separate Δ9 tetrahydrocannabinol, cannabidiol, and cannabinol., Methods: Mobile phases with different buffer pHs and acetonitrile composition were used with ultraviolet (UV) detection wavelength of 220 nm and 228 nm. The AUPs and retention times were observed using different mobile phase flow rates and stationary phase temperatures., Results: The best results were obtained when using a mobile phase composition of 20% phosphate buffer pH 2.5 or pH 3 and 80% acetonitrile v/v at a flow rate of 2 mL/min at 220 nm., Conclusion: This rapid and easy-to-use HPLC method describes the effect of changing important chromatographic parameters on separation and retention time of cannabinoids and can be effectively applied for high throughput analysis., peer-reviewed

Background and importance Pharmacists, being highly accessible healthcare professionals, can handle requests by patients for pharmacist recommended medicines and refer to physicians when prescription medications or further assessment is required. This study seeks to establish whether patients are ready to trust the pharmacist with the prescribing of medicines and whether patients associate pharmacist prescribing with risks. Aim and objectives To assess public perception regarding the risks of potential antibiotic prescribing by pharmacists. Material and methods A pre-validated questionnaire was used.1 The questionnaire was disseminated to the general public in shopping malls and popular shopping streets over a 4 week period in Malta. Statistical analysis was undertaken using Statistical Package for the Social Sciences (SPSS) V.25. Results A total of 400 participants completed the questionnaire (51% women, 33% aged >60 years). Forty-four per cent of participants stated they always visited the same pharmacy. Older participants (≥60 years) tended to visit the same pharmacy more often than the younger age group (p Conclusion and relevance The expectations of patients to be prescribed antibiotics as soon as they feel symptoms of an infection need to be addressed through proper education. There is a perception of risk with the prescribing of antibiotics by pharmacists. References and/or acknowledgements 1. Attard Pizzuto M, Sivridas M, Serracino-Inglott A, Azzopardi LM, Bouvy ML. Public perception of antibiotic prescribing by pharmacists. Poster presented at FIP, Seoul, South Korea, 2017. No conflict of interest.

Background and objective: The CYP2C19*2 allele is associated with reduced clopidogrel bioactivation, increasing the risk of complications after percutaneous coronary intervention (PCI), particularly stent thrombosis. Recently published data suggests that CYP2C19*2 allele carriers have a higher risk for in-stent restenosis (ISR) after endovascular treatment. Very few studies have investigated the relationship between CYP2C19*2 and coronary ISR, with no significant association reported. The objective of this study was to assess the relationship between CYP2C19*2 allele carrier status and coronary ISR. Methods: Patients with previous PCI with stenting and who were scheduled for elective PCI after coronary angiogram were recruited from the cardiac catheterization suite over a 12-month period. The angiography report of each patient was perused to identify patients requiring PCI due to ISR. For patients with angiography-confirmed ISR, date of previous PCI to the restenosed stent was noted. CYP2C19*2 genotyping was undertaken using a TaqMan® Drug Metabolism assay. The association between CYP2C19*2 allele carrier status and incidence of coronary ISR within 1 year was assessed using Fisher’s exact test (p < 0.05 significance) and by calculating the odds ratio (OR) with a 95% confidence interval (CI). Results: Of the 82 patients with previous PCI, 29 (35.4%) had angiography-confirmed ISR (12 carriers, 17 noncarriers of CYP2C19*2). In 13 (44.8%) of these patients, the restenosed stent was deployed within 1 year and the patients were on clopidogrel therapy at the time of repeat PCI (8 carriers, 5 non-carriers of CYP2C19*2). The association between CYP2C19*2 allele carrier status and ISR within 1 year was not statistically significant (Fisher’s exact p = 0.067; OR: 4.80, 95% CI: 0.98–23.54, p = 0.053). Conclusions: Despite a higher proportion of CYP2C19*2 allele carriers exhibiting ISR within 1 year compared to non-carriers, the association was not statistically significant. This result may be attributed to the small sample size, and larger prospective studies are recommended to further assess this association., peer-reviewed

The marked progress and increase in the number of medications available for the treatment of conditions and diseases left a footprint on the surrounding environment. The consumption of medications for human and veterinarian use impact the terrestrial and marine environment and affects the ecosystem. The increase in environmental awareness regarding pharmaceutical related activities led to the development of principles and measures to mitigate a negative environmental impact. Various measures were introduced to promote green manufacturing and practices which led to the development of alternative techniques and processes, which are of benefit to both the environment and the industry. Distributors and pharmacists can contribute through the efficient management of everyday operations which include better stock taking and rotation, grouping deliveries and reducing unused medications. The incorporation of green practices in the pharmacy curriculum empowers future pharmacists with skills and competences required at the place of work to decrease the impact of processes and medicines on the environment. The presence of a pharmacist workforce which is more conscientious about the environment leads to the needed ripple effect to embrace and implement green principles in different pharmacy related settings. Patients should also be educated to avoid hoarding of medications and dispose of medication in a safe and appropriate manner. The implementation of green practices results in a decrease in the use of chemicals and production of waste which in turn leads to a decrease in pollutants which have an impact on climate change.

Background Optimisation of drug therapy is essential in the care of older persons and may be facilitated by application of medication assessment tools (MATs). Objective To design, psychometrically evaluate and apply an innovative MAT for secondary prevention of ischaemic stroke with particular relevance to older persons. Method Review criteria were selected from clinical practice guidelines and MAT-CVA was developed, validated and tested for reliability and feasibility. MAT-CVA was applied to 150 patients with a diagnosis of ischaemic stroke or transient ischaemic attack admitted to a rehabilitation hospital. Results MAT-CVA consists of 17 criteria sectioned into antithrombotic, lipid lowering, antihypertensive and glycaemic therapy. Content validity was demonstrated for all criteria. Reliability was confirmed with kappa values of 0.80 for both inter- and intraobserver agreements. Mean application time for the two observers was 5.55 and 6.56 min. Adherence to applicable criteria was 55% and justified non-adherence was 22.3%. Non-adherence was predominantly evident for prescription of anticoagulation in concurrent atrial fibrillation (36.4%), thiazide diuretics ± angiotensin converting enzyme inhibitors for hypertension (26.8%) and dipyridamole at the recommended dose (24.0%). Conclusion Application of MAT-CVA indicated good overall adherence and identified gaps in clinical performance which may be targeted to enhance drug therapy optimisation.

As it spread to pandemic levels, COVID-19 viral infection presented a number of challenges for education, health systems and the wellbeing of society. Evidence-based information on COVID-19 was essential for designing the response to the pandemic. A series of weekly webinars were developed and presented over a 15- week period. An inter-professional panel of experts contributed to the discussions during the webinars. The webinars were planned through a multidimensional approach involving students and practitioners from different healthcare professions encompassing a range of scientific aspects from basic sciences to socio-economic aspects. The evaluations showed the value of the webinars as an e-learning method for inter-professional communication in the discussion and analysis of the scientific evidence and sharing of experiences and data.

Background Non-adherence to treatment and diet, and failure to seek care are contributors to readmissions in heart failure (HF) patients. Specific questions related to treatment adherence and living with HF improve prioritisation of patients for pre-discharge medication management and self-care education. Purpose The objective was to undertake an adherence to treatment assessment and correlate with an assessment of the potential of patients to engage in self-management. This was defined as the percentage grade of correct answers to four questions that demonstrate knowledge of living with HF. Material and methods The study was conducted between 20 June–31 August 2018 in an acute hospital. Patients who qualified for the study through pre-set inclusion and exclusion criteria were administered the Treatment Adherence Questionnaire (TAQ).1 Four supplementary questions were asked to measure the knowledge of patients concerning their diuretic treatment, the use of salt in food preparation, weight monitoring and alarm symptoms warranting referral. Results The cohort of patients (n=57) had an average TAQ score of 70 (range: 31–95) on a scale of 0–100 indicating a medium-high adherence. The mean cohort grade to the four questions was 43% (range: 0%–75%). Twenty-five patients gave an unsatisfactory answer to at least three of the questions; thirty patients were unable to name their diuretic; 51 patients were categorical about not taking salt and all knew that salt should be avoided; six patients added salt deliberately while cooking; 55 patients failed to relate the need of weight monitoring to check fluid overload and only associated weight with body fat; 34 patients were unable to mention at least one basic symptom apart from shortness of breath; and 15 patients exhibited a mismatch between the TAQ score and the percentage grade to the knowledge questions (medium-high TAQ score versus low grade 0%–25% to questions). Conclusion The patients demonstrated the need for support in improving self-management related to lifestyle and medication knowledge. The lack of engagement in self-management did not reflect a low adherence to treatment. References and/or acknowledgements 1. Anastasi A, Grech L, Serracino Inglott A, Azzopardi LM. CP-185: an innovative treatment adherence tool EJHP 2017;24: No conflict of interest.

Background Pharmacist-led interventions decrease drug-related problems (DRPs) and improve clinical outcomes. Patients with multiple-drug therapy and patients transitioning across different care settings are at higher risk of experiencing DRPs. Purpose This study aims at developing an ambulatory clinical pharmacist service at the Diabetic Hospital Out-Patient clinic focusing on medicine reconciliation and transmission of treatment updates to the community pharmacist responsible for patient follow-up. Material and methods This is an ongoing prospective investigational study. Patients>18 years of age and having at least one anti-diabetic medication are eligible to participate in the study. The clinical pharmacist meets the patients and during a medicine reconciliation session identifies any DRPs that are discussed with the physician. A Transition of Care Document capturing any changes in medication and the current patient treatment is compiled and sent to the community pharmacy, identified by the patient, which is responsible for chronic medications follow-up. Results Thirty-five patients have been included in the study to date. Fifty-six DRPs were identified and classified into five different categories. Lack or misinterpretation of information was the most common DRP (83%) followed by treatment not according to Joint British Diabetes Societies guidelines (63%), requirement of additional drug (52%) and inappropriate timing of administration and/or dosing intervals (37%). Metformin (77%) and the statins (49%) were the two most common drugs requiring interventions. The hospital pharmacist provided recommendations for the identified DRPs, either verbally, in the case of educational interventions or written in all other instances. Seven out of eight interventions were accepted by the physicians. Conclusion The DRPs identified were addressed during the intervention by the hospital pharmacist at the Out-Patients’ Clinic and the Transition of Care Document was used to transmit information on updates in treatment to the community pharmacy that follows-up the patient for chronic medication refills. References and/or acknowledgements Pharmacy Department at the University of Malta and the Diabetic Outpatient Clinic at Mater Dei Hospital. No conflict of interest.

Background A safety alert by the European Medicines Agency notified that some valsartan products were contaminated with the genotoxic impurity, N-nitrosodimethylamine (NDMA). This triggered a voluntary recall of potentially impacted valsartan medicines. Purpose To investigate the competence of the pharmacist in assessing and addressing the risk-benefit associated with the safety concern of NDMA in valsartan medicines. Material and methods A symposium was organised to evaluate the competence of the pharmacists in the application of scientific knowledge to the therapeutic challenges in the valsartan saga. A 32-slide presentation and nine questions were prepared and presented to the pharmacists (n=26, 16 females, 10 males; age 22 to 45; 10 hospital, 12 community, four industrial pharmacists) The responses given in the interactive discussion were recorded interactively by the Mentimeter and the results were related to the competence through an arbitrary evaluation. Results Eighteen pharmacists (68%) stated that NDMA is a probable human carcinogen found to cause cancer in animals. Twenty-two (84%) stated that not all sartans contain a tetrazole ring and 20 (77%) responded that the formation of NDMA occured during the synthesis of valsartan. Twenty (77%) stated that NDMA is unlikely to bioaccumulate and seven (27%) stated that the half-life of valsartan is 6 hours. Six pharmacists (24%) correctly stated that 1.5 mcg/day was the tolerated limit for daily exposure to NDMA and 24 (88%) stated that drinking water, ham, bacon and cigarettes were contaminated with NDMA. Twenty (77%) pharmacists advised that valsartan should not be stopped abruptly until alternative treatment was available and 24 (92%) stated that they would recommend switching patients to another sartan as early as possible. Conclusion The findings show that pharmacists have the necessary competence to deal with the valsartan saga. However, the symposium shows that pharmacists can benefit from an added value to their scientific knowledge such as in the pharmacokinetics and the clinical relevance of angiotensin-receptor antagonists and the threshold for toxicological concern of NDMA impurites. References and/or acknowledgements Pottegard A, Kristensen KB, Ernst MT, et al. Use of N-nitrosodimethylamine (NDMA) contaminated valsartan products and the risk of cancer: Danish nationwide cohort study. BMJ 2018;362:k3851. No conflict of interest.

Introduction and Aims: The prevalence of CYP2C19 genetic polymorphisms in the Maltese population is not reported. The aims were to determine CYP2C19 *2 and *17 allele frequencies and CYP2C19 genotype distribution in a cohort of Maltese patients on clopidogrel and to compare observed frequencies of the CYP2C19 *2 allele and *2/*2 genotype to other populations bordering the Mediterranean Sea. Methods: Genotyping for the CYP2C19 *2 and *17 alleles in Maltese patients on clopidogrel was performed using TaqMan® drug metabolism assays. The frequency of both alleles and six genotypes (*1/*1, *1/*2, *2/*2, *1/*17, *17/*17, *2/*17) were determined. Observed frequencies of the CYP2C19 *2 allele and *2/*2 genotype were compared to fourteen populations bordering the Mediterranean Sea (p>0.05 indicated similar prevalence) Results: Frequencies of the CYP2C19 *2 and *17 alleles in the 244 patients genotyped were 12.3% and 15.4% respectively. CYP2C19 genotype distribution was: *1/*1 (52.1%), *1/*17 (22.5%), *1/*2 (18.0%), 2/*17 (6.6%), *17/*17 (0.8%) and *2/*2 (0). Prevalence of the *2 allele in the Maltese cohort was similar to all fourteen populations bordering the Mediterranean Sea, while prevalence of *2/*2 was similar to Egyptian, Moroccan, Southern French, Slovenian, Turkish and Tunisian populations (p>0.05). Conclusions: This study provides an indication of the prevalence of CYP2C19 polymorphisms in Maltese patients. The high percentage of patients with CYP2C19 IM or UM phenotype demonstrates that CYP2C19 genotyping could aid clinicians to individualise treatment with clopidogrel and other drugs metabolised by the CYP2C19 enzyme., peer-reviewed

Objectives: To evaluate the educational experience and teaching methods of the collaborative Doctorate of Pharmacy (PharmD) program between the University of Malta (UM) and the University of Illinois at Chicago (UIC). Methods: A 41-question survey was developed to identify student demographics, satisfaction with the PharmD program and the utility of the current curricular components. Students who enrolled in the program in May 2017 were invited to participate. The survey contained open-ended, 5-point Likert, and multiple-choice type questions. The primary outcomes were the overall satisfaction and student motivations for pursuing the program. Secondary outcomes included the level of difficulty of courses, evaluation of assessment methods, and confidence in an interdisciplinary team. Results: Thirty-six students completed the survey (a response rate of 83.7%). The mean age was 30.1 &plusmn, 7.9 years. The majority of the students pursued the PharmD program to improve their knowledge, skills, and opportunity for obtaining a clinical position. The mean overall satisfaction of the program was 3.81 &plusmn, 1.1 (5 = very satisfied). Among the core courses, Pharmacotherapeutics had the highest overall satisfaction (4.45 &plusmn, 0.91) and level of difficulty (3.84 &plusmn, 0.51). Students felt that the tutorials/recitation case discussion sessions were the most effective teaching method (48.4%) and ranked faculties conducting case-based lectures highest for overall performance. Most students felt somewhat confident (54.8%) for participating in a multidisciplinary team. Conclusions: The UM/UIC PharmD Program is a unique program, utilizing a hybrid model of teaching, including distance education, to expose students to a broad and challenging curriculum in clinical pharmacy practice. Students are satisfied with this collaborative, international postgraduate PharmD program.

Background Antibiotics have been a breakthrough in medicine; however, their use is also associated with risks, one of which is the emergence of antimicrobial resistance. The misuse of antibiotics is affecting not just the individual patient but the community at large. Objectives The aims were to investigate antibiotic practices among local medical practitioners and to assess their perception of potential antibiotic prescribing by pharmacists. Methods A questionnaire entitled ‘Antibiotic Prescribing Practices Questionnaire’ was developed to study medical practitioners’ perception and practices on antibiotic prescribing and to establish pharmacists’ contribution in prescribing and dispensing antibiotics. The questionnaire was disseminated to medical practitioners practising in Malta. Key findings 180 medical practitioners answered the questionnaire. Activity of antibiotic against the most likely pathogen present is the most important drug-related factor when prescribing antibiotics according to 88% of respondents. Diagnosis is the most important factor which influences the choice of antibiotic in 91% of respondents. Pharmacists are regarded as being competent to treat common infections by 36% of medical practitioners. Conclusions Medical practitioners state that a clinical examination influences their prescribing of antibiotics. They assign the concept of lack of clinical examination competence by pharmacists to be one of the determining factors in their lack of support for pharmacist prescribing. A collaborative practice between medical practitioners and pharmacists should be evaluated before embarking on proposing national structures for pharmacist prescribing.

Background: Fungal infection is a common cause of mortality and morbidity in lung transplant recipients (LuTR). Treatment failure to first-line antifungals because of resistance or intolerance is an increasing problem. Posaconazole (PCZ), a triazole antifungal, is an attractive treatment option. Methods: We performed a single-center retrospective study to describe the use, tolerability, efficacy, and drug interaction effect (with tacrolimus) of PCZ oral suspension in LuTR. Results: Seventy-eight patients were treated with PCZ oral suspension for prophylaxis (n = 15), pre-emptive treatment (n = 31), and treatment of possible (n = 7) and probable (n = 25) invasive fungal infection. A range of fungal isolates was encountered. Resolution was observed in 52.4% (probable, possible, and pre-emptive treatment groups). Aggregate all-cause 1-year mortality was 12.8%. PCZ was well tolerated with 11.5% of patients experiencing adverse effects. Despite dose adjustment strategies, 11.7% of patients experienced supratherapeutic tacrolimus levels, which in 5 cases was associated with a rise (mean 21.6 μmol/L) in serum creatinine. Conclusions: PCZ is well tolerated and appears effective in the management of fungal infection after lung transplantation. Patients receiving concurrent tacrolimus require careful therapeutic drug monitoring.

The aims of this study were to evaluate factors influencing the distribution of ciprofloxacin in tissue of patients suffering from varying degrees of peripheral arterial disease (PAD). Blood and tissue samples were collected from patients undergoing debridement or amputation procedures and the amount of ciprofloxacin in them was determined using high-performance liquid chromatography. All patients were administered a 200-mg dose of intravenous ciprofloxacin prior to the debridement or amputation procedure. Data, including patient gender, age, type of diabetes, presence of neuropathy, medications taken, and severity of PAD were collected. These data were then analyzed to determine factors influencing the concentrations of ciprofloxacin in tissue of the lower limbs. The Kruskal-Wallis test, Spearman correlation, and chi-square test were used to relate covariates and fixed factors with the concentration of ciprofloxacin in tissue. Following bivariate analysis, a 3-predictor regression model was fitted to predict tissue concentrations of ciprofloxacin given information about these predictors. Blood and tissue samples were collected from 50 patients having an average age of 68 years. Thirty-three patients were males and 35 patients suffered from type 2 diabetes. The average number of medications that these patients were taking was 10. The majority of patients (n = 35) were suffering from severe PAD. Tissue concentrations of ciprofloxacin were mainly related to plasma concentrations of ciprofloxacin, number of medications that the patients were taking and severity of PAD.

Objectives The implementation of individualised pharmaceutical care plans based on the identification of pharmaceutical care issues for rheumatoid arthritis patients presenting at outpatient clinic service has been proven to be effective in improving the quality of life of these patients. However, the identification and classification of pharmaceutical care issues into drug therapy problems does not give room to assessment of prescribing trends and adherence to international guidelines. The novel concept of medication assessment tools, is a concept which integrates pharmaceutical care issues within a larger context, that of evaluating the prescribing trends. The objective of this research was to design, and validate medication assessment tools specifically for rheumatoid arthritis patients. Methods A thorough literature review was carried out to identify the latest evidence-based guidelines on rheumatoid arthritis pharmacotherapy. The rheumatoid arthritis medication assessment tool (RhMAT) was compiled and validated. Key findings The RhMAT consists of 11 general sections with a total of 54 criteria. For every criteria given, the researcher has an option of four responses ranging from criterion not applicable (N/A), criterion adherence (yes), criterion non-adherence (no) and insufficient data to comment on the criterion. In cases where the criterion is not adhered to this can be justified adherence or unjustified and insufficient data for the researcher to be able to tick appropriately. The expert panel agreed with the final version of the RhMAT. Conclusion The innovative RhMAT was designed to act as a tool used by pharmacists to be able to detect gaps within patients' pharmacotherapy against evidence-based guidelines thereby improving the quality of service offered to patients.

This study sought to determine if diffuse ventricular fibrosis improves in patients with atrial fibrillation (AF)-mediated cardiomyopathy following the restoration of sinus rhythm.AF coexists in 30% of heart failure (HF) patients and may be an underrecognized reversible cause of left ventricular systolic dysfunction. Myocardial fibrosis is the hallmark of adverse cardiac remodeling in HF, yet its reversibility is unclear.Patients with persistent AF and an idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45%) were randomized to catheter ablation (CA) or ongoing medical rate control as a pre-specified substudy of the CAMERA-MRI (Catheter Ablation versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction-an MRI-Guided Multi-centre Randomised Controlled Trial) trial. All patients had cardiac magnetic resonance imaging scans (including myocardial T1 time), serum B-type natriuretic peptide, 6-min walk tests, and Short Form-36 questionnaires performed at baseline and 6 months. Sixteen patients with no history of AF or left ventricular systolic dysfunction were enrolled as normal controls for T1 time.Thirty-six patients (18 in each treatment arm) were included in this substudy. Demographics, comorbidities, and myocardial T1 times were well matched at baseline. At 6 months, patients in the CA group had a significant reduction in myocardial T1 time from baseline compared with the medical rate control group (-124 ms; 95% confidence interval [CI]: -23 to -225 ms; p = 0.0176), although it remained higher than that of normal controls at 6 months (p = 0.0017). Improvements in myocardial T1 time with CA were associated with significant improvements in absolute LVEF (+12.5%; 95% CI: 5.9% to 19.0%; p = 0.0004), left ventricular end-systolic volume (p = 0.0019), and serum B-type natriuretic peptide (-216 ng/l; 95% CI: -23 to -225 ng/l; p = 0.0125).The improvement in LVEF and reverse ventricular remodeling following successful CA of AF-mediated cardiomyopathy is accompanied by a regression of diffuse fibrosis. This suggests timely treatment of arrhythmia-mediated cardiomyopathy may minimize irreversible ventricular remodeling.

Background Medicine use review by pharmacists has the potential to improve anticoagulation therapy management in patients on warfarin. Objective To develop, implement and evaluate a pharmacist-led medication use review service for patients on warfarin. Setting Six community pharmacies in Malta. Method Patients (N = 100) aged 18 or older and on warfarin were recruited through pre-selected community-pharmacies. These patients were then invited to attend two sessions: a review session (t1) and a follow-up session after 2 months (t2). During the medication use review session, medication reconciliation was performed (a) to detect drug-related problems using the DOCUMENT classification system, (b) to develop an individualised care plan for each patient and (c) to recommend an action for each identified problem for physician, pharmacist or patient consideration. At t2, the degree of acceptance of the recommendations was determined by assessing the number of drug-related problems for which action was taken to address the problem. International normalisation ration (INR) control was evaluated by calculating the percentage Time in Therapeutic Range (TTR) at t1 and t2 using the Rosendaal linear interpolation method. Main outcome measures Frequency and type of drug-related problems detected; percentage of accepted recommendations; and INR control. Results A total of 481 drug-related problems were identified; 40% (n = 190) were related to warfarin treatment. Need for monitoring (30%; n = 145), lack of compliance (20%; n = 97) and need for patient education (19%; n = 90) were the top three problems identified. There was a significant correlation between frequency of the problems and number of chronic medications (Spearman Correlation 0.583, p

This work has been funded through the Malta Council for Science and Technology through the R&I- 2012-061 Project (SMESH).

α-cristobalite is a metastable polymorph of silica which has the remarkable property of exhibiting a negative Poisson's ratio (auxetic). In this study, the mechanical properties and deformation mechanisms of this system were investigated through a force-field based approach. Besides simulations on the actual structure of α-cristobalite, a number of simulations where the rigidity of SiO2 tetrahedra was increased, were also conducted. This was done in order to obtain a clearer picture of the role which these tetrahedra play in determining the mechanical properties of this system. These systems were loaded in an off-axis direction in a number of planes about the [001] direction and the deformations observed were compared with those of type II rotating rectangle systems. It was discovered that the mechanical properties of α-cristobalite can be accurately described through the semi-rigid version of this model, even for cases where the tetrahedra were fully rigid.