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Appropriate prescribing remains an important priority in all medical areas of practice. Objective: The objective of this study was to apply a Medication Appropriateness Index (MAI) to identify issues of inappropriate prescribing amongst patients admitted from the Emergency Department (ED).Method: This study was carried out at Malta’s general hospital on 125 patients following a two-week pilot period on 10 patients. Patients aged 18 years and over and on medication therapy were included. Medication treatment for inappropriateness was assessed by using the MAI. Under-prescribing was also screened for. Results: Treatment charts of 125 patients, including 697 medications, were assessed using a MAI. Overall, 115 (92%) patients had one or more medications with one or more MAI criteria rated as inappropriate, giving a total of 384 (55.1%) medications prescribed inappropriately. The mean SD MAI score per drug was 1.78 (SD=2.19). The most common medication classes with appropriateness problems were supplements (20.1%), antibiotics (20.0%) and steroids (19.8%). The most common problems involved incorrect directions (26%) and incorrect dosages (18.5%). There were 36 omitted medications with untreated indications. Conclusion: There is considerable inappropriate prescribing which could have significant negative effects regarding patient care.

ERRATUM TO: West LM, Cordina M, Cunningham S. Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta. Pharmacy Practice 2012; 10(4):181-187. doi: 10.4321/s1886-36552012000400001

Background: Investigating beliefs about medicines has been of interest over the past years, with studies aiming to better understand theoretical reasons behind development of such beliefs. Objective: This study aimed to produce a culturally and contextually appropriate version of the Beliefs about Medicines Questionnaire (BMQ) in the Maltese language and to assess its psychometric properties. Methods: Medication beliefs were evaluated using the BMQ which is divided into two sections: BMQ-General (sub-scales: Overuse and Harm, 4 items per sub-scale) and BMQ-Specific (sub-scales: Necessity and Concerns, 5 items per sub-scale). Following translation/back translation, the Maltese version of the BMQ was applied to patients having asthma, diabetes, cardiovascular disease or depression who attended out-patients’ clinics at the main state general hospital in Malta between June and September 2013. Cronbach’s alpha coefficient, alpha, was used to determine internal consistency of the BMQ and Principal Component Analysis using Varimax rotation with Kaiser normalisation was carried out to analyse component loading of the items on the respective sub-scales. Results: The Maltese version of the BMQ showed acceptable internal consistency for the harm scale (alpha=0.56), the necessity scale (alpha=0.73) and the concerns scale (alpha=0.66), however the overuse scale gave poor internal consistency (alpha=0.48) due to the item on natural remedies which posed some difficulty in the Maltese sample. The final solution for Principal Component Analysis yielded a four-factor structure representing the 4 sub-scales of the BMQ, with results being comparable to previous studies out in different languages. Conclusion: The Maltese version of the BMQ was found to have acceptable psychometric properties for the beliefs about medicines in the Maltese population.

We report an extensive intra-operative bleed which may have occurred as a result of the patient taking a herbal medicine. The patient underwent orthognathic surgery as a part of his orthodontic treatment, and lost approximately 3.5 litres of blood during the procedure. Preoperative blood tests were normal; the patient took no prescription medications and an appendectomy had been performed without incident. To aid healing, however, the patient had taken arnica the day before his operation. A concise literature review is presented which outlines the causes of surgical bleeding and discusses some of the bleeding concerns that herbal medicine use may raise for clinicians. Herbal medicines may contribute to unexplained surgical bleeding in the absence of other causative factors; it would therefore be useful to include an enquiry about the taking of herbal remedies at the history-taking stage for dental and maxillofacial surgical procedures. [ABSTRACT FROM AUTHOR]

Distraction osteogenesis is a relatively new technique in the field of oral and maxillo-facial surgery. It is being increasingly employed to help rehabilitate various craniofacial abnormalities. This case report describes its use in a 20-year-old male who was born with a bilateral cleft of the lip and palate. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim of this study was to investigate the use of field emission scanning electron microscopy and electron dispersive spectrography (SEM-EDS) to identify silver solder 'tattoo.' STUDY DESIGN: SEM-EDS was used to analyze material present in the connective tissue of a patient who presented with bilateral pigmentation of the mandibular lingual gingiva adjacent to the first molars. No dental restorations were present. RESULTS: SEM-EDS analysis identified silver, with no evidence of tin, copper, or mercury. The patient was wearing an orthodontic appliance where brackets had been soldered to the archwire with silver solder. It is hypothesed that the solder underwent electrolytic corrosion with subsequent regrouping of silver ions in the submucosa leading to blue-gray discoloration. CONCLUSION: Spectrography proved to be a powerful diagnostic tool in identifying the metal within the oral mucosa. Attention is drawn to this newly described lesion, which should be included as a differential diagnosis for pigmented oral mucosal lesions. [ABSTRACT FROM AUTHOR]

Background: Antipsychotics carry a higher-risk profile than other psychotropic medications and may be prescribed for youth with conditions in which other first-line treatments are more appropriate. This study aimed to evaluate the population-level effect of the Safer Use of Antipsychotics in Youth (SUAY) trial, which aimed to reduce person-days of antipsychotic use among participants. Methods: We conducted an interrupted time series analysis using segmented regression to measure changes in prescribing trends of antipsychotic initiation rates pre-SUAY and post-SUAY trial at four U.S. health systems between 2013 and 2020. Results: In our overall model, adjusted for age and insurance type, antipsychotic initiation rates decreased by 0.73 (95% confidence interval [CI]: 0.30, 1.16, p = 0.002) prescriptions per 10,000 person-months before the SUAY trial. In the first quarter following the start of the trial, there was an immediate decrease in the rate of antipsychotic initiations of 6.57 (95% CI: 0.99, 12.15) prescriptions per 10,000 person-months. When comparing the posttrial period to the pretrial period, there was an increase of 1.09 (95% CI: 0.32, 1.85) prescriptions per 10,000 person-months, but the increasing rate in the posttrial period alone was not statistically significant (0.36 prescriptions per 10,000 person-months, 95% CI: -0.27, 0.99). Conclusion: The declining trend of antipsychotic initiation seen between 2013 and 2018 (pre-SUAY trial) may have naturally reached a level at which prescribing was clinically warranted and appropriate, resulting in a floor effect. The COVID-19 pandemic, which began in the final three quarters of the posttrial period, may also be related to increased antipsychotic medication initiation.

Introduction: Digital exposure notifications are a novel public health intervention used during the COVID-19 pandemic to alert users of possible COVID-19 exposure. We seek to quantify the effectiveness of Washington State's digital exposure notification system, WA Notify, as measured by the number of COVID-19 cases averted during a 1-year period., Methods: While maintaining individuals' privacy, WA Notify collected data that could be used to evaluate the system's effectiveness. This article uses these and other data and builds on a previous model to estimate the number of cases averted by WA Notify. Novel estimates of some model parameters are possible because of improvements in the quality and breadth of data reported by WA Notify., Results: We estimate that WA Notify averted 64,000 (sensitivity analysis: 35,000-92,000) COVID-19 cases in Washington State during the study period from 1 March 2021 to 28 February 2022. During this period, there were an estimated 1,089,000 exposure notifications generated and 155,000 cases reported to WA Notify. During the last 78 days of the study period, the median estimated number of daily active users was 1,740,000., Discussion: We believe WA Notify reduced the impact of the COVID-19 pandemic in Washington State and that similar systems could reduce the impact of future communicable disease outbreaks., Competing Interests: LM and NP were employed by the Mountain Whisper Light. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Elder, Arrouzet, Miljacic, Karras, Higgins, West, Lorigan, Revere, Polissar, Segal, Lober and Baseman.)

Background: WA Notify was Washington State's smartphone-based COVID-19 digital exposure notification (EN) tool, which was used to help limit the spread of COVID-19 between November 30, 2020, and May 11, 2023. Following the 2022 Washington State Public Health Association Annual Conference, attendees who had WA Notify activated began receiving ENs alerting them to a possible COVID-19 exposure during the conference. A survey was emailed to all conference attendees to measure WA Notify adoption, mechanisms through which attendees received ENs, and self-reported engagement in protective behaviors postexposure., Objective: This study aimed to learn more about the experiences of WA Notify adopters and nonadopters who may have been exposed to COVID-19 at a large group gathering., Methods: A web-based survey administered through REDCap (Research Electronic Data Capture; Vanderbilt University) was sent to all attendees of the Washington State Public Health Association conference. Self-reported demographic information and characteristics of respondents were summarized. Regression models were used to estimate relative risks to compare WA Notify adoption and testing behaviors between groups., Results: Of the 464 total registered attendees who were sent the survey, 205 (44%) responses were received; 201 eligible attendees were included in this analysis. Of those, 149 (74%) respondents reported having WA Notify activated on their phones at the time of the conference. Among respondents with WA Notify activated, 54% (n=77) reported learning of their potential exposure from a WA Notify EN. Respondents who reported that they did not have WA Notify activated and learned of their potential exposure via the event-wide email from conference organizers were 39% less likely to test for COVID-19 compared to respondents with WA Notify activated who learned of their potential exposure from the email (relative risk 0.61, 95% CI 0.40-0.93; P=.02), and this gap was even larger when compared to respondents who learned of their exposure from a WA Notify EN. The most commonly cited reason for not having WA Notify activated was privacy concerns (n=17, 35%), followed by not wanting to receive ENs (n=6, 12%) and being unaware of WA Notify (n=5, 10%)., Conclusions: Digital EN systems are an important tool to directly and anonymously notify close contacts of potential exposures and provide guidance on the next steps in a timely manner. Given the privacy concerns, there is still a need for increasing transparency surrounding EN technology to increase uptake by the public if this technology were to be used in the future to slow the spread of communicable diseases., (©Caitlin M Drover, Adam S Elder, Brandon L Guthrie, Debra Revere, Nicole L Briggs, Laura M West, Amanda Higgins, William B Lober, Bryant T Karras, Janet G Baseman. Originally published in JMIR Formative Research (https://formative.jmir.org), 18.03.2024.)

Objective: Health professionals must communicate prenatal screening test results effectively to patients, but these tests involve very low prevalence and high false positive risks; a situation known to be difficult for people to understand., Methods: The present experiments evaluated the effectiveness of presenting prenatal screening test results for Trisomy 21, Trisomy 13, or DiGeorge Syndrome, using either naturally sampled frequencies or standard percentages. Participants were given a task of interpreting the posterior probability of an embryo having the condition., Results: People were significantly better with naturally sampled frequencies. Numerical literacy and visuospatial ability significantly accounted for individual differences in performance within conditions. Participants nevertheless did not differ in ratings of how useful the different presentation formats were, suggesting a lack of awareness of how format influenced understanding. These results held regardless of whether the respondents were undergraduates (Experiment 1) or members of the general population recruited online (Experiment 2)., Conclusion: Using naturally sampled frequencies improves patient understanding of prenatal screening tests results, with low cost of implementation., Innovation: Using realistic prenatal screening test results, these results show how to improve patient counseling via the use of naturally sampled frequencies., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Objective: The objective of this study was to obtain information about teachers' knowledge, attitudes, practices and beliefs about medication related to working with children having asthma in state primary schools in Malta. This study provides information about management in a country with a high prevalence of asthma among children, and limited availability of school nurses., Methods: A cross-sectional electronic survey investigating beliefs about medicines, asthma knowledge, attitude toward students with asthma, self-efficacy and practice in an asthma exacerbation, current practices, views, experiences and training relating to asthma was sent to all participating state primary schools in Malta., Results: A total of 167 teachers from 26 schools answered the questionnaire. The majority of respondents (56%) were unaware of children's conditions and limited information about children's asthma was provided to them. Only 20% of teachers reported receiving training on how to support children with asthma. Overall, teachers reported low asthma knowledge scores (mean score of 5.5 ± 3.3 out of a possible maximum of 14), and poor self-efficacy with only 6% agreeing that they can support a student having an asthma exacerbation on their own rather than sending the student to hospital. The study also demonstrated a strong interest by teachers to receive asthma education., Conclusions: Interventions with regard to identifying students with asthma, asthma training for teachers, individualized asthma action plans, enhanced communication between school staff, parents and the medical team, and standard guidelines/policy are needed to provide a supportive school environment for primary school children with asthma.

Macrocyclic furanobutenolide-derived cembranoids (FBCs) are the biosynthetic precursors to a wide variety of highly congested and oxygenated polycyclic (nor)diterpenes (e.g. plumarellide, verrillin, and bielschowskysin). These architecturally complex metabolites are thought to originate from site-selective oxidation of the macrocycle backbone and a series of intricate transannular reactions. Yet the development of a common biomimetic route has been hampered by a lack of synthetic methods for the pivotal furan dearomatization in a regio- and stereoselective manner. To address these shortcomings, a concise strategy of epoxidation followed by a kinetically controlled furan dearomatization is reported. The surprising switch of facial α:β-discrimination observed in the epoxidation of the most strained E -acerosolide versus E -deoxypukalide and E -bipinnatin J derived macrocycles has been rationalized by the variation of the 3D conformational landscape between macrocyclic scaffolds. A careful conformational analysis of these macrocycles by VT-NMR and NOESY experiments at low temperature was supported by DFT calculations to characterize these equilibrating macrocyclic conformers. The shift in conformational topology associated with a swing of the butenolide ring in E -deoxypukalide is in general agreement with the reversal of β-selectivity observed in the epoxidation. We also describe the downstream functionalization of FBC-macrocycles and how the C-7 epoxide configuration is retentively translated to the C-3 stereogenicity in dearomatized products under kinetic control to secure the requisite 3 S ,7 S ,8 S configurations for the bielschowskysin synthesis. Unlike previously speculated, our results suggest that the most strained FBC-macrocycles bearing a E -(Δ 7,8 )-alkene moiety may stand as the true biosynthetic precursors to bielschowskysin and several other polycyclic natural products of this class.

Background: The likelihood of children with asthma experiencing an exacerbation at school is significantly high when considering that they spend a substantial part of their day at school. This study, therefore, aimed to systematically review the literature to determine current asthma management practices by primary school teaching staff and any existing supporting legislation/policies/guidelines., Methods: Search terms were adapted to search literature across databases: CINAHL, Cochrane Library, Education Database-ProQuest, IPA, MEDLINE, SCI. Primary research studies, reviews, systematic reviews, and meta-analyses in English about primary school teaching staff dated between 2007 and 2017 were included. Primary outcomes comprised teaching staff' practices regarding asthma management and supporting guidelines, policies, or legislation., Results: Analysis of the 13 papers eligible for full review identified that: teachers were unable to deal with an asthma exacerbation; they lacked knowledge regarding exercise-induced asthma and that there was poor communication between schools and parents of children with asthma. The only documented relevant asthma legislation found pertained to New York schools., Conclusions: Limited evidence regarding asthma management practices and inadequate asthma management knowledge amongst teaching staff highlight the need for supporting teaching staff with asthma policies and guidelines to minimize risks associated with inappropriate asthma management., (© 2021, American School Health Association.)

Objective: The 'Necessity-Concerns Framework' is an important framework which can support healthcare professionals in targeting patients' medication beliefs and decisions on adherence. Our aim was to determine how the interdependence of 'necessity' and 'concerns' beliefs for medication adherence compares across three chronic conditions., Methods: Patients diagnosed with asthma, cardiovascular conditions or diabetes attending out-patient clinics completed a self-administered questionnaire. The questionnaire gathered information regarding demographics, medication adherence using the 'Tool for Adherence Behaviour Screening', presence of unused medication in households and medication beliefs using the 'Beliefs about Medicines Questionnaire-Specific'. Polynomial regression was applied to determine the multidimensional interdependence of 'necessity' and 'concerns' beliefs for adherence. P -values ≤ 0.05 were taken to be significant., Results: Confirmatory polynomial regression rejected the differential score model in all three groups. For each condition, exploratory polynomial regression found that linear terms indicated the best fitting model for predicting adherence. In all groups, adherence increased as necessity beliefs increased and concerns decreased. Patients suffering from cardiovascular conditions and diabetes with low necessity and low concerns beliefs reported higher medication adherence compared to those with high necessity and high concerns beliefs., Discussion: Alleviating patients' concerns can enhance medication adherence and potentially curb the issue of medication wastage.

Background: While literature quantifying medication wastage and assessing public's knowledge and practices about medication disposal is substantial, less attention is given to the public's knowledge and behavior pertaining to medication wastage prevention. This study aimed to determine the public's knowledge of medication wastage, any association between knowledge and adherence, and behavioral determinants potentially leading to wastage., Methods: A mixed-method explanatory sequential approach was adopted with a quantitative survey followed by qualitative semi-structured interviews. Maltese residents ≥18 years attending social/educational events were recruited in this mixed-methods study. Participants completed a structured questionnaire comprising: 1) demographics; 2) medication adherence using 'Tool for Adherence Behaviour Screening' dichotomized into 'good adherence'/'suboptimal adherence'; 3) eight knowledge statements each carrying one point (total, 0 = lowest; 8 = highest); 4) and whether they had unused medication at home. Chi-square analysis determined associations between demographics and adherence, and having unused medication. Multiple regression was performed to predict knowledge based on demographics, adherence, having regular medication and having unused medication, p  ≤0.05. Questionnaire respondents expressing interest in participating in semi-structured face-to-face interviews, based on the Theoretical Domains Framework (TDF), were recruited consecutively until data saturation. Interviews were audio-recorded, transcribed and analyzed using the Framework Approach., Results: Of the 524 individuals attending 14 events, 80.5% completed the questionnaire (mean age±standard deviation (SD): 65 ± 13 years). Thirty-one percent (n = 130/422) of respondents reported having unused medication and 18.8% (58/309 taking chronic medication) classified as 'optimal' adherence. Mean ± SD knowledge score was 4.7 ± 1.5. Knowledge and adherence were not significantly related. Most prevalent TDF domains influencing wastage emerging from 15 interviews were knowledge, beliefs about consequences and behavioral regulation., Conclusion: Public's knowledge about medication wastage and adherence were inadequate, necessitating implementation of tailored educational interventions based on behavioral determinants recognized within this study. Identified inadequate behavior around disposal mandates inclusion of environmental/social planning issues when developing policies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Briarellins, a subset of C2-C11 cyclized cembranoids, were proposed to contain a C3-C14 ether or lactone bridge, similar to asbestinins. However, the total synthesis of the proposed structure of briarellin J revealed a misassignment. We revisited briarellins, computationally, with the help of a recently developed hybrid DFT/parametric method, DU8+, and revised the structures of briarellin C14-C3 ε-lactones to new structural types containing either a C14-C11 or C14-C12 lactone bridge. The original structures of briarellin and asbestinin ethers were confirmed.

Chemical investigations of the aerial parts of Tibetan folk medicine Delphinium chrysotrichum resulted in the isolation of two new diterpenoid alkaloids, delphatisine D (1) and chrysotrichumine A (2), together with ten known diterpenoid alkaloids (3-12) and 3β,6α-dihydroxysclareolida (13). Delphatisine D (1) is a rare atisine-type alkaloid from genus Delphinium and is the C-15 epimer of spiramine C which bears an internal carbinolamine ether linkage (N-C-O-C) between C-7 and C-20. Chrysotrichumine A (2) is a rare natural C 19 -diterpenoid alkaloid possessing a nitrone group between C-17 and C-19. Their structures were elucidated on the basis of extensive spectroscopic analysis. Compound 13 is a sesquiterpene first isolated from this genus. Compounds 1, 3-7 and 13 were investigated for cytotoxicity against human breast cancer cell lines of MCF-7 and MDA-MB-23, none of them presented significant activity except compound 7 which exhibited slight activity at 100 μM against MDA-MB-231, but did not reach the EC 50 ., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose of Review: A multidisciplinary approach is vital to reduce mortality and hospitalizations in patients with heart failure. As members of the multidisciplinary team, pharmacists are uniquely positioned to care for patients across the spectrum of heart failure. This comprehensive review explores the different facets in which pharmacists can be utilized to impact the care for patients with heart failure, including those with cardiac transplant and left ventricular assist devices (LVADs), in the outpatient setting., Recent Findings: Pharmacists can see heart failure patients in a variety of settings to reduce drug therapy-related issues, increase use of guideline-directed medical therapy (GDMT), and reduce hospitalizations. Although there is limited data available, pharmacists have also been described in aiding the therapeutic drug monitoring of warfarin for patients with LVADs and immunosuppression agents in the transplant population. Through collaborative practice agreements, pharmacists can provide progressive services such as titration of GDMT and lab monitoring, in addition to medication reconciliation, education, and review for potential drug-related problems. Pharmacists can increase access to patient care by providing services through distance-visits, shared medical appointments, and home visits.

Background: The aim of this study was to determine the type, quantity, and cost of medications being disposed of by clients in a specifically-set pharmaceutical disposal bin at a village community pharmacy. Methods: Medicines placed in a medication disposal bin by clients were examined during a nine-month period from April to December 2018. The data recorded included the active ingredient, trade name, dose, dosage form, disposed quantity, and the actual expiry date on the pack. The medications were classified according to ATC (Anatomical Therapeutic Chemical Classification System) code, and the cost of the amount wasted was calculated using the pharmacy's price list. Descriptive statistics were used to analyze the data. Results: A total of 411 medications were collected, amounting to a total cost of approximately €2600. The largest group of medications belonged to the alimentary group, and this also represented the group with the highest monetary value. The number of months that medicinal products were retained by patients beyond the expiry date ranged from 1 to 232. Conclusion : This small study provides a glimpse of what clients dispose of in a medication bin when this is readily available in their community pharmacy, a simple measure which, if adopted on a national level, could aid in ensuring the appropriate disposal of wasted medication.

Background . Education should support the gradual development of students' necessary abilities to empower them in participating in decision-making together with health care professionals. Aim . The aim of this study was (1) to evaluate baseline knowledge regarding medication and medication wastage among primary school children and (2) to determine the short- and long-term effects of an educational intervention. Methods . Ten primary state schools around Malta were invited to participate; 5 accepted participation (3 control and 2 intervention). Children aged 9 to 12 years attending the sixth grade completed a self-reported questionnaire containing 20 questions, with total scores ranging from 0 to 20. Students from the intervention classes filled in a questionnaire pre and post an educational seminar. All students answered the questionnaire again after 8 months. ANOVA (analysis of variance) with repeated measures was used to compare difference between preintervention and postintervention mean scores. Results . Overall, 40.8% (160/392) of children participated. Mean ± SD age was 10 ± 0.4years; 52.5% (n = 84) were boys. Average preintervention knowledge score for all 5 schools was 11.5 ± 3.6, with 43.1% (n = 69) obtaining responses ≥13 (median). A repeated-measures ANOVA with a Greenhouse-Geisser correction determined that mean knowledge scores differed significantly between preintervention and postintervention ( F [1, 81.000] = 75.190, P < .0005). Intervention students retained a significant increase in knowledge scores at 8 months ( P = .026). Discussion and Conclusion . The significantly improved knowledge score following the educational intervention both in the short- and long-term demonstrated the success of the intervention. These findings provide a basis for the introduction of education about medication and medication wastage in schools., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Non-adherence to short-term antibiotics is considered to be one of the factors leading to medicines wastage, and this can increase misuse of medicine taking, promote antibiotic resistance and cause environmental pollution. Interventions developed to enhance adherence to short-term antibiotics should be easily implementable into daily practice. No studies utilising Normalization Process Theory to develop interventions aiming to enhance adherence to antibiotics were identified., Objectives: To assess whether an intervention supported by an educational leaflet enhances adherence and reduces cost in relation to wastage of unused antibiotics amongst patients taking short-term antibiotics in community; and to determine a possible association between adherence and patients' general medicines' beliefs., Methods: Fourteen community pharmacies were randomly selected: seven pharmacies used an educational leaflet (intervention) to counsel patients; seven pharmacies acted as control. Patients with an antibiotic prescription were recruited until 200 patients per group was reached. Two focus groups based on Normalization Process Theory were held with pharmacists from the intervention group to refine the leaflet. After finishing the antibiotics, patients were contacted to assess adherence, storage, knowledge about antibiotic resistance and beliefs about medicines using 'Beliefs about Medicines Questionnaire-General' (BMQ-General)., Results: Ten percent from intervention group and 24% from control were non-adherent (p = < 0.0005), with a 2.8-fold more in the percentage cost of wasted antibiotics in control group. 'General-benefit' belief was significantly higher for intervention group (p = 0.044). For control group, higher 'general-overuse' beliefs were significantly associated with non-adherence (p = <0.0005)., Conclusions: An educational intervention has significantly enhanced adherence to prescribed short-term antibiotics and reduced wastage., (Copyright © 2018. Published by Elsevier Inc.)

Background: Non-adherence is a significant factor contributing to medication wastage. Whilst there is some evidence on the influence of patients' health locus of control in relation to adherence, there has been little inquiry into its relationship with mediation wastage., Objectives: To determine the relationship between medication adherence and health locus of control as well as medication wastage and health locus of control in patients with chronic conditions., Methods: Outpatients having a diagnosis of asthma, cardiovascular conditions, or diabetes participated in a cross-sectional study employing a self-administered questionnaire. The questionnaire determined presence of unused medication (wastage), adherence using 'Tool for Adherence Behaviour Screening' (TABS), and health locus of control using 'Multidimensional Health Locus of Control' (MHLC) scale Form C. Logistic regression was performed to ascertain the effects of MHLC and demographics in relation to adherence and wastage. MHLC beliefs were divided into 8 types of health locus of control. One-Way ANOVA was used to assess differences between conditions and belief types. P-values ≤ .05 were considered significant., Results: There were 330 patients recruited (58% male; age, mean±(SD): 61 ± 15 years; 110 asthma, 110 cardiovascular, 110 diabetes). In terms of health locus of control, females had higher 'doctors' beliefs (p = .054) and significantly lower 'other people' beliefs (p = < .0005). Lower 'chance' beliefs (p = .016) were associated with adherence. Lower 'doctors' beliefs and higher 'other people' beliefs were significantly associated with wastage (p = < .0005). There was a significant difference in adherence (p = < .0005) and in wastage (p = .002) between the eight types of health control. 'Yea-sayers' had the least presence of unused medication, followed by 'pure internal' believers. 'Pure powerful others external' had the highest presence of unused medication., Conclusions: Healthcare professionals should take into account patients' health locus of control beliefs whilst conducting an intervention with patients; this can impact positively medication adherence and minimisation of medication wastage., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To determine the impact of lean thinking on the original time required to prepare the necessary documentation in relation to the preparation of parenteral chemotherapy/monoclonal antibodies., Method: Four pharmacists and one pharmacy technician from the oncology hospital (Malta) all participated in eight focus groups linked to the different constructs of Normalisation Process Theory (NPT): coherence, cognitive participation, collective action and reflexive monitoring. The value stream documentation process was mapped by analysing all steps in the process where each activity must add value for the patient; tools of lean thinking were applied. Points causing delay in processing were considered critical; possible changes to minimise time waste were discussed and implemented. Time spent on critical points was measured by timing in minutes each step of the process 1 month before and after the changes had been implemented and calculating the mean±SD. An audit was performed comparing the process with standard operating procedures to determine whether any steps required quality improvement., Results: Three critical points were identified: time required to search for pharmacy patient medication records for chemotherapy/monoclonal antibodies required on the day; time to generate preparation labels; and time to generate worksheets. Overall, a total of 122±8.6 min (p=0.06) were saved per day, a 37% decrease from the original documentation time. Five deficiencies were identified in the documentation process audit; corrective action was proposed., Conclusions: By applying lean thinking, non-value-added steps leading to time waste in the documentation process were eliminated. This concept could be implemented by using NPT as part of a strategic system to reduce waste., Competing Interests: Competing interests: None declared.

Background: With the update of the directive 2005/36/EU on the recognition of professional qualifications (2013/55/EU), the European Union (EU) legislation opened also to pharmacists the possibility to define specialisations via a common training framework (CTF)., Objective: The aim of this study was to review, synthesise and present published evidence on the impact of health educational interventions targeting healthcare professionals on patients' health outcomes that support a hospital pharmacy CTF in EU., Method: The search was carried out in Medline and Cumulative Index to Nursing & Allied Health Literature and was limited to English language full review articles or primary research published since 2000. Data were extracted independently and compared by three of the researchers., Results: Ten papers (9 primary research studies and one literature review) were identified. Almost one-third of the studies (30%, n=3) targeted pharmacists in their research. The majority of studies (80%, n=8) have shown that higher education levels among healthcare professionals improved patient outcomes. No study discussed the importance of a CTF., Conclusion: The review of the literature has demonstrated the need for education and training of health personnel to improve patient outcome. Controlled studies about pharmacist education and training in European countries showed that the benefit of a CTF is lacking., Competing Interests: Competing interests: None declared.

Objective: Cervical excision procedures are essential to the care of cervical dysplasia and malignancy. We sought to determine whether learner involvement in cervical excision procedures affects the quality of excision specimen., Materials and Methods: A retrospective cohort study of cervical cancer patients diagnosed from July 1, 2000, to July 1, 2015, was performed. We included patients who had (1) a cervical excision procedure, either loop electrosurgical excision procedure or cold knife cone, and (2) pathologic information available. Primary outcome was the margin status of the specimen; secondary outcome was the size of the excision specimen including both width and depth. The exposure of interest was trainee participation, defined as resident physicians under the supervision of either a gynecologist or gynecologic oncologist. Descriptive statistics and general linear models were used for analysis., Results: Ninety-four patients were identified. Overall, 58% (n = 54) of procedures were performed with trainee involvement. There was no difference in age, body mass index, or specimen width between trainee-performed and nontrainee-performed excisions. There was no significant difference in the status of margins with or without a trainee [44/57 (77%) and 29/37 (78%), respectively, p = .89]. There was a statistically significant difference in median specimen depth between trainee-performed and nontrainee-performed cases (15.4 mm vs 12 mm, p < .02). When adjusting for age, body mass index, excision type, indication, presence of trainee, and type of supervising physician, only the indication and type of excision were associated with greater depth of excision, (p < .01)., Conclusions: Trainee involvement in cervical excision procedures does not alter the quality of excision specimen.

Chemical investigation of the MeOH extract from the gorgonian Pseudopterogorgia americana afforded two rare sterols, ameristerenol A (1) and B (2), both 9,11-secosterols possesses a seven-membered cyclic enol-ether in ring C, and ameristerol A (3) is the first example of a naturally occurring 9,11-secosterol containing a gorgosterol side chain with a C-24(28) double bond. Ameristerenol A (1) was converted to the sterol derivatives 4-6 to provide additional chemical diversity and comparison for biological screening. The structures of compounds 1-6, along with three related known analogues 7-9, were determined on the basis of extensive spectroscopic analysis and by comparison with literature data. Compound 6 exhibited slight cytotoxicity activity against human breast cancer cell line MDA-MB-231., (Copyright © 2017. Published by Elsevier Inc.)

A biomimetic synthesis of briareolate ester B (3) from briareolate ester L (1) via the intermediate briareolate ester G (2) has been achieved through a unique transannular oxa-6π electrocyclization induced by UVA light. UVC irradiation of 3 triggered a rapid retro-6π electrocyclization to establish an unprecedented photochromic switch. In the ground state, reaction of 1 led to the formation of a polycyclic γ-spiroketal γ-lactone 5, architecturally related to the ether-bridged cembranoids of the cladiellin class.

Unlabelled: Background The World Health Organization states that globally more than half of all medication is inappropriately prescribed, dispensed or sold with a need to implement wastage reduction strategies. Developing processes which include behaviour change theories, such as the Theoretical Domains Framework (TDF), significantly impacts the positive implementation of evidence into healthcare practice. Objective To describe and understand the beliefs and behaviours regarding medication wastage of the Maltese public and healthcare professionals (HCPs) and to explore potential solutions., Setting: Malta. Method Five 90 min audio recorded focus groups (2 public and 3 HCPs) were conducted with a purposive sample who responded to a previous survey study and were willing to participate in focus groups in Malta. The guide was based upon the TDF with interview questions derived from findings of the questionnaire phase. Focus groups were audio recorded and transcribed verbatim. Analysis was carried using the framework approach. Main outcome measure Beliefs and behaviours regarding medication wastage and potential solutions to reduce medication wastage. Results A total of eleven pharmacists, six doctors and six members of the public consented to participate. Focus groups conducted with HCPs and the general public identified the following four key themes aligned with the TDF domains to address proposed solutions to minimise medication wastage: (1) practitioner effects; (2) patients effects; (3) political effects; (4) societal effects. Conclusion This study has employed a theoretical framework to obtain a better understanding of facilitators which require attention as part of strategic development.

Objectives: The current study explores the potential mediating role of internalized racism in the relationship between racist experiences and anxiety symptomology in a Black American sample., Method: One hundred and 73 Black American participants, between 18 and 62 years of age, completed a questionnaire packet containing measures of anxious arousal and stress symptoms, internalized racism, and experiences of racist events., Results: Results indicated that internalized racism mediated the relationship between past-year frequency of racist events and anxious arousal as well as past-year frequency of racist events and stress symptoms., Conclusions: Internalized racism may be 1 mechanism that underlies the relationship between racism and anxious symptomology for Black Americans. These preliminary findings suggest that internalized racism may be an avenue through which clinicians can target the anxiety elicited by racist experiences. The clinical implications of these findings and future research directions are discussed. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Background: Medication wastage is a global issue, with key public health implications in terms of safety, the environment and the economy. A recently conducted systematic review of the published literature identified a lack of focus on the views of healthcare professionals and the general public., Objective: To explore awareness, attitudes and behaviours relating to medication wastage amongst the general public in Malta., Setting: Malta., Method: Survey methodology employing a pre-piloted questionnaire was developed from theoretical frameworks of behaviour. Questionnaire items comprised open, closed and 5-point Likert scales. Medication adherence as a possible factor associated with wastage was measured using the 8-item Morisky Medication Adherence Scale. Random sample of 1920 was obtained from the Maltese electoral register 2013. Ethical approval was obtained., Main Outcome Measures: Awareness, attitudes and behaviours relating to medication wastage amongst the general public in Malta., Results: Response rate was 20.4 %. The majority (70.6 %) agreed that they were fully aware of the issue of wastage and 71.9 % disagreed that they had no interest in wastage. The following were significantly related to increased awareness of wastage: older age (p = 0.003), pensioners (p = 0.011), on regular medication (p = 0.021) and obtaining free medication (p = 0.026). Lack of interest in wastage was significantly related to obtaining free medication by government (p = 0.022), with those purchasing medication being significantly more interested (p = 0.028). While 75.1 % of respondents on regular medication self-reported not being fully adherent, there were no associations with awareness (p = 0.100) and interest in wastage (p = 0.385). Unemployed were more likely to report contribution towards wastage (p = 0.010) and the presence of a healthcare professional as family member was significantly related to confidence in ability to reduce wastage (p = 0.009). 46.2 % claimed to have unused medication at home and improvement in patient's medical condition was the main reason for this., Conclusion: More effort is warranted to raise awareness of the public as an initial step in promoting behavioural change in relation to medication wastage.

Natural products have provided an invaluable source of inspiration in the drug discovery pipeline. The oceans are a vast source of biological and chemical diversity. Recently, this untapped resource has been gaining attention in the search for novel structures and development of new classes of therapeutic agents. Pseudopterosins are group of marine diterpene glycosides that possess an array of potent biological activities in several therapeutic areas. Few studies have examined pseudopterosin effects during cellular stress and, to our knowledge, no studies have explored their ability to protect synaptic function. The present study probes pseudopterosin A (PsA) for its neuromodulatory properties during oxidative stress using the fruit fly, Drosophila melanogaster. We demonstrate that oxidative stress rapidly reduces neuronal activity, resulting in the loss of neurotransmission at a well-characterized invertebrate synapse. PsA mitigates this effect and promotes functional tolerance during oxidative stress by prolonging synaptic transmission in a mechanism that differs from scavenging activity. Furthermore, the distribution of PsA within mammalian biological tissues following single intravenous injection was investigated using a validated bioanalytical method. Comparable exposure of PsA in the mouse brain and plasma indicated good distribution of PsA in the brain, suggesting its potential as a novel neuromodulatory agent.

The current study investigated whether a cultural factor (i.e., social connectedness) and a dispositional characteristic (i.e., intolerance of uncertainty) would serve as risk factors or protective factors in the association between perceived racial microaggressions and anxiety symptoms in a sample of 126 Black American individuals. Results demonstrated that perceived racial microaggression was positively associated with anxiety symptoms in Black Americans. In addition, hierarchical regression analyses identified ethnic social connectedness and intolerance of uncertainty as moderators for anxiety symptoms. Specifically, social connectedness to one's ethnic community served as a buffer and intolerance of uncertainty acted as an exacerbating factor in the relationship between perceived racial microaggressions and anxiety symptoms. Future research directions and clinical implications are discussed., ((c) 2016 APA, all rights reserved).)

Background: Omalizumab was introduced in Malta in 2011. To date, no local data have been published., Objective: To obtain baseline characteristics of our local cohort, determine effectiveness of omalizumab at 52 weeks, compare clinical outcomes 52 weeks pre- and postomalizumab therapy and to assess its safety and tolerability., Setting: The Mater Dei Hospital in Malta., Method: All consented adult patients who were eligible to start treatment with omalizumab for asthma were enrolled in this open, prospective observational real-life study. A questionnaire was completed and an Asthma Control Test and spirometry performed. Patients were reviewed on a regular basis. Any undesirable symptoms were recorded. Treatment effectiveness was evaluated at 16 and 52 weeks, during which a decision was taken whether patients were responders. Outcomes were compared 52 weeks pre- and post- treatment initiation. Main outcome measure To determine effectiveness of treatment following 1 year of omalizumab by assessing its impact on the rate of asthma-related exacerbations and health care utilization including hospitalizations., Results: Our cohort included 22 patients, all non-smokers (mean age 52.7 ± 11, 64 % males). The mean baseline IgE level was 448.6 ± 444 IU/ml. At week 12, treatment was stopped in one patient due to arthralgias. The drug was stopped in two patients at week 16 due to treatment ineffectiveness. At week 20, treatment was stopped in another patient in view of arthralgias. A significant reduction in the number of asthma exacerbations (p = .03) and number of systemic steroid courses required (p = .03) was identified at 52 weeks. There was a significant improvement in the ACT score (p < .001) after 52 weeks but no significant improvement in FEV1. There was a non-significant decline in the number of hospitalizations (p = .6), asthma-related healthcare visits (p = .2) and days off work (p = .09). Adverse events occurred in 10 % of patients. Costs related to asthma hospital-stay and medicines administered during hospitalisations were decreased by half following 1 year on omalizumab., Conclusion: Omalizumab treatment resulted in an improved asthma control, with a significant reduction in asthma exacerbations and systemic steroid courses required and improvement on ACT score. Adverse events were infrequent and the drug was well tolerated.

Background: Donation after circulatory determination of death (DCDD) involves variable definitions of death among hospitals, and DCDD hearts are not generally considered for transplantation. The definition can affect ischemic times, and machine perfusion preservation appears promising for recovery of DCDD hearts. The purpose of the current study was to investigate the agonal phase of DCDD donors and evaluate retrograde perfusion preservation of DCDD donor hearts in a large animal model of cardiac transplantation., Methods: Ten canines were anesthetized and then disconnected from mechanical ventilation. Time to loss of pulse (systolic blood pressure <50 mm Hg), loss of pressure, and asystole or fibrillation were recorded. Five minutes after asystole, hearts were exposed and arrested with 1 L of University of Wisconsin Machine Perfusion Solution. Eight hearts were cold preserved for 4 hours by retrograde machine perfusion or static storage (n = 4/group), then reimplanted and reperfused for 6 hours. The preload recruitable stroke work was used to measure myocardial function., Results: The agonal phase was similar between groups. Loss of pulse and pressure were consistent between animals (7.9 ± 0.5 minutes [range, 5 to 11 minutes], 10.2 ± 0.4 minutes [range, 9 to 13 minutes], respectively). Electrical silence was variable at 26.9 ± 3.8 minutes (range, 11 to 43 minutes). All perfused hearts separated and remained off cardiopulmonary bypass. Three of four static hearts initially separated from cardiopulmonary bypass, but two returned by the end of the reperfusion period. The preload recruitable stroke work was significantly higher in perfused hearts., Conclusions: Protocols for DCDD have implications on ischemic times of donor hearts. Machine perfusion preservation can recover DCDD hearts more consistently than static storage., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Machine perfusion of donor hearts is a promising strategy to increase the donor pool. Antegrade perfusion is effective but can lead to aortic valve incompetence and nonnutrient flow. Experience with retrograde coronary sinus perfusion of donor hearts has been limited. We tested the hypothesis that retrograde perfusion could support myocardial metabolism over an extended donor ischemic interval., Methods: Human hearts from donors that were rejected or not offered for transplantation were preserved for 12 hours in University of Wisconsin Machine Perfusion Solution by: (1) static hypothermic storage; (2) hypothermic antegrade machine perfusion; or (3) hypothermic retrograde machine perfusion. Myocardial oxygen consumption (MVO2), and lactate accumulation were measured. Ventricular tissue was collected for proton and phosphorus 31 magnetic resonance spectroscopy (MRS) to evaluate the metabolic state of the myocardium. Myocardial water content was determined at the end of the experiment., Results: Stable perfusion parameters were maintained throughout the perfusion period with both perfusion techniques. Lactate/alanine ratios were lower in perfused hearts compared with static hearts (P<.001). Lactate accumulation (antegrade 2.0±0.7 mM, retrograde 1.7±0.1 mM) and MVO2 (antegrade 0.25±0.2 mL, retrograde 0.26±0.3 mL O2/min/100 g) were similar in machine-perfused groups. High-energy phosphates were better preserved in both perfused groups (P<.05). Left ventricular myocardial water content was increased in retrograde perfused hearts (80.2±0.8%) compared with both antegrade perfused hearts (76.6±0.8%, P=.02) and static storage hearts (76.7±1%, P=.02)., Conclusions: Machine perfusion by either the antegrade or the retrograde technique can support myocardial metabolism over long intervals. Machine perfusion seems promising for long-term preservation of human donor hearts., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Reducing any wastage, including that of medications, is a paramount objective in promoting appropriate utilisation of finite resources. The objective was to systematically review the published literature, the possible causative factors associated with medication wastage and the effectiveness of any interventions to reduce wastage., Method: A systematic review of studies published in English was identified from the following databases: Cumulative Index to Nursing and Allied Health Literature, Embase, Medline, PubMed, Science Citation Index and The Cochrane Library. Data extraction and critical appraisal was undertaken independently by two researchers., Results and Discussion: Title, abstract and full paper screening reduced the 14,157 studies to 42. A general definition of medication wastage was reported in one paper only. 'Medication changed', 'patient death', 'resolution of patient's condition' and 'expired medications' were most commonly cited reasons for wastage. Only two studies were identified reporting wastage as a research outcome measure following intervention., Conclusion: The systematic review has identified a limited literature on medication wastage with a lack of consistency of terms. There is a paucity of robust research focusing on the impact of healthcare interventions on outcomes around medication wastage.

A new iridoid glucoside, cornusoside A (1), and four new natural product iridoid aglycones, cornolactones A-D (2-5), together with 10 known compounds were isolated from the leaves of Cornus florida. The structures of compounds 1-5 were established by interpretation of their spectroscopic data. Cornolactone B (3) is the first natural cis-fused tricyclic dilactone iridoid containing both a five- and a six-membered lactone ring. A biosynthesis pathway is proposed for cornolactones C (4) and D (5), the C-6 epimers of compounds 1-3.

Interprofessional collaboration requires that health professionals think holistically about presenting concerns, particularly for multimodal problems like sexual dysfunction. However, health professions students appear to receive relatively little sexual health education, and generally none is offered on an interprofessional basis. To assess current degree of interprofessional thinking in sexual health care, 472 health professions students in Georgia, United States, were presented with a sexual dysfunction vignette and asked to rate the relevance of, and their familiarity with, interventions offered by several professionals. They also were asked to identify the most likely cause of the sexual dysfunction. Students rated relevance and familiarity with interventions as highest for physicians and lowest for dentists, with higher ratings of nurses by nursing students. More advanced students reported greater familiarity with mental health, physician, and physical therapy interventions. Finally, nursing students were less likely to attribute the dysfunction to a physical cause. These findings indicate that students may prioritize biomedical approaches in their initial assessment and may need additional supports to consider the spectrum of biopsychosocial factors contributing to sexual functioning. To encourage interprofessional critical thinking and prepare students for interprofessional care, sexual health curricula may be improved with the inclusion of interprofessional training. Specific recommendations for curriculum development are offered.