Maurice Zarb Adami

Predictors of post-caesarean section pain and analgesic consumption

Background: Ideally, the intensity of postoperative pain should be predicted so as to customize analgesia. The objective of this study was to investigate whether preoperative electrical and pressure pain assessment can predict post-caesarean section pain and analgesic requirement. Materials and Methods: A total of 65 subjects scheduled for elective caesarean section, who gave written informed consent, were studied. Preoperatively, PainMatcher® was used to evaluate electrical pain threshold, while manual PainTest™ FPN 100 Algometer and digital PainTest™ FPX 25 Algometer determined pressure pain threshold and tolerance. Postoperatively, numerical rating scales were used to assess pain at regular time intervals. Patients received intramuscular pethidine (100mg, 6 hourly), rectal diclofenac (100mg, 12 hourly), and oral paracetamol (1g, p.r.n.) for pain relief. Statistical analysis was conducted using PASW Statistics 18 software. Results: Preoperative electrical pain threshold correlated significantly with post-caesarean pain scores at 6 and 24 hours (r = –0.26, P < 0.02; r = –0.23, P < 0.04, respectively), and with the quantity of paracetamol consumed by the patient within 48 hours of surgery (r = –0.33, P < 0.005). Preoperative pressure pain tolerance measured by PainTest™ FPX 25 Algometer was significantly correlated with pain scores 6 hours postsurgery (r = –0.21, P < 0.05). Pain scores 6 hours post-caesarean section correlated significantly with anesthesia—general or spinal (F = 4.22, v1 = 1, v2 = 63, P < 0.05). Conclusions: The predictive methods proposed may aid in identifying patients at greater risk for postoperative pain. Electrical pain threshold could be useful in personalizing the postoperative analgesic protocol.

Pre-operative pain sensitivity: A prediction of post-operative outcome in the obstetric population.

CONTEXT Experimental assessments can determine pain threshold and tolerance, which mirror sensitivity to pain. This, in turn, influences the post-operative experience. AIMS The study intended to evaluate whether the pre-operative pressure and electrical pain tests can predict pain and opioid requirement following cesarean delivery. SETTINGS AND DESIGN Research was conducted on females scheduled for cesarean section at a tertiary care hospital of the state. Twenty women were enrolled, after obtaining written informed consent. MATERIALS AND METHODS PAIN ASSESSMENT WAS PERFORMED ON THE EVE OF CESAREAN SECTIONS USING THREE DEVICES: PainMatcher(;) determined electrical pain threshold while the algometers PainTest(™) FPN100 (manual) and PainTest(™) FPX 25 (digital) evaluated pressure pain threshold and tolerance. Post-operative pain relief included intravenous morphine administered by patient-controlled analgesia, diclofenac (100 mg, every 12 h, rectally, enforced) and paracetamol (1000 mg, every 4-6 h, orally, on patient request). Pain scores were reported on numerical rating scales at specified time intervals. STATISTICAL ANALYSIS USED Correlational and regression statistics were computed using IBM SPSS Statistics 21 software (IBM Corporation, USA). RESULTS A SIGNIFICANT CORRELATION WAS OBSERVED BETWEEN MORPHINE REQUIREMENT AND: (1) electrical pain threshold (r = -0.45, P = 0.025), (2) pressure pain threshold (r = -0.41 P = 0.036) and (3) pressure pain tolerance (r = -0.44, P = 0.026) measured by the digital algometer. The parsimonious regression model for morphine requirement consisted of electrical pain threshold (r(2)= 0.20, P = 0.049). The dose of morphine consumed within 48 h of surgery decreases by 0.9 mg for every unit increment in electrical pain threshold. CONCLUSIONS The predictive power of pain sensitivity assessments, particularly electrical pain threshold, may portend post-cesarean outcomes, including opioid requirements.

Time and motion study for pharmacists' activities in a geriatric hospital

Objectives This study aimed to identify and quantify activities undertaken by pharmacists in a geriatric hospital.

Impact of drugs counselling by an undergraduate pharmacist on cardiac surgical patient’s compliance to medicines.

Open heart surgery is a procedure which warrants patient education about the complexity of drug regimens and lifestyle modifications. Patient nonadherence is likely to have a considerable negative impact on the patients’ quality of life post-cardiac surgery. Objective To evaluate the impact of pharmacist intervention on patients’ adherence to medication and lifestyle changes. Methods This case-controlled study was conducted at the Cardiac Surgical Ward and Outpatients Clinic of Mater Dei Hospital, Malta. Eighty consecutive patients who underwent coronary artery bypass or heart valve surgery were interviewed on their day of discharge using the ‘Past Medical History Questionnaire’. The patients were then randomized to receive pharmacist intervention or usual care. Those who received intervention (40 patients) were given a chart with pictorial explanation of the time of day together with a colorful photograph of each tablet prescribed. This group of patients was also counselled to comply to oral analgesia and exercise and also on the avoidance of alcohol and smoking during the recovery period. The control patients received usual care without the pharmacist intervention. All patients were re-interviewed eight weeks after discharge using the ‘Assessing Patient Compliance Questionnaire’. Any differences between the control and experimental groups were analysed using Chi-square, Three-Way Cross tabulation One-Way ANOVA and Two-Way ANOVA tests using the SPSS software version 17.0. Results A statistically significant difference between the two groups in the mean percentage compliance was registered following pharmacist intervention (p<0.05). Patients in the experimental group had a higher mean percentage compliance score (88%) than patients in the control group (66%). Conclusions The statistically significant difference in the mean percentage compliance between the two groups following pharmacist intervention shows conclusive evidence of the advantage patients gain when offered this intervention. The pharmacist intervention provides patients with sufficient information to help them achieve optimal benefit from the medication prescribed.

Pharmacist interventions in non-prescription medicine use

The aim was to investigate the factors that influence non‐prescription medicines (NPMs) recommendation by community pharmacists and to compare products available in different countries.

Pharmacoeconomics and Rheumatoid Arthritis

Pharmacoeconomics refers to the scientific discipline that compares the value of one pharmaceutical drug or drug therapy to another. It is a subdiscipline of health economics. How do health, pharmacy, medications and financial constraints impact on each other? What are the consequences of innovative drug development and expensive medications? Does quality of life and health come at a cost? This chapter attempts to delve into the aspects of pharmacoeconomics and presents case scenarios of pharmacoeconomic analysis within rheumatoid arthritis.

Pharmacist intervention in pain management following heart surgery

Objectives Pain is a common symptom in cardiac surgery patients. This study aimed to investigate the influence of pharmacist intervention to ease postoperative pain in cardiac surgery patients. Methodology Patients undergoing heart surgery were randomised to control or intervention. The intervention group was given systematic verbal information and, at discharge, a pharmaceutical care plan. Pain score and diary assessment were compared up to 6 weeks after the surgery. Results 100 patients participated. Mean Pain Score was lower in the intervention group from week 1 to 6 (p<0.05). Compliance with analgesic was higher in the intervention group. Conclusions The intervention improved compliance and decreased pain score, illustrating the positive effect the pharmacist had on these patients.

Development and evaluation of a Drug Information Bulletin

The study aimed to issue a bulletin which provides information on new medicines released on the Maltese market and on changes in Summary of Product Characteristics specific to the local scenario.

Anticoagulation services in Malta--an economic study comparing a central laboratory model vs. a point-of-care approach.

Sir, the international normalized ratio (INR) is used for monitoring treatment with coumarin anticoagulants (warfarin). Warfarin remains the preferred method of prophylaxis and treatment for thrombosis in a wide range of clinical scenarios (Spandorfer & Merli, 1996). The costs incurred in providing INR point-of-care testing (POCT) depends on the model of care adopted. According to the MSAC Report (2005), within the Australian Health system in 2005, the cost of replacing INR testing through laboratories with INR POCT represented a 47% increase over the annual direct cost. In Malta, warfarin is used as oral anticoagulation therapy, and INR testing is centralized at Mater Dei Hospital. Patient sampling for all anticoagulated patients takes place at one of eight health centres and at the Anticoagulation Clinic (ACC) within Mater Dei Hospital. Patients are allotted the sampling locality according to their hometown; however, part of the patients attending ACC are because of emergency or dental cases and INR variations because of drug treatment such as antibiotics. This study estimates the proportion of Maltese patients who require anticoagulation therapy with warfarin, and the direct cost of an INR test using a centralized laboratory system against a point-of-care (PoC) system. Epidemiological data for patients undertaking INR monitoring at the public system in Malta was gathered for the basis year 2008. The total number of anticoagulated patients was acquired from the Mater Dei Hospital ACC database. The total INR requests for these patients were obtained over an 8-year period (2000–2008) from the Pathology Department at Mater Dei Hospital. It is understood that anticoagulated patients checking their INR at private laboratories are few, and they still check their INR at the ACC. Therefore, these numbers were not taken into consideration. Population information was obtained from annual publications generated by the National Statistics Office as of year 2008. Confidence intervals for proportions were calculated using the equations of Fleiss (1981). The direct costs of the current Sysmex CA-1500 laboratory system (Sysmex Europe GmbH, Bornbarch, Norderstedt, Germany) used at Mater Dei Hospital were compared against the CoaguChek XS Plus PoC system produced by Roche Diagnostics (Roche Diagnostics GmbH, Sandhofer Straße, Mannheim, Germany). These costs were estimated on the basis of the total number of INR tests requested from ACC during the year 2008. The scenario taken into consideration in this study was that of transferring the total annual ACC INR requests (50 031) in 2008 from the current laboratory system to a centralized PoC system at ACC. A reagent contract with equipment on loan for a total duration of 3 years was considered. Four major components to the direct cost of INR testing were included: the equipment cost, which in the case of the laboratory system was not considered because this was already being used to perform other tests; the consumable equipment cost of items that must be purchased each time a test is performed; the other cost attributable to other related consumables and activities, which are required to complete the service; and the labour cost required to perform the test and record results. In 2008, the Maltese population was 413 609. The proportion of anticoagulated patients was 9.48/1000 (95% Confidence Limit 9.19–9.78/1000) that is, 0.95% of the Maltese population. The total number of unique patients attending ACC for 2008 was 3922. The INR requests generated by these patients more than doubled over the period 2000–2008, reaching a figure of 50 031 total INR requests in 2008. Approximately 65 cases per day required a change in warfarin dose. Taking into consideration, the average total of 193 INR requests per day, this meant that 33.7% of anticoagulated patients required a change in warfarin dose. This was a significant number, taking into account that all these patients had to be informed by phone on the same day. The direct costs of the four major components included in Table 1 are specific for the 3922 anticoagulated patients. Results show that the laboratory-centralized system works out to be more expensive than a PoC system. The cost per INR test using a PoC system would be € 4.217 when compared to € 4.946 using a centralized laboratory system. The approximate annual cost per LETTER TO THE EDITOR INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY