Transfusion in hemoglobinopathies and red blood cell alloimmunization: data from Sicily, Sardinia and Malta

BACKGROUND

Hemoglobinopathies are a group of diseases that include those due to globin gene mutations, such as thalassemia major (TM) and thalassemia intermedia (TI) or due to alteration of hemoglobin structure such as sickle cell disease (SCD), as well as a combination of these conditions such as thalasso-drepanocytosis (TD). They constitute the most frequent hereditary anemias requiring blood transfusion.

MATERIALS AND METHODS

In April 2022, a questionnaire was sent to the Transfusion Services (TS) of Sicily, Sardinia and the Maltese National Blood Transfusion (MNBT) service. The questionnaire was divided into a generic part including the number of patients followed and the type of hemoglobinopathy, and a section relating to transfusion therapy, including the number of units transfused, whether red blood cells (RBC) were washed and, finally, a section relating to the presence or absence of alloantibodies and their identification.

RESULTS

Data was retrieved for 2,574 patients: 68.6% TM, 15.4% TI, 10.3% TD, 4.1% SCD, and 1.6% other hemoglobinopathies (OHA). The number of RBC units transfused was 76,974, equivalent to 24.5% of all the RBCU transfused from the total number of patients followed. The number of washed RBCU was 21.1% of all the units used; 337 patients (37%) were diagnosed with alloantibodies, the majority of which were patients with SCD (20.6%). Of the 485 alloantibodies found, 90.3% were identified. The antibodies found most frequently were related to the Kell system (41.7%) followed by antibodies to the Rhesus system (37.9%); 29.7% of patients had more than one antibody.

DISCUSSION

From our study, certain indications can be formulated: complete the National Registry for patients with hemoglobinopathies; create a Registry of alloimmunized patients to ensure transfusion therapy is as safe as possible, considering antibody evanescence; and 3) increase the recruitment of blood donors of diverse ethnicities.

Independent clinic-based evaluation of dual POCTs for screening for HIV and syphilis in men who have sex with men in Italy, Malta, Peru, and the United Kingdom

INTRODUCTION

Globally, the incidence of HIV and syphilis can be reduced by the use of validated point of care tests (POCTs). As part of the WHO PRoSPeRo Network, we aimed to evaluate the performance, acceptability, and operational characteristics of two dual HIV/syphilis POCTs (Bioline HIV/Syphilis Duo (Abbott) and DPP® HIV-Syphilis assay (Chembio) for the screening of HIV and syphilis amongst men who have sex with men (MSM).

METHOD AND ANALYSES

A cross sectional study of 2,577 MSM in Italy, Malta, Peru, and the United Kingdom (UK) presenting to seven clinic sites, were enrolled. Finger prick blood was collected to perform POCTs and results compared with standard laboratory investigations on venepuncture blood. Acceptability and operational characteristics were assessed using questionnaires. Diagnostic meta-analysis was used to combine data from the evaluation sites.

RESULTS

Based on laboratory tests, 23.46% (n = 598/2549) of participants were confirmed HIV positive, and 35.88% of participants (n = 901/2511) were positive on treponemal reference testing. Of all participants showing evidence of antibodies to Treponema pallidum, 50.56% (n = 455/900) were Rapid Plasma Reagin (RPR) test reactive. Of HIV positive individuals, 60.62% (n = 354/584) had evidence of antibodies to T. pallidum, and of these 60.45% (n = 214/354) exhibited reactive RPR tests indicating probable (co)infection. For Bioline POCT, pooled sensitivities and specificities for HIV were 98.95% and 99.89% respectively, and for syphilis were 73.79% and 99.57%. For Chembio pooled sensitivities and specificities for HIV were 98.66% and 99.55%, and for syphilis were 78.60% and 99.48%. Both tests can detect greater than 90% of probable active syphilis cases, as defined by reactive RPR and treponemal test results. These dual POCTs were preferred by 74.77% (n = 1,926) of participants, due to their convenience, and the operational characteristics made them acceptable to health care providers (HCPs).

CONCLUSIONS

Both the Bioline and the Chembio dual POCT for syphilis and HIV had acceptable performance, acceptability and operational characteristics amongst MSM in the PRoSPeRo network. These dual POCTs could serve as a strategic, more cost effective, patient and healthcare provider (HCP) friendly alternative to conventional testing; in clinical and other field settings, especially those in resource-limited settings.

A blueprint for health technology assessment capacity building: lessons learned from Malta

OBJECTIVES

The development and strengthening of health technology assessment (HTA) capacity on the individual and organizational level and the wider environment is relevant for cooperation on HTAs. Based on the Maltese case, we provide a blueprint for building HTA capacity.

METHODS

A set of activities were developed based on Pichler et al.'s framework and the starting HTA capacity in Malta. Individual level activities focused on strengthening epidemiological and health economic skills through online and in-person training. On the organizational level, a new HTA framework was developed which was subsequently utilized in a shadow assessment. Awareness campaign activities raised awareness and support in the wider environment where HTAs are conducted and utilized.

RESULTS

The time needed to build HTA capacity exceeded the planned two years accommodating the learning progress of the assessors. In addition to the planned trainings, webinars supplemented the online courses, allowing for more knowledge exchange. The advanced online course was extended over time to facilitate learning next to the assessors' daily tasks. Training sessions were added to implement the new economic evaluation framework, which was utilized in a second shadow assessment. Awareness by decision-makers was achieved with reports, posters, and an article on the current and developing HTA capacity.

CONCLUSIONS

It takes time and much (hands-on) training to build skills for conducting complex assessment such as HTAs. Facilitating exchange with knowledgeable parties is crucial for succeeding as well as the buy-in of local managers motivating staff. Decision-makers need to be on-boarded for the continued success of HTA capacity building.

The discovery of Moniliformis saudi (Acanthocephala: Moniliformidae) in the Algerian hedgehog Atelerix algirus in Malta: morphological, molecular, and metal analyses

The acanthocephalan Moniliformis saudi Amin, Heckmann, Mohammed, Evans, 2016 was originally described from the desert hedgehog, Paraechinus aethiopicus (Ehrenberg) in central Saudi Arabia. The distribution of P. aethiopicus extends to North Africa and west to Mauritania. Moniliformis saudi was recently found in the Algerian hedgehog Atelerix algirus (Lereboullet) in Malta. The distribution of A. algirus is restricted to the North African and east Iberian Mediterranean coast and associated islands. Both host species cohabit and share the same feeding grounds in northern Algeria where common infections appear to take place. The morphology of specimens from both acanthocephalan populations was similar, with minor variations mostly related to the relatively larger Maltese specimens especially the trunk and the male reproductive system. Taxonomic features like the cone-shaped anterior trunk, size and formula of proboscis and hooks, the receptacle, size and shape of eggs, anatomy of the apical proboscis sensory pores, and the stellate body wall giant nuclei were, however, practically identical. SEM and microscope images of specimens of the Maltese population emphasize their qualitative characteristics such as the degree of the extreme spiral muscle development and the development of the posterior nucleated pouches of the proboscis receptacle. Proboscis hooks of specimens from both the Maltese and the Saudi populations had similarly high levels (percent weights) of calcium, moderate levels of phosphorus, and minimal levels of sulfur, magnesium and sodium marking the diagnostic value of the Energy Dispersive x-ray analysis in species recognition. Newly generated partial sequences of the 18S ribosomal RNA and cytochrome C oxidase subunit 1 (Cox1) of the mitochondrial gene were generated from M. saudi from Malta. Moniliformis saudi from Malta, when compared with other available sequences of the same species isolates available in the GenBank database, formed a strongly supported clade with other congeners. The comparison of the molecular profiles of specimens from populations in Malta, Spain, and Saudi Arabia shows no or low genetic variation between them. Ultimately, we provide a morphological and molecular description of a new population of M. saudi from a new host species in a new geographical location, vastly exceeding the originally described ones from Saudi Arabia. A Cox 1 haplotype network inferred with 10 sequences revealed the presence of eight haplotypes, one of which was shared between the populations of Malta and Spain of M. saudi.

Squamous cell carcinoma and MYH9-associated elastin aggregation (MALTA) syndrome

MYH9-associated elastin aggregation (MALTA) syndrome is a rare inherited syndrome of irregular elastin aggregation and sweat duct proliferation associated with pathogenic variants in MYH9. MALTA syndrome was first proposed in 2019, unifying Nicolau–Balus and Rombo syndromes as phenotypes arising from pathogenic variants in the same gene; however, it has not been associated with cutaneous squamous cell carcinoma (cSCC). Here, we report the clinical features of a family with a novel MYH9 c.1952A>C p.(Lys651Thr) pathogenic variant, providing evidence that cSCC development may be an associated feature of MALTA syndrome.

Evolutionary and spatiotemporal analyses reveal multiple introductions and cryptic transmission of SARS-CoV-2 VOC/VOI in Malta

IMPORTANCE

Our study provides insights into the evolution of the coronavirus disease 2019 (COVID-19) pandemic in Malta, a highly connected and understudied country. We combined epidemiological and phylodynamic analyses to analyze trends in the number of new cases, deaths, tests, positivity rates, and evolutionary and dispersal patterns from August 2020 to January 2022. Our reconstructions inferred 173 independent severe acute respiratory syndrome coronavirus 2 introductions into Malta from various global regions. Our study demonstrates that characterizing epidemiological trends coupled with phylodynamic modeling can inform the implementation of public health interventions to help control COVID-19 transmission in the community.

Case study: the development of specialist nurse roles in Malta

Specialist nurses play a significant role in healthcare. This study investigated and evaluated the primary and extended roles and the development of specialist nurses in Malta.

METHODS

A qualitative case study design and purposive sampling techniques were used to gain a deep understanding of the complex issues surrounding specialist nurses from multiple data sets. A survey of the total specialist nurse population in 2013 (n=27), in-depth interviews with a group of specialist nurses (n=9) and four focus groups with key professionals and policy stakeholders (total n=28) were carried out. Data were collected between 2013 and 2015 and analysed using thematic analysis.

FINDINGS

Three themes emerged: the roles and attributes of specialist nurses in Malta; the development of specialist nurses; and the influences on the advancement of specialist nursing practice in Malta. Although these data are nearly a decade old, no further research has been carried out.

CONCLUSIONS

A legally accepted set of definitions as well as preparation and evaluation of the specialist nurse role from a national policy perspective is needed. Attitudes and systems that limit specialist nurses need to be challenged.

Rehabilitation Nurses' Knowledge About Pain in Older Adults in Malta

PURPOSE

Rehabilitation nurses require adequate knowledge about pain to improve patient experience and quality of care. We explored nurses' knowledge and attitudes towards pain in older adults in a large rehabilitation hospital in Malta.

DESIGN

A cross-sectional study.

METHODS

In total, 130 nurses received a short survey, which gathered sociodemographic data, information regarding usual pain management, and prior education on pain. A modified version of the Knowledge and Attitudes Survey Regarding Pain (KASRP) with 18 questions was used, alongside the 24-item Pain in the Older Adults' Knowledge Survey (POAKS). Non-parametric tests identified factors associated with KASRP and POAKS scores.

RESULTS

Overall, 89 nurses completed the survey (response rate 68%). The median modified KASRP score was 50% (IQR 3.00), with only two nurses achieving the proposed "adequate" score of >80%. The median POAKS score was 79% (IQR 4.00). The only determinant of performance was nationality, with Maltese nurses performing better in POAKS than non-Maltese nurses (median 20.00 (3.00) vs. 16.50 (5.00); p = .003), indicating a possible language-related performance issue. Nurses scored poorly in some questions relating to analgesia administration, particularly opioids, as well as pain indicators and pain assessment.

CONCLUSIONS

Rehabilitation nurses have fair knowledge of pain management in older people but require further education, particularly in opioid indications for pain management, pain expression, and assessment.

Improving physiotherapy students' anatomy learning experience and short-term knowledge retention-An observational study in Malta

Anatomy is physiotherapy's foundation. However, undergraduate classroom learning and knowledge acquisition-retention remain questionable. This study explored the possibility of improving this learning experience and evaluates the gross anatomy of abdomen and pelvis short-term knowledge retention among first-year physiotherapy students in Malta. The online Kahoot! game-based quiz platform was used through an instructor-designed best-of-four multiple-choice questions. Correctly answered questions and Kahoot! scores generated by the platform were utilized to measure knowledge retention. Kahoot! sessions 1 and 3 shared similar attendance and response rate and were compared together. The Mann-Whitney U test was used to compare Kahoot! scores and Chi test for trend to compare correctly answered questions. Students' perceived learning experiences before and after the introduction of the Kahoot quizzes were gathered through Likert scores and analyzed using McNamar's chi-square test. Overall, a significantly increased trend in correctly answered questions (χ2 : 23.38, p-value: <0.001) across the Kahoot! sessions were evident. Four questions out of 12 exhibited significant Kahoot! scores differences. Students reported better learning experiences following the initiation of Kahoot! (χ2 : 5.1, p-value: 0.02). Indeed, all students agreed that the use of the interactive quiz improved their anatomy short term knowledge retention. Introducing an online interactive quiz as part of the lecture program may be useful to improve the learning experience and anatomy knowledge retention among physiotherapy students.

Remote workers' perceived health during the COVID-19 pandemic: an exploratory study of influencing factors in the IT and communications sector in Malta

The COVID-19 pandemic resulted in a sudden switch to remote working that many organisations and workers were unprepared for. The study investigates the perceived impact of remote working on workers' health and influencing factors. The topic has received limited attention within published studies. A cross-sectional online survey was distributed to IT and communication remote workers in Malta (N=459). Closed-ended questions were analysed quantitatively in order to identify perceived changes in health. Open-ended questions were analysed qualitatively to determine the perceived reasons for such changes. More workers reported that their health had deteriorated than improved during the first 12 months of the pandemic. Greater proportions of remote work were associated with improved levels of health. Several factors were perceived to have influenced levels of health, including: health behaviours, such as physical activity, nutrition, and sleep; the development of disease, particularly mental health issues; work related factors, such as social support, work demands, and the blurring of work-life boundaries; and personal factors, including family life and leisure. The study concludes that remote working can be beneficial for health when workers engage in the correct health-promoting behaviours and are provided with the necessary support, both during their working and private life.

Accessing abortion in a highly restrictive legal regime: characteristics of women and pregnant people in Malta self-managing their abortion through online telemedicine

OBJECTIVE

To examine the numbers and characteristics of women and pregnant people in Malta seeking at-home medical abortion using online telemedicine from 2017 to 2021.

DESIGN

Population-based study.

SETTING

Republic of Malta PARTICIPANTS: Between 1 January 2017 and 31 December 2021, 1090 women and pregnant people requested at-home medical abortion through one online telemedicine provider (Women on Web). Mifepristone and misoprostol were shipped to 658 women (60.4% of requests).

MAIN OUTCOME MEASURES

The numbers and demographics of persons to which abortion pills were shipped, their reasons for accessing abortion, and reasons for requesting medical abortion via telemedicine between January 2017 and December 2021 were analysed. Selected data were compared across different groups.

RESULTS

The number of people in Malta to whom medical abortion pills were shipped increased significantly in the 5 years analysed. Women and pregnant people requesting medical abortion were diverse with respect to age, pregnancy circumstances and reasons for seeking an abortion. More than half had existing children and over 90% reached out to Women on Web at <7 weeks. Among those completing a medical abortion, 63% did not use contraception, and in 30% there was contraception failure. The most common reasons for ordering medical abortion pills online were difficulty accessing abortion because of legal restrictions (73%) and abortion pills not being available (45%) in the country.

CONCLUSIONS

Despite a complete ban on abortion, the number of women and pregnant people residing in Malta completing at-home medical abortions is considerable and has been steadily increasing.

Rebreather Forum Four consensus statements

Closed circuit rebreathers have been widely adopted by technical divers as tools for reducing gas consumption and extending depth and duration capabilities. Rebreathers are technologically complex with many failure points, and their use appears associated with a higher accident rate than open circuit scuba. Rebreather Forum Four (RF4) was held in Malta in April 2023 attracting approximately 300 attendees and representatives of multiple manufacturers and training agencies. Over two and a half days a series of lectures was given by influential divers, engineers, researchers and educators on topics of contemporary relevance to rebreather diving safety. Each lecture was followed by a discussion session with audience participation. Potential consensus statements were drafted by the authors (SJM and NWP) during the course of the meeting. These were worded to be confluent with some important messages emerging from the presentations and subsequent discussions. The statements were presented one by one in a half-day plenary session of participants, and discussion was invited on each. After discussion and any necessary revision, the participants voted on whether to adopt the statement as a position of the forum. A clear majority was required for acceptance. Twenty-eight statements embracing thematic areas designated 'safety', 'research', 'operational issues', 'education and training', and 'engineering' were adopted. Those statements are presented along with contextualising narrative where necessary. The statements may help shape research and teaching initiatives, and research and development strategies over subsequent years.

A qualitative exploration of the experiences of post-mortem forensic imaging in Malta: A psychological perspective

INTRODUCTION

This study aimed to qualitatively explore the experiences of post-mortem forensic imaging on theatre and trauma radiographers from a psychological perspective at a general hospital in Malta.

METHODOLOGY

The study utilised purposive sampling to recruit five radiographers undertaking forensic post-mortem imaging in a general hospital in Malta. Individual face-to-face semi-structured interviews were held. Interpretative phenomenological principles and reflexivity were applied throughout the transcription and analysis phases.

RESULTS

Four themes were developed from the interpretive phenomenological analysis of semi-structured interviews: 'The impact of the imaging process,' 'Psychological distancing,' 'Finding meaning in work,' and 'Resource needs,' the latter comprising three subordinate themes: 'Protocols,' 'Physical resources,' and 'Psychological training.'

CONCLUSION

Forensic radiography is a rewarding area of practice yet one that can be complex and have a lasting psychological impact. Many factors including working close to the cadaver, a lack of appropriate training and staffing levels and a lack of evidence-based protocols were identified by participants as contributing to potential psychological stress and emotional distress.

IMPLICATIONS FOR PRACTICE

Exploration and evaluation of the psychological experiences of radiographers undertaking post-mortem imaging will inform the development of appropriate psychological services and reinforce the need for the appropriate application of best practice guidelines and protocols to support radiographers working on traumatic cases within forensic and general radiographic practice.

European IoT Use in Homes: Opportunity or Threat to Households?

The residential sector is characterized by new digital challenges. The Internet of Things (IoT) is a key-driver of innovation and operations management. This study aims to measure and assess IoT devices at the level of individuals, which are households, in European countries. For this scope, through the multi-criteria decision analysis (MCDA), we analyse data from Eurostat providing a mix of indicators allowing information to be aggregated at the level of individual Europeans and disaggregated by age group. The results highlight that only four countries (Netherlands, Denmark, Sweden and Malta) are classified as a high cluster in the examined scenarios. The 16-24 age group is the most involved in the uses of IoT devices, but the previous three northern European countries also show very high values for the 35-44 age group. IoT devices serve as a springboard for achieving a powerful propulsion toward technological innovation in the new business models, identifying opportunities and being a way to make many routine tasks more agile. Training programs and awareness campaigns are policy suggestions for the development of IoT devices favouring a cultural change on their use. However, there is an emerging need for studies that monitor environmental health impacts to prevent possible threats.

Living on a razor's edge: Experiences of mothers caring for a son on synthetic cannabinoids in Malta

Various studies have explored collectively the experiences of carers of individuals using illicit substances. Yet such experiences vary by gender, by relationship status to the substance user, by type of drug taken and whether the substance user lives within the same household. A hermeneutic phenomenological design was undertaken with five mothers of sons on synthetic cannabinoids (SC). These sons were receiving community mental health care following admission to hospital for episodes of drug-induced psychosis. Interview data were collected between August and October 2019. The transcribed texts were analysed using interpretative phenomenological analysis and interpreted using the Common-sense model. The superordinate theme 'Living on a Razor's edge' was extracted and consisted of two themes: 'A living Calvary' and 'Fighting a Lone battle'. The findings highlight the intense psycho-emotional suffering of the mothers, who experienced anxiety and fear relating to their welfare and that of the family; helplessness at not being able to communicate their concerns to their son and shame triggered by the judgmental attitude of others. Carers primarily associated the effects of SC such as psychotic episodes, to their sons being vulnerable individuals with mental health challenges rather than due to their drug habit. The mothers expressed feeling isolated as they could not turn to any family member or friends for support. The highly volatile and impulsive nature of their son further introduced a wedge between the female carer and her spouse, children, extended family and friends. Caring for a son on SC has a significant psycho-emotional and social impact on the mothers as informal carers. Hence, there is a need for a person-centred care approach to be provided, in which the shared understandings of the mothers narratives are explored and where their needs and concerns are integrated and addressed within a care plan.

From invisibility to inclusion: Opening the doors for older men at the University of the Third Age in Malta

Older men are highly under-represented in late-life learning programmes. In reaction, the University of the Third Age in Malta (U3A) planned and implemented an 'Older Men Learning in the Community' project that (i) employed advertising strategies targeting specifically older men; (ii) organized preliminary meetings with older men to elicit 'generative themes' for possible subject content; and (iii), prompted facilitators to employ novel teaching styles such as peer and situated learning approaches. Data demonstrated that older men were highly inclined to participate in learning activities that intrigued their interest, were deemed practical to their lives, and resonated with their occupational careers and generational habitus. Moreover, the U3A presented older men with a possibility to address perceived challenges to their masculinity following their retirement from work and physical aging. However, the study also emphasized that U3As must not let such an interest on older men serve to reinforce patriarchal and masculine hegemony. Rather than a late-life learning programme be designed to address older men's inclinations to learn about subjects that are not of interest to older women, it is certainly also valuable for future learning projects to organize learning programmes that enable older men to overcome misogynistic notions.

Dental continuing professional development - Part II: The Malta CPD Pilot Project

INTRODUCTION

Continuing professional development (CPD) remains voluntary in nine European countries. Evidence suggests a move towards mandatory CPD across Europe with the objective of harmonisation of dental CPD. Although the importance of CPD is acknowledged, the literature regarding its effectiveness is limited and under debate.

AIMS AND OBJECTIVES

The main aim was to measure the effectiveness and success of a new CPD programme with the objective to devise a strategy, guidelines and recommendations for the establishment of a dental CPD programme in Malta.

METHODOLOGY

This project was divided into two phases; Phase 1 was the analysis of a survey sent out to 135 members of the Dental Association of Malta. Phase 2 involved the evaluation of eight verifiable CPD events, through pre-event and post-event tests and feedback forms, to investigate the effect on short-term knowledge retention and the respective satisfaction levels of participants at each event.

RESULTS

The survey had a response rate of 78%. The CPD events in Phase 2 all showed statistically significant improvement in short-term knowledge retention on each subject (p < 0.05). Satisfaction levels ranged from 70% to 99%.

CONCLUSIONS

The information gathered from this project was used to provide guidelines and recommendations for the local regulatory body and CPD providers for the set-up of a dental CPD framework and programmes in Malta, a country where dental CPD is still voluntary. This article is the second article from a two-part series of articles about the Malta Dental CPD Pilot project.

Does optimal HbA1c in diabetes differ according to drug treatment? An evaluation of national electronic database in Malta

BACKGROUND AND AIMS

A J-shaped relationship between HbA_1c and mortality has been reported in subjects with type 2 diabetes. The postulated mechanism linking low HbA_1c with increased mortality is increased hypoglycaemia risk. We tested this hypothesis by comparing the relationship between low HbA_1c to mortality in patients on therapies with different hypoglycaemia risk.

METHODS

We selected patients on any type of treatment for diabetes from a national electronic database (n = 25,743) and linked to other databases, including laboratory database and the national mortality register.

RESULTS

We observed a J-shaped or U-shaped association between HbA_1c and all-cause mortality in the whole type 2 diabetes patient cohort as well as in patients on metformin monotherapy and in those on metformin-sulphonylurea combination therapy, but not in subjects on sulphonylurea monotherapy or in those on insulin.

CONCLUSIONS

Our data confirm the J-shaped relationship between HbA_1c and mortality in type 2 diabetes, but suggest that a low HbA_1c is deleterious even in absence of hypoglycaemia and that subjects with type 2 diabetes might require a slightly elevated blood glucose for optimal outcome. Our data also suggest that the increased mortality associated with sulphonylureas cannot be mediated solely through increased hypoglycaemia risk.

Outcomes of endovascular treatment for acute ischaemic stroke in Mater Dei Hospital, Malta

INTRODUCTION

The aim of this study was to assess the outcomes of endovascular treatment for acute ischaemic stroke in Mater Dei Hospital, Malta and compare them with international data.

METHODS

A prospective review of all patients who underwent mechanical thrombectomy from 2015 to the end of 2019 was performed. Eligible patients had large vessel occlusion confirmed on computed tomography angiography. Demographical data, the National Institutes of Health stroke scale at presentation, endovascular procedure details and process times were analysed. The thrombolysis in cerebral infarction score was used to assess the degree of reperfusion. A thrombolysis in cerebral infarction score of 2b-3 was considered as successful recanalisation. Functional outcome (modified Rankin scale score) and mortality at 90 days were measured. Functional independence was defined as a modified Rankin scale score of 2 or less.

RESULTS

A total of 132 patients underwent endovascular treatment, one patient was excluded due to incomplete data. The mean age was 71 (range 25-94) years, and the mean National Institutes of Health stroke scale at presentation was 14. Of the 131 patients treated, 69 received intravenous thrombolysis. Successful recanalisation (thrombolysis in cerebral infarction score 2b-3) was achieved in 80% of patients (105/131); 53% of patients (69/131) achieved functional independence at 90 days, with a mortality of 21% at 90 days. Symptomatic intracranial haemorrhage was recorded in 16 patients (12%) There was a statistical difference in the functional independence and mortality rate in favour of the successful recanalisation group.

CONCLUSION

Our data are consistent with a favourable clinical outcome after successful recanalisation. Service in Malta is achieving favourable outcomes for patients treated with mechanical thrombectomy for acute ischaemic stroke.

Secondhand smoke exposure in school children in Malta assessed through urinary biomarkers

School children may be exposed to secondhand smoke (SHS) either at home, in transit or in social gatherings permitting smoking in their presence. Questionnaires about SHS often underestimate prevalence and extent of exposure. A more accurate tool is the use of biomarkers such as cotinine (COT) and trans-3'-hydrocycotinine (3HC) as biomarkers of SHS exposure, alongside 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a reduction product in the body of the tobacco-specific nitrosamine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), both potent carcinogens. We measured urinary COT, 3HC and total NNAL using sensitive and specific high-performance LC-MS/MS methods. The limit of quantification (LOQ) for each assay were 0.05 ng/mL, 0.1 ng/mL and 0.25 pg/mL respectively. The aim of this study was to evaluate the exposure to SHS of school children (9-11 years), from five public schools in the island of Malta, from questionnaire information about smoking at home and verify it by urinary biomarker data of COT, 3HC and NNAL. These biomarkers were measurable in 99.4%, 95.4% and 98.3% of the participating children respectively. From the children reporting smoking at home, 11% had a history of asthma and had COT, 3HC and NNAL geometric mean concentrations double compared to the non-asthmatic group. In has been confirmed that non-smokers exposed to SHS and THS have a higher NNAL/COT ratio than the group identified as smokers according to specific and defined COT threshold levels (despite the fact that a priori, the entire study group was composed of non-smokers). The implication of high measured levels of urinary NNAL in children should be of concern given its potency. A main effects multifactor ANOVA model was developed and the children's house and school locations and the smoking frequency were statistically significant to predict the levels of the three metabolites. For 3HC only, the status of the employment of the mother was also an important predictor.

Caring for a parent with pulmonary fibrosis in Malta: The lived experiences of daughters in mid-adulthood

Idiopathic pulmonary fibrosis is a progressive fibrotic lung disease that is on the rise globally. The disease is associated with significant morbidity and hence poses significant challenges for their informal carers, particularly daughters in mid-adulthood, who struggle with their own personal demands and that of their ill parents. Yet there is a dearth of literature on the experiences of these specific carers. Hence, the purpose of this study is to explore the lived experiences of daughters caring for a parent with pulmonary fibrosis within a community setting. This was explored using a phenomenological qualitative framework that was conducted between January and April 2017. Semi-structured audio-recorded interviews were conducted with six adult daughters who provided care to a parent having pulmonary fibrosis. Purposive sampling was used to recruit study participants. Transcribed data were analysed using Interpretative Phenomenological Analysis. Three main themes were extracted which communicate the essence of the daughters' lived experiences: "Walking on tiptoes", "Flooded by emotions" and "Shifts in family dynamics." Participants described experiencing the toll of being constantly vigilant for symptoms. They also expressed a range of emotions that included guilt, helplessness and worry related to their care experience. However, these emotional struggles were suppressed in order to present an external facade of strength and control. A shift in roles was also described where the daughters became the informal carers/support for both their ill and well parent, albeit in different ways. Caring for a person with pulmonary fibrosis is an emotional and life changing experience and hence, there is the need for individualised interventions that target the unique perceptions of these informal carers.

Mortality comparisons of COVID-19 with all-cause and non-communicable diseases in Cyprus, Iceland and Malta: lessons learned and forward planning

OBJECTIVES

The COVID-19 pandemic has spread throughout the world, including Cyprus, Iceland and Malta. Considering the small population sizes of these three island countries, it was anticipated that COVID-19 would be adequately contained and mortality would be low. This study aims to compare and contrast COVID-19 mortality with mortality from all causes and common non-communicable diseases (NCDs) over 8 months between these three islands.

METHODS

Data were obtained from the Ministry of Health websites and COVID dashboards from Cyprus, Iceland and Malta. The case-to-fatality ratio (CFR) and years of life lost (YLLs) were calculated. Comparisons were made between the reported cases, deaths, CFR, YLLs, swabbing rates, restrictions and mitigation measures.

RESULTS

Low COVID-19 case numbers and mortality rates were observed during the first wave and transition period in Cyprus, Iceland and Malta. The second wave saw a drastic increase in the number of confirmed cases and mortality rates, especially for Malta, with high CFR and YLLs. Similar restrictions and measures were evident across the three island countries. Results show that COVID-19 mortality was generally lower than mortality from NCDs.

CONCLUSIONS

The study highlights that small geographical and population size, along with similar restrictive measures, did not appear to have an advantage against the spread and mortality rate of COVID-19, especially during the second wave. Population density, an ageing population and social behaviours may play a role in the burden of COVID-19. It is recommended that a country-specific syndemic approach is used to deal with the local COVID-19 spread based on the population's characteristics, behaviours and the presence of other pre-existing epidemics.

Adverse reactions to Pfizer-BioNTech vaccination of healthcare workers at Malta's state hospital

BACKGROUND

The long-term control of COVID-19 depends on an effective global vaccination strategy. Protecting healthcare workers (HCWs) from serious infection is critical. Malta, a European country, initiated the vaccination roll-out using Pfizer-BioNTech COVID-19 vaccine targeting HCWs. This study determined vaccination adverse effects (AEs) in this cohort.

METHOD

An online survey was disseminated to all HCWs via work email (29/3/21 to 9/4/21) to gather AEs regarding pain, redness and swelling at injection site, fever, chills, fatigue, muscle/joint pains, headache, vomiting and diarrhoea severity following each dose (Likert scale). Descriptive, comparative and multiple binary regression analyses were performed.

RESULTS

A response of 30.30% (n = 1480) was achieved with the commonest AEs being pain at injection site (88.92% CI 95%: 87.21-90.42), mostly mild (51%) and moderate (43%). Fatigue was reported by 72.97% (CI 95%: 70.65-75.17), 42% were mild and 41% were moderate. Females reported significantly (P ≤ .05, respectively) more pain (OR: 1.90), redness (OR: 2.49), swelling at injection site (OR: 1.33), fever (OR: 1.74), chills (OR: 2.32), fatigue (OR: 2.43), muscle (OR: 1.54) and joint pains (OR: 2.01), headache (OR: 2.07) and vomiting (OR: 3.43) when adjusted for age and HCW role. Localised AEs were reported following both vaccine doses unlike systemic AEs that were mostly reported after second doses.

CONCLUSION

Vaccination benefits outweigh the minor AEs experienced, with females exhibiting a higher susceptibility. The general low vaccination AEs observed within the HCW cohort is encouraging and should help in allaying vaccine hesitancy among the population.

Disaster preparedness and cultural factors: a comparative study in Romania and Malta

This exploratory study investigates the relationships between the disaster preparedness of citizens and cultural factors in Romania and Malta. With regard to methodology, quantitative and qualitative data were collected during two Citizen Summits, which consisted of a real-time survey and focus group discussions. The results point to two specific cultural factors that may bridge this 'gap' and be operationalised to enhance people's readiness for a disaster event. In Malta, the findings reveal how community cohesion is altered from a personal to a cultural value, which has the potential to encourage the transformation of preparedness intentions into actual preparedness behaviour. In Romania, meanwhile, the findings highlight the ambivalent aspects of trusting behaviour as a cultural norm on the one hand, and distrust in authorities based on experience and unmet expectations on the other hand. Social media use may reduce this tension between trust and distrust, and thus foster successful disaster risk-related communication.

The Impact of COVID-19 on Hospitalised COPD Exacerbations in Malta

METHOD

Data was collected retrospectively from electronic hospital records during the periods 1st March until 10th May in 2019 and 2020.

RESULTS

There was a marked decrease in AECOPD admissions in 2020, with a 54.2% drop in admissions (n = 119 in 2020 vs. n = 259 in 2019). There was no significant difference in patient demographics or medical comorbidities. In 2020, there was a significantly lower number of patients with AECOPD who received nebulised medications during admission (60.4% in 2020 vs. 84.9% in 2019; p ≤ 0.001). There were also significantly lower numbers of AECOPD patients admitted in 2020 who received controlled oxygen via venturi masks (69.0% in 2020 vs. 84.5% in 2019; p = 0.006). There was a significant increase in inpatient mortality in 2020 (19.3% [n = 23] and 8.4% [n = 22] for 2020 and 2019, respectively, p = 0.003). Year was found to be the best predictor of mortality outcome (p = 0.001). The lack of use of SABA pre-admission treatment (p = 0.002), active malignancy (p = 0.003), and increased length of hospital stay (p = 0.046) were also found to be predictors of mortality for AECOPD patients; however, these parameters were unchanged between 2019 and 2020 and therefore could not account for the increase in mortality.

CONCLUSIONS

There was a decrease in the number of admissions with AECOPD in 2020 during the COVID-19 pandemic, when compared to 2019. The year 2020 proved to be a significant predictor for inpatient mortality, with a significant increase in mortality in 2020. The decrease in nebuliser and controlled oxygen treatment noted in the study period did not prove to be a significant predictor of mortality when corrected for other variables. Therefore, the difference in mortality cannot be explained with certainty in this retrospective cohort study.

A preliminary study into the use of tree-ring and foliar geochemistry as bio-indicators for vehicular NOx pollution in Malta

Emissions from traffic over the past few decades have become a significant source of air pollution. Among the pollutants emitted are nitrogen oxides (NO_x), exposure to which can be detrimental to public health. Recent studies have shown that nitrogen (N) stable isotope ratios in tree-rings and foliage express a fingerprint of their major N source, making them appropriate for bio-monitoring purposes. In this study, we have applied this proxy to Aleppo pines (Pinus halepensis) at three distances from one of the busiest roads in Malta, a country known to suffer from intense traffic pollution. Our results showed that N and organic carbon (C) stable isotope ratios in tree-rings do not vary over the period 1980-2018 at any of the investigated sites; however, statistically significant spatial trends were apparent in both tree-rings and foliage. The roadside and transitional sites exhibited more positive δ¹⁵N and more negative δ¹³C values compared to those at a rural control site. This is likely due to the incorporation of ¹⁵N-enriched NO_x and ¹³C-depleted CO₂ from traffic pollution. Sampled top-soil also exhibited the δ¹⁵N trend. Our results constitute the first known application of dendrogeochemistry to atmospheric pollution monitoring in Malta.

Extended study on floating litter in Malta's coastal waters (Central Mediterranean)

This study aims to determine the level of floating marine litter in coastal and inshore areas around Malta and Gozo (Central Mediterranean) and to investigate factors which influence litter distribution. Observations of macro-litter and mega-litter were conducted through seasonal boat surveys around Malta and Gozo during 2018-2019. Visual observations were conducted along line transects whilst maintaining a 6 m observation width. For coastal areas, of up to -1 km away from the shoreline, the total density of litter ranged between 27 and 2428 items/km², with a mean of 292 ± 85 items/km². Within inshore areas the density varied between 180 and 46,289 items/km², with a mean of 3242 ± 1880 items/km². The highest density was present in winter, this being 2.5 higher than the lowest density season. 91% of the litter was plastic. The manner in which anthropogenic factors and natural events influenced litter accumulations and distributions, are described.

Asylum Caseworkers' Experience Working in Lesvos: A Grounded Theory Analysis

PURPOSE

Assisting asylum applicants through their procedure for international protection implies a commitment that most caseworkers accept with deep satisfaction. However, working with asylum applicants who disclose the claim for protection and stories of their journey can be challenging and distressing. The study aimed to understand the experience of caseworkers with the asylum applicants in Lesvos, specifically, the challenges they face and their perception of the qualities that facilitated or inhibited coping.

METHOD

A grounded theory analysis within a constructivist framework involved interviews with thirteen caseworkers, cultural mediators, and operations officers in Levos and Malta.

FINDINGS

A two-phase analysis was conducted due to unexpected findings. The first phase of the analysis uncovered the challenges posed by the work itself, and the caseworkers' personal characteristics which were either helping or hindering addressing these challenges. The second analysis revealed a four-step process as perceived by the asylum caseworkers: starting from the work context, facing challenges, finding ways to respond to them, and finally, the effect that this process had on the caseworkers' perspective about themselves and life.

CONCLUSION

For those who developed adaptative coping, interviews indicated a process of transformation in the caseworkers' perception, a new sense of self and world view, including the development of self-awareness, personal power, the relation to work and the refugees, and a deeper cultural understanding. Recommendations are provided for caseworkers' mental-health and operational support as well as for future research.

Spiritual coping strategies and quality of life in older adults who have sustained a hip fracture: A cross-sectional survey

AIMS

To investigate the relationship between spiritual coping strategies and quality of life in persons with a hip fracture.

DESIGN

A correlational, cross-sectional survey design.

METHODS

The total population of Maltese-speaking adults over 65 years (N = 299), with a hip fracture receiving treatment in a public hospital in Malta in 2015, were invited. The WHOQOL-BREF questionnaire and the Spiritual Coping Strategies Scale were used.

RESULTS

A response rate of 51% (n = 147) was achieved. The poorest quality of life was for the physical and psychological domains. Spiritual coping strategies were associated with better quality of life with the exception of physical quality of life. Non-religious coping strategies were the stronger predictor of quality of life compared with religious coping strategies. The former predicted physical, psychological, environmental, social and overall quality of life.

CONCLUSION

Hip fractures have serious implications on quality of life which could be improved by promoting non-religious spiritual coping strategies.

Cervical cancer and screening: knowledge, awareness and attitudes of women in Malta

Objectives

This study comes at an opportune time due to recent introduction of the National Cervical Cancer Screening programme in Malta. It aims to assess the knowledge of 25-64 year-old females on cervical cancer and attitudes towards screening.

Study design

A cross-sectional, telephone-based, quantitative survey conducted in 2017.

Methods

The survey tool was based on the Cervical Cancer Awareness Measure questionnaire and was carried out among a random stratified sample of females of 25-64 years, resident in Malta. Multivariate logistic regression models were applied.

Results

407 females (85% response rate) were interviewed. Knowledge of cervical cancer risk factors and symptoms was found to be significantly higher in women with a higher level of education (p < 0.001). Cervical screening was attended every 3 years by 69% of respondents. Regular attendees were more likely to have children (p = 0.001), have experienced cancer in a close family member (p = 0.002), and were between 35-44 and 45-54 years old (p < 0.001). The main reasons for non-attendance were embarrassment, fear of the test and fear of the result.

Conclusion

This research provides a better understanding of who are the vulnerable groups with respect to cervical cancer knowledge and screening attendance. Improving health literacy and implementing health promotion campaigns will improve early symptom recognition, risk factor knowledge and attendance for screening.

Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: A qualitative study with general practitioners in Malta

BACKGROUND

Antibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta.

METHODS

Face-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour.

FINDINGS

We found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed.

CONCLUSION

This study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment.

TRIAL REGISTRATION NUMBER

NCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930.

ESTABLISHING LOCAL AND NATIONAL DIAGNOSTIC AND INTERVENTIONAL CARDIOLOGY AND RADIOLOGY REFERENCE LEVELS IN A SMALL EUROPEAN STATE: THE CASE OF MALTA

European Directive 2013/59/EURATOM requires the establishment and use of diagnostic reference levels (DRLs) for diagnostic and interventional procedures. The purpose of this study was to establish local DRLs for a major tertiary public hospital. As the hospital is the only such hospital in Malta, the same data collected for setting local DRLs can also be used for setting national DRLs, making local DRLs de facto national DRLs. A retrospective survey of cumulative kerma-area product (KAP) and fluoroscopy time data from the cardiac catheterisation laboratory and interventional radiology suites was carried out. The effect of system upgrades on cumulative KAP was also assessed. Local DRLs were set for common cardiology and interventional radiology procedures. All DRLs compare favourably with those in European literature. A Philips Allura Clarity upgrade to the cardiac catheterisation laboratories led to significant reductions in cumulative KAP (p ≪  0.05) for most procedures.

Attitudes of Medical Students in Malta Toward Psychiatry and Mental Illness

OBJECTIVE

The study aimed to explore the attitudes of medical students in Malta toward psychiatry and mental illness. It looked at the effect of sex, clinical exposure, and experience with mental illness on students' attitudes.

METHODS

A questionnaire containing the ATP 30 and MICA-2 scales was distributed to all medical students in Malta in a cross-sectional study. Factor analysis was followed by reliability testing using Cronbach Alpha. Factor scores were achieved using the regression method. The independent sample t test and the Mann-Whitney U test were used to check for relationships between factor scores and variable of interest. Following this, the means and medians of factor scores for each group were calculated and compared.

RESULTS

Three hundred ninety-six students (51%) answered the questionnaire. Males had more positive attitudes toward psychiatry as a career choice (p = 0.01) and more positive attitudes toward the importance of psychiatry (p = 0.00). Those with clinical exposure to psychiatry had more negative attitudes toward the efficacy of psychiatry and psychiatrists (p = 0.00). Having experience with mental illness in some form was associated with decreased appeal in psychiatry as a career (p = 0.01 for personal experience, p = 0.01 for relatives, p = 0.00 for friends).

CONCLUSIONS

The factor structures obtained using ATP 30 and MICA-2 scales in this study are different from those found in the original literature. Having undergone psychiatry rotations had no significant impact on the attitudes toward psychiatry as a career choice but led to more negative attitudes toward the efficacy of psychiatry and psychiatrists.

Dementia knowledge, attitudes and training needs of speech-language pathology students and practitioners: A countrywide study

BACKGROUND

Due to dementia-related communication difficulties, speech-language pathologists (SLPs) play a significant role in supporting individuals with dementia and their caregivers. Nevertheless, SLP practitioners may not have received adequate dementia training during their undergraduate programme and skills updating post-qualification. Investigating the knowledge, attitudes and training needs of SLP students and practitioners would provide evidence on the need of enhancing training in dementia care and management at both the undergraduate level and through continuous professional development programmes.

AIMS

To assess the levels of dementia knowledge, attitudes and training needs of SLP students and practitioners.

METHODS & PROCEDURES

A countrywide survey was conducted with undergraduate students reading for a BSc degree in communication therapy and SLPs currently in practice. Dementia knowledge and attitudes were assessed using the Alzheimer's Disease Knowledge Scale (ADKS) and the Dementia Attitude Scale (DAS). Training needs were measured using a three-point Likert scale from a list of topics related to dementia management and care. Quantitative methods were used to analyse the collected data.

OUTCOMES & RESULTS

A total of 49 SLP students (94.2% response rate) and 113 practitioners (57.4% response rate) completed the survey. Although SLP practitioners scored significantly better than students on the ADKS and its constructs, both cohorts showed inadequate knowledge of dementia, in particular dementia risk factors. In general, both SLP students and practitioners showed positive attitudes towards individuals with dementia, even though significant differences were observed. With respect to training needs, SLP practitioners significantly scored less compared with students denoting that, in this cohort, there was the belief that less training in dementia was required.

CONCLUSIONS & IMPLICATIONS

Although SLPs have an important role to play in the management and care of individuals with dementia, the findings of this study indicated a shortage of in-depth knowledge in this area of practice. This continues to highlight the need of enhancing dementia training programmes through undergraduate curriculum development and continuous professional programmes for skills updating. What this paper adds What is already known on the subject One of the symptoms of dementia is that affected individuals progressively lose the ability to communicate effectively. With an increase in the number of people with dementia due to global ageing growth, SLPs are more likely to come into contact with such individuals and their caregivers. At present, there is little research on the levels of dementia knowledge, attitudes and training needs among individuals pursuing their career in this profession. What this paper adds to existing knowledge This study highlights a dearth of in-depth knowledge among undergraduate students and practising SLPs in various aspects of dementia management and care and argues on the need of enhancing training in this field of study. What are the potential or actual clinical implications of this work? Improving SLPs' knowledge on dementia can enhance their professional role in several areas, including the provision of information on risk factors, disease progression and its effect on communication abilities, screening of cognitive communication difficulties and developing management plans aimed at maintaining communication abilities at the highest level.

Spotlight on the Shift to Remote Anatomical Teaching During Covid-19 Pandemic: Perspectives and Experiences from the University of Malta

Covid-19 has spread globally, affecting all nations. Preventive measures were implemented by governments including the closure of universities. The aim of this study was to evaluate the student's perspectives and experiences on the shift to remote preclinical medical education while inquiring whether there has been any psychological impact on the students. A customized questionnaire utilizing Likert-scale-based questions and the Generalized Anxiety Disorder-7 assessment tool was distributed online to enrolled preclinical medical students at the Faculty of Medicine and Surgery at the University of Malta. Quantitative and qualitative analyses of the data gathered was carried out. Multivariate logistic regression analyses was performed to establish independent variables associated with anxiety symptoms. A total of 172 responded out of a cohort of 299 preclinical students (58%). The majority perceived a positive learning experience following the shift to remote lectures, however, it was not the case for small group teaching including dissection sessions. Nonetheless students reported concerns about their education, examinations, progression to next academic year and wellbeing. Less than half the students exhibited symptoms of anxiety. Students exhibiting "moderate" worry (OR:7.6; CI 95%:1.98-29.31; P < 0.01) and "severe" worry (OR: 2.0; CI 95%: 5.0-80.5; P < 0.01) on their mental, emotional, and wellbeing due to Covid-19 were associated with anxiety symptoms after adjusting for cofounders. Apart from the short-term effects, the Covid-19 pandemic may have a long-term impact on both the medical education and the students' future careers. It is important that the implemented changes in medical education are recorded and studied since such data will be essential on how to proceed post-Covid-19 pandemic.

The first wave of COVID-19 in Malta; a national cross-sectional study

Introduction

The COVID-19 pandemic has posed major challenges to all aspects of healthcare. Malta’s population density, large proportion of elderly and high prevalence of diabetes and obesity put the country at risk of uncontrolled viral transmission and high mortality. Despite this, Malta achieved low mortality rates compared to figures overseas. The aim of this paper is to identify key factors that contributed to these favorable outcomes.

Methods

This is a retrospective, observational, nationwide study which evaluates outcomes of patients during the first wave of the pandemic in Malta, from the 7^th of March to the 24^th of April 2020. Data was collected on demographics and mode of transmission. Hospitalization rates to Malta’s main general hospital, Mater Dei Hospital, length of in-hospital stay, intensive care unit admissions and 30-day mortality were also analyzed.

Results

There were 447 confirmed cases in total; 19.5% imported, 74.2% related to community transmission and 6.3% nosocomially transmitted. Ninety-three patients (20.8%) were hospitalized, of which 4 were children. Patients with moderate-severe disease received hydroxychloroquine and azithromycin, in line with evidence available at the time. A total of 4 deaths were recorded, resulting in an all-cause mortality of 0.89%. Importantly, all admitted patients with moderate-severe disease survived to 30-day follow up.

Conclusion

Effective public health interventions, widespread testing, remote surveillance of patients in the community and a low threshold for admission are likely to have contributed to these favorable outcomes. Hospital infection control measures were key in preventing significant nosocomial spread. These concepts can potentially be applied to stem future outbreaks of viral diseases. Patients with moderate-severe disease had excellent outcomes with no deaths reported at 30-day follow up.

Religion, Health, Social Capital and Place: The Role of the Religious, Social Processes and the Beneficial and Detrimental Effects on the Health and Wellbeing of Inhabitants in Deprived Neighbourhoods in Malta

This paper emphasises the important role that place has in determining how religious social processes operate and impact on health and wellbeing. It draws upon evidence through qualitative in-depth interviews with families (both parents and children) living in two deprived neighbourhoods in Malta, a 'traditional' and a 'modern' one. It emerged that religious faith and practices can generate normative and resource-based social capital which can positively impact on health and wellbeing. However, some individuals found this social capital constraining and this had detrimental effects on their wellbeing. The context, composition, history and norms of the place emerge as highly important. This study emphasises that religious social processes operate in a highly complex manner, and 'adherents' and 'disaffiliates' are likely to enjoy positive or negative health and wellbeing according to where they live and according to important persons living in the neighbourhood such as the parish priest. This study contributes to the research gap between religion, social capital and health and the complex, social processes that operate at the local level of place.

Common patterns of functional and biotic indices in response to multiple stressors in marine harbours ecosystems

Evaluating the effects of anthropogenic pressure on the marine environment is one of the focal objectives in identifying strategies for its use, conservation and restoration. In this paper, we assessed the effects of chemical pollutants, grain size and plastic litter on functional traits, biodiversity and biotic indices. The study was conducted on the benthic communities of three harbours in the central Mediterranean Sea: Malta, Augusta and Syracuse, subjected to different levels of anthropogenic stress (high, medium and low, respectively). Six traits were considered, subdivided into 22 categories: reproductive frequency, environmental position, mobility, life habit, feeding habit and bioturbation. Functional diversity indices analysed were: Functional Divergence, Quadratic Entropy, Functional Evenness and Functional Richness. To assess the trait responses to environmental gradients, we applied RLQ analysis, which considers simultaneously the relationship between three components: environmental data (R), species abundances (L) and species traits (Q). From our analyses, significant relationships (P-value = 0.0018 for permutation of samples, and P-value = 0.00027 for permutation of species) between functional traits and environmental data were highlighted. The trait categories significantly influenced by environmental variables were those representing feeding habits and mobility. In particular, the first category was influenced by chemical pollutants (organotin compounds and polycyclic aromatic hydrocarbons) and grain size (silt and sand), while the latter category was influenced only by chemical pollutants. Pearson correlations performed for functional vs biotic and diversity indices confirmed the validity of the chosen conceptual framework for harbour environments. Finally, linear models assessing the influence of stressors on functional parameters underlined the link between environmental data vs benthic and functional indices. Our results highlight the fact that functional trait analysis provides a useful and fast method for detecting in greater depth the effects of multiple stressors on functional diversity in marine ecosystems.

The Prioritization of Island Nations as Refuges from Extreme Pandemics

In this conceptual article with illustrative data, we suggest that it is useful to rank island nations as potential refuges for ensuring long-term human survival in the face of catastrophic pandemics (or other relevant existential threats). Prioritization could identify the several island nations that are most suitable for targeting social and political preparations and further investment in resiliency. We outline a prioritization methodology and as an initial demonstration, we then provide example rankings by considering 20 sovereign island states (all with populations greater than 250,000 and no land borders). Results describe each nation in nine resilience-relevant domains covering location, population, resources, and society according to published data. The results indicate that the most suitable island nations for refuge status are Australia, followed closely by New Zealand, and then Iceland, with other nations all well behind (including the relatively high-income ones of Malta and Japan). Nevertheless, some key contextual factors remain relatively unexplored. These include the capacity of the jurisdiction to rapidly close its borders when the emerging threat was first detected elsewhere, and whether or not large subnational islands should be the preferred focus for refuge design (e.g., the Australian state of Tasmania, the island of Hokkaido in Japan, or the South Island of New Zealand). Overall, this work provides conceptual thinking with some initial example analysis. Further research could refine the selection of metrics, how best to weight the relevant domains, and how the populations of prioritized island nations view their nation's selection as a potential refuge for human survival.

Trends in ambient ozone, nitrogen dioxide, and particulate matter concentrations over the Maltese Islands and the corresponding health impacts

This study presents an overview of the air pollution levels in the Maltese Islands including trends in particulate matter (PM), ozone (O₃) and nitrogen dioxide (NO₂) at four monitoring stations in Malta and one in Gozo between 2008 and 2017. In addition, the health impacts associated with long-term exposure to annual mean PM_2.5 and NO₂ are estimated at each site. Irrespective of the site, PM₁₀ and PM_2.5 concentrations show statistically significant decreasing trends while statistically significant increasing trends are noted for the coarse fraction, PM_2.5-10 and O₃. Trends for the different pollutants vary for each site and differ from the overall trend both in magnitude and sign especially for NO₂ concentrations. The attributable fraction (AF) associated with long-term exposure to PM_2.5 and NO₂ ranges from 0.67% (CI: 0.27%,1.07%) in Għarb to 11.79% (CI: 7.77,15.45) in Msida (2011). The corresponding attributable mortality is estimated to reach a maximum of 119 (CI: 78,156) attributable deaths associated with long-term exposure to PM_2.5 in Msida in 2011. This paper thus highlights the importance of continuous air quality monitoring in distinctively different conurbations especially for pollutants showing increasing trends and is the first to outline the potential long-term health effects of air pollutant concentrations in the Maltese Islands.

Hyperbaric oxygen therapy awareness within a doctor population

Hyperbaric medicine is a relatively young specialty that remains in the blind spot of most doctors' awareness. This study endeavors to identify the level of awareness of the indications for hyperbaric oxygen (HBO2) therapy among a doctor population in a developed country and factors which may improve referral rates. An anonymized questionnaire was distributed to doctors licensed to practice in Malta. Questions included physician specialty, demographics and previous exposure to diving and/or hyperbaric medicine. Moreover, two scoring systems were used to score subjects on HBO2-related topics. Binomial logistic regression models and generalized linear models were used in the statistical analysis. A total of 152 full replies were obtained and analyzed. Respondents who had visited a hyperbaric unit (HBU) (p=0.002) or attended a lecture on HBO2 (p=0.006) scored better than their counterparts, indicating better awareness of HBO2 indications and local chamber location. A previous HBU visit (p=0.001), being a hospital-based doctor (p=0.027) and a history of scuba diving (p=0.03) were associated with willingness to refer patients for HBO2 in the future. Encouraging visits to an HBU has been shown to be associated with multiple factors, which are expected to result in improved referral rates. Targeted educational sessions to doctors and medical students are likely to be beneficial in improving correct referral of patients for HBO2. The findings from this study may prove useful in improving appropriate referral rates of patients who may benefit from this useful treatment modality.

Contamination of water resources of a small island state by fireworks-derived perchlorate: A case study from Malta

We have previously reported on the ubiquitous presence of perchlorate in the deposited and airborne fine dusts of Malta and shown that the source of the chemical in the dusts of this small central Mediterranean island is fireworks. There are no local geologic or anthropogenic sources of perchlorate other than firework manufacture and display. The hypothesis was tested that ground-deposited perchlorate will be mobilized in runoff and would partly migrate to the water table and eventually also affect tap water, one third of which being derived from groundwater. Forty four percent of 36 groundwater samples contained perchlorate above detection limit with mean and median values of 1.09 and 1.1 μg L^-1. Sixty-two percent of 16 runoff samples collected during storms contained perchlorate above detection limit with mean and maximum concentrations, respectively, of 50.8 and 129 μg L^-1, values which are far too high to be explained by atmospheric inputs given that rainwater perchlorate levels are typically <3 μg L^-1. Between 42 and 89% of the tap waters analyzed in three sampling campaigns contained perchlorate above detection limit and had mean concentrations ranging from 0.4 to 1.6 μg L^-1 suggesting contamination levels similar to those reported from China but lower than levels reported from the USA. The phenomenon of contamination of the water resources of Malta by perchlorate is probably unique in that it results not from geologic or industrial inputs but from an intense and prolonged pyrotechnic activity that is deeply rooted in the popular culture of the islanders.

Assessment of intelligibility in dysarthria: development of a Maltese word and phrase list

This paper describes the development of the Maltese Intelligibility Lists (MIL) for the assessment of word and phrase intelligibility in dysarthria. Two main tools were employed: the Frenchay Dysarthria Assessment-2 (FDA), and the Maltese Language Resource Server (MLRS). Three main criteria served as the basis for the construction of the word and phrase lists: frequency of occurrence of Maltese phonemes, word frequency and an analysis of syllable types and structures. The most common 500 words in the MLRS corpus (Korpus Malti v. 3) were broadly transcribed and an analysis of different types of syllables and their frequency of occurrence was carried out. Based on this analysis, the relevant proportion of different syllable types required for the word and phrase lists for Maltese was calculated in line with the number of items present in the FDA-2. With regards to phoneme frequency, the words chosen demonstrate a similar short-vowel and consonant distribution as reported in a previous large-scale study. The MIL consists of 116 words and 50 phrases which are representative of Standard Maltese and can be used in the clinic to assess speech intelligibility in Maltese individuals with dysarthria.

Are Mediterranean Marine Protected Areas sheltered from plastic pollution?

Comparisons of six selected Mediterranean MPAs were conducted to find similarities and site-specific differences in coastline fluxes and sources of plastic marine litter. Output from the recently developed 2D Lagrangian model for the Mediterranean was post-processed to study (1) the National Park of ses Salines d'Eivissa i Formentera, (2) Nature Reserve of Bouches de Bonifacio, (3) North-East Malta MPA, (4) Specially Protected Area of Porto Cesareo, (5) Community Importance Site of Torre Guaceto, and (6) Ethniko Thalassio Parko Alonnisou Voreion Sporadon. Model coastline fluxes of plastic ranged from 0.4 to3.6 kg (km day)^-1, which is relatively low compared to the average flux of 6.2 ± 0.8 kg (km day)^-1 calculated over the Mediterranean 2013-2017. Shipping was identified as a major source of plastic litter in all MPAs studied, contributing 55%-88% of total plastic. Site-specific rankings of the top 5 land-based plastic sources revealed that sea surface kinematics control plastic drift.

Diabetes foot screening: Challenges and future strategies

BACKGROUND

Healthcare options for people with diabetes is still not uniform both within and between countries. This is particularly evident for diabetic foot disease. The number of existing documents/guidelines, together with discrepancies which exist between different organizations or countries can lead to confusion for both practicing health care professionals and new countries or organizations who are in the process of developing local clinical guidelines. This study was aimed at exploring different stakeholder perspectives with a view to develop and introduce culturally competent foot screening guidelines.

METHODS

A phenomenological study which incorporated non-structured interviews with eleven local stakeholders and experts related to the field were conducted to explore interviewees' perspectives regarding foot screening guidelines in Malta.

FINDINGS

Qualitative analysis identified 3 key themes from the data highlighting barriers to the implementation of diabetes foot screening guidelines. These focused on organizational factors, healthcare professional factors and patient factors.

CONCLUSION

Current procedures related to diabetes foot screening has shortcomings. The findings of this study clearly highlight the need for change in current practices if effective diabetic foot screening is to be offered. Recommendations from this study are relevant to other countries especially those who share same cultures and practices. Making changes today and implementing them in the appropriate manner could make a world of difference in diabetes foot care.

Predicting reattendance to the second round of the Maltese national breast screening programme: an analytical descriptive study

BACKGROUND

A range of barriers influence women's uptake to a first breast screening invitation. Few studies however, have examined factors associated with second screening uptake. This study follows Maltese women to explore predictors and behaviours to re-attendance, and to determine if uptake of first invitation to the Maltese Breast Screening Programme (MBSP) is a significant predictor of second screening uptake.

METHODS

A prospective study was conducted to determine factors associated with re-attendance for 100 women invited to the second MBSP round. Records of women's second attendance to the MBSP were extracted in January 2016 from the MBSP database. Data were analyzed using chi-square tests, Independent Samples t-test, Mann Whitney test, Shapiro Wilk test and logistic regression.

RESULTS

There were no significant associations for sociodemographic or health status variables with second screening uptake (p > 0.05), except breast condition (Fisher's exact test, p = 0.046). Non-attendees at second screening were most unsure of screening frequency recommendations (χ2 = 9.580, p = 0.048). Attendees were more likely to perceive their susceptibility to breast cancer (p = 0.041), believed breast cancer to be life changing (p = 0.011) and considered cues to action to aid attendance (p = 0.028). Non-attendees were in stronger agreement on mammography pain (p = 0.008) and were less likely to consider cues to action (15.4% non-attendees vs 1.4% attendees) (p = 0.017 respectively). 'Perceived barriers', 'breast cancer identity', 'causes' and 'consequences' were found to be significant predictors of second screening uptake, with 'perceived barriers' being the strongest. The inclusion of illness perception items improved the regression model's accuracy in predicting non-attendance to the second screening round (84.6% vs 30.8%). First screening uptake was found to be a significant predictor of subsequent uptake (OR = 0.102; 95% CI = 0.037, 0.283; p = 0.000).

CONCLUSIONS

Interventions to increase uptake should target first invitees since attending for the first time is a strong predictor of uptake to the second cycle. Further research is required given the small sample. Particular attention should be paid to women who did not respond to their first invite or are unsure or reluctant participants initially.

A case study in Siġġiewi, Malta

Maltese agriculture faces great challenges due to the severe scarcity of water. Sufficient water resources, in quantity and quality, are necessary to cover the demand in the production of wine grape, one of the most important crops in Maltese agriculture. But also, economic efficiency is essential in the grape cultivation. A Cost-Benefit Analysis (CBA) is defined for Maltese vineyards in the Siġġiewi region, considering two irrigation scenarios, irrigation with groundwater or "do-nothing", compared with the "use non-conventional waters" from mixing water from a small desalination plant and groundwater. For the alternative 'mixing desalinated water with groundwater' it is possible to improve water availability and quality for vine crops, while increasing economic benefits for farmer. The results indicate a profitable project from a minimum area of 1 ha, but final benefit is highly dependent on the irrigated surface extension according to water price. Desalination, compared with other type of non-conventional water is considered the best option in this assessment with a small reverse osmosis (RO) desalination plant (120 m³/day) for covering the irrigation needs.

Write a Scientific Paper (WASP): Past and anticipated trends in cardiology service requirements at Mater Dei Hospital, Malta

INTRODUCTION

The requirement for medical services fluctuates. This study was carried out in order to attempt to extrapolate the service requirements for various cardiology services at Mater Dei Hospital, Malta over the coming five years, based on service demands from previous years.

METHODS

Past annual data was obtained from hospital records for various services (to 2017). Linear regression was carried out using a bespoke Excel™ spreadsheet in order to extrapolate possible services requirements up to 2022.

RESULTS

All services are expected to increase, with forecasts ranging between 41 and 354%, depending on services being considered.

DISCUSSION

It is easy to "get on with it" and perform the work required at the workplace but this study has shown that it is equally important to anticipate demands lest lack of planning leads to long and important waiting lists for critical diagnostics and treatments. Health care provision requirements are increasing worldwide. Even using conservative estimates and in the absence of the creation of new services, the demands for extant services are likely to continue to grow. Unless medium term plans are made for hardware, software, physical space and staffing, and the funding thereof, waiting lists for investigations in this speciality are bound to rise. This may be mitigated by novel treatments but since these cannot be predicted, it would be safer and wiser to plan ahead lest we are overwhelmed. This paper has also shown how WASP (Write a Scientific Paper) precepts can be applied to elegantly study a problem and write up a paper.

Estimation of the contributions of the sources driving PM2.5 levels in a Central Mediterranean coastal town

Receptor modelling techniques are widely used in order to identify the main natural and anthropogenic processes driving aerosol levels at a receptor. In this work, Positive Matrix Factorization (PMF) was used to apportion PM_2.5 levels at a traffic site (Msida) located in a coastal town. 180 filters collected throughout a yearly sampling campaign conducted in 2016, were chemically characterized by light absorbance analysis, x-ray fluorescence and ion chromatography in order to determine the concentrations of black carbon, 17 elements and 5 ions, respectively. The resulting chemical data base was used in conjunction with PMF in order to identify the 7 components affecting the PM_2.5 levels at the receptor site. Six of these sources are considered to be typical of the atmospheric composition of coastal traffic sites: traffic (27.3%), ammonium sulfate (23.6%), Saharan dust (15%), aged sea salt (12.7%), shipping (5%) and fresh sea salt (4.6%). This is the first time that such a study was carried out in Malta and helps in understanding the aerosol pollution climate of the Central Mediterranean, which is still relatively understudied when compared to the Eastern and Western Mediterranean. Furthermore, we have isolated a factor exclusive to Malta: the fireworks component, which is responsible for 2.9% of the PM_2.5 and which has health implications due to its chemical composition. The results of this work should also serve to guide the policy makers in achieving the necessary emission reductions in order to achieve the WHO guideline for PM_2.5 by 2020.