Association between a polygenic lipodystrophy genetic risk score and diabetes risk in the high prevalence Maltese population

BACKGROUND

Type 2 diabetes (T2DM) is genetically heterogenous, driven by beta cell dysfunction and insulin resistance. Insulin resistance drives the development of cardiometabolic complications and is typically associated with obesity. A group of common variants at eleven loci are associated with insulin resistance and risk of both type 2 diabetes and coronary artery disease. These variants describe a polygenic correlate of lipodystrophy, with a high metabolic disease risk despite a low BMI.

OBJECTIVES

In this cross-sectional study, we sought to investigate the association of a polygenic risk score composed of eleven lipodystrophy variants with anthropometric, glycaemic and metabolic traits in an island population characterised by a high prevalence of both obesity and type 2 diabetes.

METHODS

814 unrelated adults (n = 477 controls and n = 337 T2DM cases) of Maltese-Caucasian ethnicity were genotyped and associations with phenotypes explored.

RESULTS

A higher polygenic lipodystrophy risk score was correlated with lower adiposity indices (lower waist circumference and body mass index measurements) and higher HOMA-IR, atherogenic dyslipidaemia and visceral fat dysfunction as assessed by the visceral adiposity index in the DM group. In crude and covariate-adjusted models, individuals in the top quartile of polygenic risk had a higher T2DM risk relative to individuals in the first quartile of the risk score distribution.

CONCLUSION

This study consolidates the association between polygenic lipodystrophy risk alleles, metabolic syndrome parameters and T2DM risk particularly in normal-weight individuals. Our findings demonstrate that polygenic lipodystrophy risk alleles drive insulin resistance and diabetes risk independent of an increased BMI.

Cardiovascular Risk Factors Among First-Degree Relatives of Patients with Premature Cardiovascular Disease in Malta. Baseline Findings from the CRISO Project

Purpose

A family history of premature atherosclerotic cardiovascular disease (ASCVD) confers a greater risk of developing ASCVD. However, the prevalence of ASCVD risk factors among asymptomatic Maltese adults with parental or fraternal history of premature ASCVD is unknown. The study aimed to evaluate and compare their risk with the general population.

Patients and Methods

Posters to market the project were distributed in cardiac rehabilitation areas. Patients with premature cardiovascular disease facilitated recruitment by informing their relatives about the project. Medical doctors and cardiac rehabilitation nurses referred first-degree relatives. Posters were put up in community pharmacies, and an explanatory video clip was shared on social media for interested individuals to contact researchers. Those eligible were enrolled in a preventive cardiology lifestyle intervention. Their data were compared with the risk in the general population.

Results

Many first-degree relatives had a suboptimal risk profile, with 60% (N = 89) having a total cholesterol level of >5.0 mmol/L; 54% having a low-density lipoprotein-cholesterol level of >3 mmol/L; 70.5% being overweight/obese, with 62% having a waist circumference greater than the recommended values; 34.8% having hypertension; 56.2% being inadequately adherent to the Mediterranean diet; 62% being underactive, with 18% being sedentary; and 25.8% being smokers. First-degree relatives had significantly higher proportions of underactive lifestyle (p = 0.00016), high body mass index (>25kg/m2) (p = 0.006), and systolic blood pressure (p = 0.001) than the general population, with 30% having metabolic syndrome.

Conclusion

This study determined the prevalence of lifestyle, biochemical, physiological, and anthropometric cardiovascular risk factors among asymptomatic first-degree relatives of Maltese patients with premature ASCVD. First-degree relatives had considerable prevalences of an underactive lifestyle, hypertension, and obesity, suggesting better screening and early risk factor intervention are needed to modify their risk of ASCVD.

The epidemiology of CHD in Malta

BACKGROUND

CHD refers to structural cardiac abnormalities which comprise the commonest group of congenital malformations. Malta is a small island in the central Mediterranean with excellent diagnostic and therapeutic facilities. It is unique in the European population as termination of pregnancy is illegal. This study was carried out to ascertain patterns in CHD prevalence in comparison with EUROCAT data (European Surveillance of Congenital Anomalies).

METHODS

Anonymised data were obtained from the EUROCAT website for 1993-2020.

RESULTS

There were a total of 22,833,032 births from all EUROCAT Registries, of which 121,697 were from Malta. The prevalence rate for Malta CHD was 32.38/10,000 births (at the higher end of the range). Malta had a significant excess of commoner, comparatively non-severe CHDs. For most of the severe lesions analysed rates reported were higher than EUROCAT average, however, apart from Ebstein's anomaly, they all fell within the ranges reported from the different registries.

DISCUSSION

Wide variations in reported CHD prevalence are known, and the Malta rates may be higher for milder defects due to quicker pickup prior to spontaneous resolution. There may also be a higher pickup of milder forms of more severe conditions. For the more severe conditions, lack of termination may be the explanation. These factors may result in the higher neonatal mortality observed in Malta.

Clinical features and diagnostic challenges of mpox (monkeypox) outbreak in Malta: a retrospective cohort study

BACKGROUND

In May of 2022, an mpox (formerly known as monkeypox) outbreak was reported from countries where the disease is not endemic, rising worldwide concern. Malta, the smallest European Union member state, faced unique challenges, with high infection rates compared to the rest of Europe. The aim of the study is to describe the clinical characteristics, diagnostic challenges, and unique demographics of mpox patients diagnosed in Malta.

METHODS

This is a retrospective analysis of medical records of all mpox cases recorded from May to September 2022. Demographic data, sexual behaviors and practices, travel history, comorbidities, and HIV status were investigated.

RESULTS

In the study period, we recorded 33 mpox cases, 97% of them were male, in the age group 30-39 (39%). Ninety percent were gay or bisexual men and 76% non-Maltese. The most common clinical presentations included skin rash (78%), lymphadenopathy (71%), anogenital lesions (67%), and fever (67%). Twenty-seven percent of the patients were people living with HIV. In terms of coinfection with STIs, 27% of patients tested positive for gonorrhea, 12% for syphilis, 15% for chlamydia, 9% for herpes simplex virus, and 3% for hepatitis C virus.

CONCLUSION

The results shed light on unique challenges faced by the local sexual health clinic and call for more resources in response to the global emerging of infectious diseases.

Addressing childhood obesity through policy: A cross-sectional study in Malta

Introduction

Childhood overweight and obesity are major public health challenges, with Malta having one of the highest prevalences among European countries. The COVID-19 pandemic may further worsen this epidemic. The food and physical activity environments impact children's behaviours. This study looks at barriers to maintain a healthy weight, responsibility to address obesity, and assesses parental support for 22 policies aimed at addressing childhood obesity. Public support for policy is key because it influences which policies are adopted and their success.

Methods

A cross-sectional, paper-based, quantitative survey was conducted amongst parents of primary school-aged children in Malta in 2018-2019. Ethical approval was obtained. Statistical analysis was performed using SPSS.

Results

1,169 parents participated. The food environment was more commonly identified as a barrier to maintain a healthy weight than the physical activity environment. Parents were least supportive of taxation policies, and most in favour of increasing spaces available for safe physical activity (94.0%), followed by providing free weight management services for children (90.8%). The level of support varied significantly by various socio-demographic/economic characteristics; parents with a higher educational level were significantly more supportive of most policies. Most findings were consistent with the international literature.

Conclusions

Most policies supported are trans-sectoral; a health-in-all policies approach is needed to address the obesogenic environment. The strong public support identified for several policies should embolden policymakers to consider policy options that were not previously considered.

Digitalizing and Upgrading Severe Acute Respiratory Infections Surveillance in Malta: System Development

BACKGROUND

In late 2020, the European Centre for Disease Prevention and Control and Epiconcept started implementing a surveillance system for severe acute respiratory infections (SARI) across Europe.

OBJECTIVE

We sought to describe the process of digitizing and upgrading SARI surveillance in Malta, an island country with a centralized health system, during the COVID-19 pandemic from February to November 2021. We described the characteristics of people included in the surveillance system and compared different SARI case definitions, including their advantages and disadvantages. This study also discusses the process, output, and future for SARI and other public health surveillance opportunities.

METHODS

Malta has one main public hospital where, on admission, patient data are entered into electronic records as free text. Symptoms and comorbidities are manually extracted from these records, whereas other data are collected from registers. Collected data are formatted to produce weekly and monthly reports to inform public health actions. From October 2020 to February 2021, we established an analogue incidence-based system for SARI surveillance. From February 2021 onward, we mapped key stakeholders and digitized most surveillance processes.

RESULTS

By November 30, 2021, 903 SARI cases were reported, with 380 (42.1%) positive for SARS-CoV-2. Of all SARI hospitalizations, 69 (7.6%) were admitted to the intensive care unit, 769 (85.2%) were discharged, 27 (3%) are still being treated, and 107 (11.8%) died. Among the 107 patients who died, 96 (89.7%) had more than one underlying condition, the most common of which were hypertension (n=57, 53.3%) and chronic heart disease (n=49, 45.8%).

CONCLUSIONS

The implementation of enhanced SARI surveillance in Malta was completed by the end of May 2021, allowing the monitoring of SARI incidence and patient characteristics. A future shift to register-based surveillance should improve SARI detection through automated processes.

Back pain: An aftermath of Covid-19 pandemic? A Malta perspective

BACKGROUND

Back pain is the commonest musculoskeletal complaint across the world. The Covid-19 pandemic led to mitigating measures including remote working that enhanced a sedentary lifestyle. The aim of this study was to investigate whether back pain complaints have increased from pre-Covid-19 to during the Covid-19 period among the adult population of Malta, while exploring the possible contributing factors.

METHODS

An online survey was distributed through social media targeting the adult population of Malta. Questions on sociodemographic data, occurrence of back pain pre-Covid-19 and since the onset of Covid-19 was gathered, along with changes in behavioural attitudes, daily routine and physical activity. Descriptive and multiple logistic regression analyses were performed.

RESULTS

Out of the 388 responders, 30% experienced chronic back pain pre-Covid-19, 49% experienced back pain since Covid-19, with the majority of the latter claiming that they never experienced back pain before Covid-19. Significant changes were present in daily routine and physical activity (PA) patterns. Indeed, continuously sitting down (OR: 15.53; p ≤ 0.01), no PA (OR: 4.22; p ≤ <0.01), once a week PA (OR: 5.74; p ≤ <0.01), two to three times PA a week (OR: 2.58; p = 0.05) and four to five PA a week (OR: 3.46; p = 0.02) were associated with experiencing new onset back pain since the onset of Covid-19, when adjusted for sex, age, education and employment status.

CONCLUSION

The pandemic has changed population behaviour resulting in an enhanced back pain occurrence. This is anticipated to impact the individual's disability adjusted life years as well as increase the burden on the economy and healthcare services. A designated multidisciplinary action plan is recommended to reduce back pain impact.

Dental Public Health in Action: Experiences and Responses of Oral Health Care Professionals during the First Wave of the COVID-19 Pandemic in Malta

Initial impetus for action: Maltese Oral Health Care Professionals (OHCP) experienced changes to clinical practice and redeployment during the COVID-19 pandemic. In the early stages, there were few data on the resultant changes to the provision of dental services or their impact on the wellbeing of dental professionals. Solutions Suggested: Two questionnaires were designed to explore different domains in OHCP working on the frontline of the COVID-19 pandemic as well as in other areas/sectors. The findings were intended to inform guidance documents and to better support the profession. Findings: Anxiety-provoking factors, challenges, and areas of concern of OHCP were identified and practical recommendations to support transitioning to the 'new normal' were presented. OHCP expressed anxiety about contracting COVID-19 from their workplace and passing infection to other family members, friends, or patients. As a result, OHCP expressed the need for better protective clothing, workplace ventilation, and air filtration systems. Future implications: Provision of adequate PPE for OHCP was a priority. New guidelines for dental practice were informed by the experiences of the particpating OHCP. University modules to enhance the resilience of OHCP were among the recommendations to support practitioners.

Estimating the direct Covid-19 disability-adjusted life years impact on the Malta population for the first full year

BACKGROUND

Disability-adjusted life years (DALYs) combine the impact of morbidity and mortality, allowing for comprehensive comparisons of the population. The aim was to estimate the DALYs due to Covid-19 in Malta (March 2020-21) and investigate its impact in relation to other causes of disease at a population level.

METHODS

Mortality and weekly hospital admission data were used to calculate DALYs, based on the European Burden of Disease Network consensus Covid-19 model. Covid-19 infection duration of 14 days was considered. Sensitivity analyses for different morbidity scenarios, including post-acute consequences were presented.

RESULTS

An estimated 70,421 people were infected (with and without symptoms) by Covid-19 in Malta (March 2020-1), out of which 1636 required hospitalisation and 331 deaths, contributing to 5478 DALYs. These DALYs positioned Covid-19 as the fourth leading cause of disease in Malta. Mortality contributed to 95% of DALYs, while post-acute consequences contributed to 60% of morbidity.

CONCLUSIONS

Covid-19 over 1 year has impacted substantially the population health in Malta. Post-acute consequences are the leading morbidity factors that require urgent targeted action to ensure timely multidisciplinary care. It is recommended that DALY estimations in 2021 and beyond are calculated to assess the impact of vaccine roll-out and emergence of new variants.

Characterisation of body size phenotypes in a middle-aged Maltese population

Obesity is increasingly recognised as being a heterogeneous disease. Some obese individuals may present a metabolically healthy profile (metabolically healthy obese (MHO)), while some normal weight individuals exhibit an adverse cardiometabolic phenotype (metabolically unhealthy normal weight individuals (MUHNW)). The objectives of the present study were to examine the prevalence and associated characteristics of the different body composition phenotypes within a Maltese cohort. This was a cross-sectional analysis involving 521 individuals aged 41 ± 5 years. The metabolically unhealthy state was defined as the presence of ≥2 metabolic syndrome components (NCEP-ATPIII parameters), while individuals with ≤1 cardiometabolic abnormalities were classified as metabolically healthy. Overall, 70 % of the studied population was overweight or obese and 30⋅7 % had ≥2 cardiometabolic abnormalities. The prevalence of MHO and MUHNW was 10⋅7 and 2⋅1 %, respectively. Individuals with the healthy phenotype were more likely to consume alcohol, participate in regular physical activity and less likely to be smokers. While the MHO phenotype had similar values for waist, hip and neck circumferences, waist-hip ratio and insulin resistance when compared with MUHNW individuals, there was a lower proportion of MHO subjects having a high fasting plasma glucose, hypertriglyceridaemia or low HDL-C when compared with the unhealthy lean individuals. A high prevalence of the metabolically unhealthy phenotype was observed in this relatively young population which may result in significant future cardiovascular disease burden if timely assessment and management of modifiable risk factors are not implemented. Furthermore, the present study suggests that the MHO phenotype is not totally benign as previously thought.

Malta's only acute public hospital service during COVID-19: a diary of events from the first wave to transition phase

INTRODUCTION

COVID-19 has challenged healthcare systems worldwide. Some countries collapsed under surge conditions, while others (such as Malta) showed resilience. Public health measures in Malta quickly reined in COVID-19 spread. This review summarizes pandemic preparedness measures in Malta and the impact on routine services.

METHODS

A literature search was conducted using Google, Google Scholar and PubMed and by reviewing Maltese online newspapers. A comprehensive summary of internal operations conducted at Mater Dei Hospital (MDH) was made available.

RESULTS

A hospital 'Incident Command Group' was set up to plan an optimal COVID-19 response strategy. A 'rapid response team' was also created to cater for the logistics and management of supplies. A 'COVID-19 Emergency Operation Centre' simulated different COVID-19 scenarios. All elective services were suspended and all staff were mandatorily trained in wearing personal protective equipment. Staff were also retrained in the care of COVID-19 patients. In preparation for potential admission surges, MDH underwent rapid expansion of normal and intensive care beds. Swabbing was ramped up to one of the highest national rates worldwide. The cost for hospital COVID-19 preparedness exceeded €100 million for Malta's half a million population.

CONCLUSION

Malta and its sole acute hospital coped well with the first wave with 680 cases and 9 deaths. The increased ability to deal with COVID-19 (a principally respiratory pathogen) will serve well for the anticipated combined annual influenza and the COVID-19 second wave this coming winter.

At-risk population for COVID-19: multimorbidity characteristics of a European small Island state

OBJECTIVES

Multimorbidity, defined as the co-occurrence of at least two chronic diseases, is a common occurrence with ageing and a recognised public health concern, especially during the COVID-19 pandemic. The multimorbidity population is more susceptible to the virus, its complications, and death. The study aimed to explore the multimorbidity characteristics and their associations at a population level for the first time in Malta. Such data enables adequate priority and policy planning due to COVID-19's predilection for this population.

STUDY AND METHODS

Baseline data was collected from 3,947 adults recruited between 2014-2016 through a cross-sectional study. A single-stage sampling strategy was implemented and stratified by age (18 -70 years), sex and locality. Participants were invited to attend a health examination survey consisting of a questionnaire, anthropometric and biological measurements. Descriptive (chi-square) and analytic (regression modelling) statistics were used to determine the characteristics and associations of the multimorbidity population. The chronic diseases considered for multimorbidity were type 2 diabetes, obesity, hypertension, myocardial infraction, coronary heart disease and dyslipidaemia.

RESULTS

Multimorbidity was present in 33% (95% confidence interval 31.54-34.47) of the study population, with a male predominance. Hypertension and myocardial infarction were the commonest multimorbidity combination from a young age group (20-30 years). Low socio-economic status and residing on the island of Gozo were positively associated with multimorbidity.

CONCLUSION

Multimorbidity in Malta was evident from a young age, with the highest occurrence among the low socio-economic status and residents of Gozo, bringing forward the need for preventive action. An adaptive healthcare system and policies are recommended to prevent, support, and manage multimorbidity non-communicable diseases while bracing for the current COVID-19 pandemic.

COVID-19 admissions calculators: General population and paediatric cohort

The world is in the grip of pandemic COVID-19 (SARS-CoV-2). Children appear to be only mildly affected but for those countries that are still preparing for their first wave of infections, it is salutary to have some estimates with which to plan for eventual contingencies. These assessments would include acute hospital admission requirements, intensive care admissions and deaths per given population. It is also useful to have an estimate of how many paediatric admissions to expect per given population. However it is only very recently that paediatric epidemiological data has become available. This paper will create an interactive spreadsheet model to estimate population and paediatric admissions for a given population, with the author's country, Malta, as a worked example for both.

Detection of Flea-Borne Pathogens from Cats and Fleas in a Maltese Shelter

In a sanctuary located on the island of Malta, 23 clinically healthy cats randomly selected were sampled for blood and fleas. Only fleas were collected from 35 cats. All fleas were identified as Ctenocephalides felis, except for one specimen of Ctenocephalides canis. To the best of the authors' knowledge, this may be the first time to establish the occurrence of Bartonella koehlerae and B. clarridgeiae, as well as of Candidatus Mycoplasma haemominutum in the blood samples of 11 cats (47.82% [95% CI: 29.33-67.04]) with conventional PCR assays. One or more pathogens were found in 54 (96.42% [95% CI: 86.74-99.70]) out of 56 pooled flea samples, the most prevalent was Rickettsia felis. The DNA of Bartonella henselae, the commonest etiological agent of cat scratch disease, was detected first time in a pooled flea sample of a cat.

Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta: a 1-year repeated cross-sectional surveillance study

OBJECTIVE

To identify factors that influence general practitioners' (GPs') oral antibiotic prescribing for acute respiratory tract complaints (aRTCs) in Malta.

DESIGN

Repeated, cross-sectional surveillance.

SETTING

Maltese general practice; both public health centres and private GP clinics.

PARTICIPANTS

30 GPs registered on the Malta Medical Council's Specialist Register and 3 GP trainees registered data of 4831 patients of all ages suffering from any aRTC. Data were collected monthly between May 2015 and April 2016 during predetermined 1-week periods.

OUTCOME MEASURES

The outcome of interest was antibiotic prescription (yes/no), defined as an oral antibiotic prescription issued for an aRTC during an in-person consultation, irrespective of the number of antibiotics given. The association between GP, practice and consultation-level factors, patient sociodemographic factors and patient health status factors, and antibiotic prescription was investigated.

RESULTS

The antibiotic prescription rate was 45.0%. Independent factors positively associated with antibiotic prescribing included female GP sex (OR 2.3, 95% CI 1.22 to 4.26), GP age with GPs ≥60 being the most likely (OR 34.7, 95% CI 14.14 to 84.98), patient age with patients ≥65 being the most likely (OR 2.3, 95% CI 1.71 to 3.18), number of signs and/or symptoms with patients having ≥4 being the most likely (OR 9.6, 95% CI 5.78 to 15.99), fever (OR 2.6, 95% CI 2.08 to 3.26), productive cough (OR 1.3, 95% CI 1.03 to 1.61), otalgia (OR 1.3, 95% CI 1.01 to 1.76), tender cervical nodes (OR 2.2, 95% CI 1.57 to 3.05), regular clients (OR 1.3, 95% CI 1.05 to 1.66), antibiotic requests (OR 4.8, 95% CI 2.52 to 8.99) and smoking (OR 1.4, 95% CI 1.13 to 1.71). Conversely, patients with non-productive cough (OR 0.3, 95% CI 0.26 to 0.41), sore throat (OR 0.6, 95% CI 0.53 to 0.78), rhinorrhoea (OR 0.3, 95% CI 0.23 to 0.36) or dyspnoea (OR 0.6, 95% CI 0.41 to 0.83) were less likely to receive an antibiotic prescription.

CONCLUSION

Antibiotic prescribing for aRTCs was high and influenced by a number of factors. Potentially inappropriate prescribing in primary care can be addressed through multifaceted interventions addressing modifiable factors associated with prescription.

TRIAL REGISTRATION NUMBER

NCT03218930.

Characterisation of Patients with Systemic Lupus Erythematosus in Malta: A Population Based Cohort Cross-Sectional Study

Systemic Lupus Erythematosus (SLE) is a multisystemic autoimmune disorder. The aim of this study was to characterise the SLE patients living in Malta in order to estimate the prevalence and incidence of SLE and characterise the clinical presentation as well as identify any unmet needs. 107 SLE patients who fulfilled SLICC classification criteria were identified. These were invited to participate in the study by means of an interview, blood and urine tests, and filling of the following questionnaires: Fatigue Severity Scale (FSS), visual analogue scale (VAS) for fatigue, Hospital Anxiety and Depression Scale (HADS), VAS for pain, Pittsburgh Sleep Quality Index (PSQI), and modified Health Assessment Questionnaire (mHAQ). The estimated prevalence of SLE in Malta is 29.3 patients per 100,000 and the estimated incidence is 1.48 per 100,000 per year. 93.5% of SLE patients were female, and the mean age at diagnosis was 33.1 years. 60.8% were overweight or obese and body mass index (BMI) had a significant positive correlation with daily dose of prednisolone (R=0.177, p=0.046). 20.7% and 3.3% had a moderate and high disease activity, respectively, as measured by SLEDAI-2K. Disease activity had a significant positive correlation with functional disability measured by mHAQ (R=0.417, p<0.001). 56.5% had an abnormal level of fatigue (FSS >3.7) and 57.6% had a high level of anxiety (HADS ≥8). This study has identified a number of unmet needs of SLE patients, including obesity, uncontrolled disease activity, fatigue, and anxiety.

Relationship of Hyperglycaemia, Hypoglycaemia, and Glucose Variability to Atherosclerotic Disease in Type 2 Diabetes

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is known to be associated with increased cardiovascular risk. The aim of this study was therefore to investigate the independent effects of hyperglycaemia, hypoglycaemia, and glucose variability on microvascular and macrovascular disease in T2DM.

METHODS

Subjects with T2DM of <10 years duration and on stable antiglycaemic treatment underwent carotid intima-media thickness (CIMT), ankle-brachial index (ABI), albumin-creatinine ratio (ACR), and HbA_1c measurement, as well as 72-hour continuous glucose monitoring. Macrovascular disease was defined as one or more of the following: history of ischaemic heart disease (IHD), cerebrovascular accident (CVA), ABI < 0.9, or abnormal CIMT.

RESULTS

The study population comprised 121 subjects with T2DM (89 males : 32 females). The mean age was 62.6 years, and the mean DM duration was 3.7 years. Macrovascular disease was present in 71 patients (58.7%). In multivariate logistic regression analysis, body surface area (BSA) (OR 18.88 (95% CI 2.20-156.69), p = 0.006) and duration of blood glucose (BG) < 3.9 mmol/L (OR 1.12 (95% CI 1.014-1.228), p = 0.024) were independent predictors of macrovascular disease. BSA (OR 12.6 (95% CI 1.70-93.54), p = 0.013) and duration of BG < 3.9 mmol/L (OR 1.09 (95% CI 1.003-1.187), p = 0.041) were independent predictors of abnormal CIMT. Area under the curve for BG > 7.8 mmol/L (β = 15.83, p = 0.005) was the sole independent predictor of albuminuria in generalised linear regression.

CONCLUSIONS

This study demonstrates that hypoglycaemia is associated with the occurrence of atherosclerotic disease while hyperglycaemia is associated with microvascular disease in a Caucasian population with T2DM of recent duration.

The effect of age, gender, TG/HDL-C ratio and behavioral lifestyles on the metabolic syndrome in the high risk Mediterranean Island population of Malta

AIMS

Metabolic syndrome (MetS) is a public health epidemic, typically with female predominance. The aim was to analyse the effect of gender and age on MetS and its components; analyse effects of lifestyle, diabetes mellitus and identify predictors for MetS including TG/HDL ratio, on a national level in a Mediterranean island. Findings will provide evidence-based data for neighboring countries to aid in combat of this epidemic.

METHOD

A cross-sectional survey was conducted in Malta (2014-2016) on a randomized adults population sample. Various components of MetS were measured along with lifestyle habits (smoking, alcohol and physical activity) and family history (cardiovascular and diabetes). Both descriptive and statistical analyses were performed.

RESULTS

A total of 80,788 Maltese adults estimated to suffer from MetS. Males were predominantly affected with significant difference from females. All MetS components were found to be significant predictors along with alcohol habits but not smoking. Neither physical inactivity nor family history of cardiovascular disease, showed any predictive ability for MetS even after adjustment. Elevated triglyceride levels exhibited highest predictive effect on MetS. TG/HDL ratio showed predictive ability in the Maltese population.

CONCLUSIONS

Males were at higher risk for MetS in Malta. A number of predictors were established but not sedentary lifestyle. TG/HDL ratio may provide to be a good indicator for development of MetS.

Global patterns and trends in stomach cancer incidence: Age, period and birth cohort analysis

The cases of stomach cancer (SC) incidence are increasing per year and the SC burden has remained very high in some countries. We aimed to evaluate the global geographical variation in SC incidence and temporal trends from 1978 to 2007, with an emphasis on the effect of birth cohort. Joinpoint regression and age-period-cohort model were applied. From 2003 to 2007, male rate were 1.5- to 3-fold higher than female in all countries. Rates were highest in Eastern Asian and South American countries. Except for Uganda, all countries showed favorable trends. Pronounced cohort-specific increases in risk for recent birth cohorts were seen in Brazil, Colombia, Iceland, New Zealand, Norway, Uganda and US white people for males and in Australia, Brazil, Colombia, Costa Rica, Czech Republic, Ecuador, Iceland, India, Malta, New Zealand, Norway, Switzerland, United Kingdom, Uganda, US black and white people for females. The cohort-specific ratio for male significantly decreased in Japan, Malta and Spain for cohorts born since 1950 and in Austria, China, Croatia, Ecuador, Russia, Switzerland and Thailand for cohorts born since 1960 and for female in Japan for cohorts born since 1950 and in Canada, China, Croatia, Latvia, Russia and Thailand for cohorts born since 1960. Disparities in incidence and carcinogenic risk persist worldwide. The favorable trends may be due to changes in environmental exposure and lifestyle, including decreased Helicobacter pylori prevalence, increased intake of fresh fruits and vegetables, the availability of refrigeration and decreased intake of salted and preserved food and smoking prevalence.

Insights into secular trends of respiratory tuberculosis: The 20th century Maltese experience

Over half a century ago, McKeown and colleagues proposed that economics was a major contributor to the decline of infectious diseases, including respiratory tuberculosis, during the 19^th and 20^th centuries. Since then, there is no consensus among researchers as to the factors responsible for the mortality decline. Using the case study of the islands of Malta and Gozo, we examine the relationship of economics, in particular, the cost of living (Fisher index) and its relationship to the secular trends of tuberculosis mortality. Notwithstanding the criticism that has been directed at McKeown, we present results that improvement in economics is the most parsimonious explanation for the decline of tuberculosis mortality. We reaffirmed that the reproductively aged individuals were most at risk of dying of tuberculosis, seeing that 70 to 90% of all deaths due to tuberculosis occurred between the ages of 15 and 45. There was a clear sex differential in deaths in that, prior to 1930, rates in females were generally higher than males. During times of extreme hardship, the sex differential was exacerbated. Over the course of World War I, the sex gap in tuberculosis rates increased until peaking in 1918 when there was also the influenza pandemic. The heightened differential was most likely a result of gendered roles as opposed to biological differences since female tuberculosis rates again surpassed male rates in 1945 during World War II. Respiratory tuberculosis in both urban and rural settlements (in Malta proper) was significantly influenced by the Fisher index, which explains approximately 61% of the variation in TB death rates (R = 0.78; p<0.0001). In Gozo, there was no significant impact on respiratory tuberculosis (R = 0.23; p = 0.25), most likely a consequence of the island’s isolation, a self-sufficient economy and limited exposure to tuberculosis.

First detection of tick-borne pathogens of dogs from Malta

The knowledge about the vector-borne infections in domestic dogs has been increasing worldwide. However no studies have been done on hard tick infestation and tick-borne pathogens (TBPs) of dogs present in Malta. Therefore, a total of 99 dogs was selected and inspected between March and July 2013 in 18 urban and 17 rural areas on the islands of Malta and Gozo. All ticks were removed from the dogs and identified. Blood samples were taken and tested for protozoa (Babesia spp. and Hepatozoon spp.) and bacteria (Anaplasma spp., Ehrlichia spp., Rickettsia spp.) by conventional PCR. All of the ticks collected from 34 (34.3%; 95% CI: 26-44) dogs belong to the species Rhipicephalus sanguineus sensu lato. Tick infestation on the farm dogs was significantly higher than that of dogs kept outdoors as pets (OR: 15.19, 95% CI: 2.72-118.92, p<0.001) or in a sanctuary (OR: 35.11, 95% CI: 3.20-1986.67, p<0.001). Altogether 22 animals were infected with one or two TBPs, most of them with Hepatozoon canis (16/22; 72.7%). Anaplasma platys and Babesia vogeli were detected in 5 and 4 dogs, respectively. Three dogs had co-infections caused by H. canis and A. platys. To the best of our knowledge, this is the first report on tick infestation and TBPs of dogs in Malta.

Epidemiology and radiological geometric assessment of pituitary macroadenomas: population-based study

CONTEXT

Pituitary adenomas are relatively common tumours with diverse clinical features. Epidemiological data are important to help quantify health burden.

OBJECTIVE

To provide in-depth epidemiological data on macroadenomas and radiologically characterize macroadenomas.

DESIGN

Population-based retrospective analysis, Prevalence as at 2014; Incidence based on data from 2000 to 2014, Retrospective analysis of baseline MRI.

SETTING

The Maltese islands.

PATIENTS

173/136 patients with macroadenomas for prevalence/incidence estimates respectively, 122 baseline MRI for radiological characterization.

MAIN OUTCOME MEASURES

Prevalence rates, Standardized Incidence rates (SIR), MRI findings.

RESULTS

The prevalence for macroadenomas was 40·67/100 000 people and the SIR was 1·90/100 000/year. Giant pituitary adenomas (>40 mm) constituted 4·8% of the whole cohort of PAs and the SIR was 0·18/100 000/year. Giant prolactinomas constituted 4·7% of all the prolactinomas and the SIR was 0·07/100 000/year, while giant NFPA constituted 6·0% of all NFPA and the SIR was 0·12/100 000/year. There was a statistically significant difference in the degree of suprasellar extension (P < 0·001) and infrasellar extension (P = 0·028) between the different macroadenoma subtypes and in the vertical extension indices (median vertical extension index NFPA 3·0 mm; PRLoma -7·7 mm; GH-secreting PA -1·7 mm; P < 0·001). Pituitary macroadenomas with cavernous sinus invasion were statistically significantly larger than those without cavernous sinus invasion (P < 0·001). NFPA had predominantly a superior extension into the cavernous sinus (63·6%) compared to the functional PAs which had predominantly an inferior extension into the cavernous sinus (59·1%) (P = 0·032).

CONCLUSIONS

The various macroadenoma subtypes' epidemiological data are presented and differences between growth patterns among the various subtypes are highlighted.

Bone mineral density and intervertebral disc height in type 2 diabetes

BACKGROUND

Studies of the effect of type 2 diabetes (T2D) on bone mineral density (BMD have produced conflicting results, possibly due to failure to adjust for potential confounding factors. Nonetheless, T2D has consistently been associated with increased fracture risk, suggesting that other factors might play a role.

OBJECTIVE

This study assesses the relationship between T2D and BMD at the femoral neck and spine in diabetic and non-diabetic subjects, after adjusting for multiple covariates which may affect BMD. Intervertebral disc height was also investigated in view of its possible relation to fracture risk.

METHODS

A cross-sectional study of 100 patients with T2DM of at least 5 years duration and 86 non-diabetic subjects was carried out.

RESULTS

There were no significant differences in T scores in either the spine or femoral neck after adjustment for potential confounding variables between T2D subjects and controls. Diabetic patients had a statistically lower intervertebral disc height between the 2nd and 3rd lumbar vertebrae (D3) after adjustment for potential confounders (p=0.004). Urinary albumin:creatinine ratio, total cholesterol, LDL-cholesterol and cigarette smoking were independently associated with lower height of D3 in diabetic subjects.

CONCLUSIONS

There is no significant independent association between T2D and BMD. However we found a novel association of significantly lower disc height in patients with T2D. This may contribute to the increased vertebral fracture risk in subjects with T2D. Further studies are needed to investigate the relationship of disc height, T2D and fracture risk.

Biochemical Predictors of Low Bone Mineral Density and Fracture Susceptibility in Maltese Postmenopausal Women

Osteoporosis and fractures are complex conditions influenced by an interplay of genetic and environmental factors. The aim of the study was to investigate three biochemical parameters including total serum calcium, total serum alkaline phosphatase (sALP) and albumin in relation to bone mineral density (BMD) at the lumbar spine and femoral neck (FN), and with all-type of low-trauma fractures in Maltese postmenopausal women. Levels were also correlated with age and physical activity. A case-control study of 1045 women was performed. Women who suffered a fracture were classified as cases whereas women without a fracture history were included as controls subdivided into normal, osteopenic, or osteoporotic according to their BMD measurements. Blood specimens were collected following good standard practice and testing was performed by spectrophotometry. Calcium and sALP levels were weakly correlated with FN BMD levels (calcium: r = -0.111, p = 0.002; sALP: r = 0.089, p = 0.013). Fracture cases had the lowest serum levels of calcium, sALP and albumin relative to all other control groups, which decreased with increasing age, possibly increasing fracture risk. Biochemical levels were lowest in women who sustained a hip fracture and more than one fracture. Biochemical parameters decreased with reduced physical activity; however, this was most evident for fracture cases. Reduced physical activity was associated with lower BMD levels at the hip, and to a lower extent at the spine. In conclusion, results suggest that levels of serum calcium and albumin could be indicative of fracture risk, whereas calcium levels and to lower extent sALP levels could be indicators of hip BMD.

Using molecular tools to identify the geographical origin of a case of human brucellosis

Although Malta is historically linked with the zoonosis brucellosis, there had not been a case of the disease in either the human or livestock population for several years. However, in July 2013 a case of human brucellosis was identified on the island. To determine whether this recent case originated in Malta, four isolates from this case were subjected to molecular analysis. Molecular profiles generated using multilocus sequence analysis and multilocus variable number tandem repeat for the recent human case isolates and 11 Brucella melitensis strains of known Maltese origin were compared with others held on in-house and global databases. While the 11 isolates of Maltese origin formed a distinct cluster, the recent human isolation was not associated with these strains but instead clustered with isolates originating from the Horn of Africa. These data was congruent with epidemiological trace-back showed that the individual had travelled to Malta from Eritrea. This work highlights the potential of using molecular typing data to aid in epidemiological trace-back of Brucella isolations and assist in monitoring of the effectiveness of brucellosis control schemes.

Screening for type 2 diabetes and pre-diabetes in general practice: a descriptive study of Maltese practices

OBJECTIVE

The aim of this research study was to ascertain the awareness of Maltese family doctors to the prevalence and significance of impaired glucose regulation and early diagnosis of type 2 diabetes and whether practices were influenced by employment status, post-graduate training in diabetes or years since graduation.

METHODS

A specially constructed questionnaire was distributed by mail to all the 298 family doctors listed as Specialists in Family Medicine in the Maltese Medical Council register. Participants had to be practising family medicine in Malta. Results were analysed using SPSS 20.0 aiming for a significance criterion of 0.05 and a power of 80%.

RESULTS

Valid replies were received from 154 GPs (51.7%). 93.2% claimed to offer their patients some form of screening. Screening levels reached up to 95.9% in the presence of specific risk factors (e.g., high previous HbA1c levels) but fell to between 46.2% and 58.7% in patients over 50, the physically inactive and those who suffer from polycystic ovarian syndrome. Screening using capillary glucose is widespread (70.8%) as opposed to the oral glucose tolerance test (23.4%). Results also show a high use of urinalysis in screening (53.2%) and a paradoxical lack of use of HbA1c in screening by young doctors and by those with recent extra training in diabetes.

CONCLUSIONS

The need for a structured screening programme in Malta and its viability need to be evaluated by further studies. Educational support to GPs together with logistic support for GPs needs to be improved.

Mortality risk score for Klebsiella pneumoniae bacteraemia

BACKGROUND

Klebsiella pneumoniae bacteraemia (KPB) has been associated with multiple risk factors. However association of these risk factors with mortality secondary to KPB has been poorly documented.

OBJECTIVES

To assess underlying co-morbidities in patients with KPB and any associated presentations. These findings were then used to devise a score to estimate the risk of in-hospital mortality in patients with underlying KPB.

METHODS

A retrospective analysis of all patients diagnosed with KPB between November 2007 and March 2012 at Mater Dei hospital in Malta was carried out. Using the odds ratios of risk factors for mortality associated with KPB, a mortality risk score was then prepared.

RESULTS

186 patients (mean age 62 years; mean hospital stay 22.6 days) were included. 51 patients died as inpatients. Being admitted to intensive care (Overall risk (OR): 9, p<0.0001), having a solid organ tumour (OR 3, p<0.005), and having an underlying pneumonia (OR 3, p<0.021) were statistically significant risk factors associated with mortality. There were 0% mortality in patients with a score of 0, and progressively increasing mortalities with increasing scores up to a 100% mortality in patients with scores of >15. This translated into a validated risk score where an increasing score reflected an increasing mortality.

CONCLUSIONS

Klebsiella pneumoniae bacteraemia is associated with high in-patient mortality. ICU admission, underlying solid tumours, and co-existent pneumonias are among the factors used in our mortality risk score. This needs to be further validated in larger populations.

Prevalence and incidence of pituitary adenomas: a population based study in Malta

Epidemiological data is important to correctly quantify the extent of disease and needed health care resources. The aim of the study was to establish the prevalence and incidence of pituitary adenomas (PAs) in the same well defined population, with in-depth analysis of the various subtypes. The design involved a retrospective cross-sectional analysis of PA patients diagnosed prior to 31 July 2011 for prevalence estimates and those diagnosed between July 2000 and July 2011 for incidence estimation. A thorough search for patients with PAs was carried out in central hospital registries including outpatients departments, surgical registries, radiological department and specialty clinic databases. Prevalence rates/100,000 and Standardised incidence ratios (SIR)/100,000/year were worked out. The respective prevalence rates and SIR for PAs overall were 75.7/100,000, and 4.27/100,000/year, for Prolactinomas 35.0/100,000 and 2.05/100,000/year, for nonfunctioning PA 25.9/100,000 and 1.79/100,000/year and for GH-secreting PAs 12.5/100,000 and 0.31/100,000/year. The overall prevalence for macroadenomas was 32.8/100,000 and SIR was 1.49/100,000/year. The prevalence rate in males for PAs overall was 46.3/100,000 and SIR was 2.08/100,000/year and in females 104.8/100,000 and SIR was 6.58/100,000/year. Females had a lower proportion of macroadenomas than males (29.5 vs. 75.0%; P < 0.001) and macroadenomas tended to present at a later age compared to microadenomas (48 vs. 34.5; P < 0.001). The highest SIR was reached in the 30-39 age group at 7.42/100,000/year. Our data confirm the considerable disease burden that PAs bear on health care resources. Males and females have similar prevalence and SIR rates for macroadenomas but there is a significant increase in SIR in females of child bearing age compared to males. These observations may have important implications in terms of the economic burden and need for early intervention.

Eating disorders in Malta

In the beginning of 2014 a new service (residential and non residential) for eating disorders is being planned to open in Malta. A telephone based survey was conducted between 30 May and 11 June 2012. A randomized sample of 6000 of the population between 15 and 50 years old was chosen. 2.9 per cent of respondents have suffered from an eating disorder at some point in time. 2.0 percent of these had suffered from an eating disorder in the past, while the remaining (0.9 per cent) were suffering from an eating disorder at the time of study. Out of these 2,008 individuals participated in the study. Binge Eating was the most common eating disorder, with 55.8 per cent of respondents having this condition, followed by Anorexia (34.3 per cent) and Bulimia (13.3 per cent). These results were comparable to those of other European countries. Awareness of these conditions in the general population was generally good, higher in females and in those with a higher educational level.

The mental health of newly graduated doctors in Malta

BACKGROUND

Several studies have shown high rates of psychiatric morbidity in young doctors at various stages of their training (Paice, et al. 2002, Levine et al. 2006). Migration is also known to have an impact on emotional wellbeing (Bhugra 2004). Foreign doctors in Malta now make up over 30% of the junior doctor cohort. This is a new situation for trainers here.This study was carried out in part fulfillment of the requirements for the completion of Specialist Training in Psychiatry in Malta. This article focuses on the first part of the study: the quantitative analysis aimed to answer the following questions: 1. What are the rates of mental health problems amongst recently qualified doctors? 2. What are the factors associated with the increased rates of mental distress?

SUBJECTS AND METHODS

A quantitative cross-sectional analysis was carried out by means of self-report questionnaire including demographic details and the General Health Questionnaire-28 (GHQ-28) (Goldberg 1972). This study was approved by the Health Ethics Committee (HEC23/12).

RESULTS

117 (78.5%) of junior doctors participated in this study. 70.9% were Maltese. 49.4% were found to have GHQ-28 scores of more than 6, indicating significant psychological distress. Further analyses revealed that lack of leisure time (p<0.001), uncertainty (p=0.009), migration (p=0.03) and being female (p=0.04) were significantly related to caseness.

CONCLUSION

As trainers and supervisors in medical education, it is important to be aware of the difficulties that young doctors face. These may include psychological distress, significant enough to reach caseness. Lack of leisure time seems to be an important factor which is possibly an area that can be easily tackled.

The prevalence of coeliac disease in Down's syndrome in Malta

The prevalence of coeliac disease is increased in individuals with Down's syndrome. The objective of this study was to assess the frequency of coeliac disease in Down's syndrome in Malta. One hundred children and adults with Down's were screened for coeliac disease. A history was taken from all of them and they were examined and measured for weight and height. A full blood count, antigliadin (IgG and IgA) and anti-endomysial antibodies were estimated. Equivocal cases were also screened for antireticulin antibodies. Jejunal biopsy was recommended in all serologically positive cases. The frequency of coeliac disease in Down's syndrome was 8%, much greater than that in the general population. Screening for coeliac disease in all cases of Down's syndrome is therefore recommended.

Risk factors for osteoporosis in Crohn's disease: infliximab, corticosteroids, body mass index, and age of onset

BACKGROUND

We analyzed the characteristics associated with increased risk of osteoporosis in patients with Crohn's disease in Malta.

METHOD

Eighty-three patients with histologically and endoscopically confirmed Crohn's disease underwent a DEXA bone density scan and their phenotypic characteristics were analyzed.

RESULTS

There was a significant association between body mass index and bone mineral density (P = 0.004) and a significant difference in the T scores of patients according to age at diagnosis (Montreal Classification: P = 0.0006) with patients diagnosed <17 years (n = 13) having lower T scores than those diagnosed at older age groups (n = 70). There was a significant difference between the T scores of patients on infliximab (n = 33) and those not on biological therapy (n = 50, P = 0.0058). Patients with high cumulative corticosteroid doses (>10 mg/d for >3 mo, n = 18) had lower bone mineral densities than patients who received smaller corticosteroid doses (P = 0.013). There was however no significant difference in the T scores of patients according to disease location (P = 0.18), disease type (P = 0.64), gender (P = 0.30), and history of ileal resection (P = 0.68). There was also no significant correlation between disease duration and T scores (hip) (P = 0.61).

CONCLUSIONS

Low body mass index, early disease onset, high corticosteroid doses and, anti-tumor necrosis factor α therapy are associated with increased risk of osteoporosis. Lower T scores in patients on infliximab occur as patients receiving this therapy have more severe inflammation, which is associated with elevated osteoclastogenic factors, rather than as a side-effect of the anti-tumor necrosis factor-α therapy.

The importance of clinical biomechanical assessment of foot deformity and joint mobility in people living with type-2 diabetes within a primary care setting

AIMS

The aim of the study was to assess foot morphology and document foot deformities and joint mobility in a cohort of subjects living with type-2 diabetes mellitus in Malta in a Primary Care setting.

METHODS

A retrospective observational study was conducted on 243 subjects who participated in a local pilot diabetes foot screening project. Assessments included hammer/claw toes, hallux valgus, hallux limitus, prominent metatarsal heads, bony prominences, Charcot deformity, plantar callus, foot type and ankle and hallux mobility. The clinical assessments used during this screening program were based on validated and previously published tools.

RESULTS

Upon clinical examination 38% of the sample was found to have developed some form of corns or callosities in their feet. Hallux valgus deformity was present in 49.4% of the sample, whilst 39% of the sample had hammer toes. Prominent metatarsal heads (24%), other bony prominences (44%) and limited joint mobility were also reported. Furthermore, 56% of the sample presented with unsuitable footwear and upon clinical biomechanical examination a further 28% of the sample required prescription orthosis.

CONCLUSIONS/INTERPRETATION

A significant proportion of participants living with type-2 diabetes presented with foot deformities which are known to be predictive of foot ulceration in this high risk population. This research conducted in a primary care setting highlights the importance of increased vigilance coupled with strengthening of existing screening structures and introducing clinical guidelines with regards to biomechanical assessment of the feet in a primary care setting in order to reduce the incidence of diabetes foot complications.

Diabetic foot complications in Malta: prevalence of risk factors

AIMS

The main objective of this research was to identify the prevalence of diabetes-related lower-extremity complications in a cohort of Maltese patients living with type 2 diabetes.

METHODS

A retrospective study was conducted on a cohort of 243 patients living with type 2 diabetes mellitus in two Maltese Health Centre catchment areas. A convenience sampling was adopted to recruit subjects from a local pilot diabetes foot screening program. The clinical assessments used during this screening program were based on validated and previously published tools such as: neuropathy disability score, vibration perception threshold, Semmes-Weinstein monofilaments, vascular status and foot deformities were evaluated.

RESULTS

The results from this study demonstrate that risk factors for foot deterioration and ulceration are common in Maltese population living with type 2 diabetes. Whilst, metabolic outcomes such as hypertension and dyslipidaemia were present in most subjects, peripheral vascular disease, peripheral sensory neuropathy and foot deformities were also common. Twenty-six per cent of the sample had to be referred for further vascular assessment following this screening program due to their critical vascular status.

CONCLUSIONS/INTERPRETATION

A significant proportion of Maltese participants living with type 2 diabetes presented with vascular insufficiency, abnormal neural function and deformities in the feet. Metabolic outcomes such as high blood pressure and high levels of cholesterol were also highly prevalent. Strengthening of existing screening structures is imperative in order to reduce the burden of this disease in Malta.

Screening for peripheral vascular disease in patients with type 2 diabetes in Malta in a primary care setting

BACKGROUND

Peripheral vascular disease (PVD) is strongly associated with type 2 diabetes. PVD assessment and diagnosis are often neglected in primary care office visits, and ankle/brachial pressure index (ABPI) examinations are seldom performed for PVD detection. The purpose of this study was to evaluate the occurrence of PVD in a primary care setting using ABPI in patients with type 2 diabetes in Malta.

METHOD

A retrospective study was conducted on a cohort of 243 patients with type 2 diabetes to address various issues. As part of this large study, data from ABPI measurements collected using a portable hand-held Doppler with ankle pressures of <0.8 suggestive of PVD were extracted.

RESULTS

Twenty-six per cent of the sample had to be referred for further vascular assessment following this screening programme due to their critical vascular status. Furthermore, at the time of examination, approximately 7% of the patients had an ABPI of less than 0.8 in both left and right extremities.

CONCLUSION

A significant proportion of Maltese patients with type 2 diabetes who visit primary care present with vascular insufficiency. The use of ABPI should be considered as an added measurement in order to facilitate early detection and treatment and reduce the burden of PVD in this high-risk population.

Paper 2: EUROCAT public health indicators for congenital anomalies in Europe

OBJECTIVE

The purpose of this article is to present the specific public health indicators recently developed by EUROCAT that aim to summarize important aspects of the public health impact of congenital anomalies in a few quantitative measures.

METHODS

The six indicators are: (1) congenital anomaly perinatal mortality, (2) congenital anomaly prenatal diagnosis prevalence, (3) congenital anomaly termination of pregnancy, (4) Down syndrome livebirth prevalence, (5) congenital anomaly pediatric surgery, and (6) neural tube defects (NTD) total prevalence. Data presented for this report pertained to all cases (livebirths, fetal deaths, or stillbirths after 20 weeks of gestation and terminations of pregnancy for fetal anomaly [TOPFA]) of congenital anomaly from 27 full member registries of EUROCAT that could provide data for at least 3 years during the period 2004 to 2008. Prevalence of anomalies, prenatal diagnosis, TOPFA, pediatric surgery, and perinatal mortality were calculated per 1000 births.

RESULTS

The overall perinatal mortality was approximately 1.0 per 1000 births for EUROCAT registries with almost half due to fetal and the other half due to first week deaths. There were wide variations in perinatal mortality across the registries with the highest rates observed in Dublin and Malta, registries in countries where TOPFA are illegal, and in Ukraine. The overall perinatal mortality across EUROCAT registries slightly decreased between 2004 and 2008 due to a decrease in first week deaths. The prevalence of TOPFA was fairly stable at about 4 per 1000 births. There were variations in livebirth prevalence of cases typically requiring surgery across the registries; however, for most registries this prevalence was between 3 and 5 per 1000 births. Prevalence of NTD decreased by about 10% from 1.05 in 2004 to 0.94 per 1000 in 2008.

CONCLUSION

It is hoped that by publishing the data on EUROCAT indicators, the public health importance of congenital anomalies can be clearly summarized to policy makers, the need for accurate data from registries emphasized, the need for primary prevention and treatment services highlighted, and the impact of current services measured.

Obstetric outcome and cytokine levels in threatened miscarriage

OBJECTIVES

To evaluate the proportion of women with threatened miscarriage (TM) who proceed to miscarriage in a population of single ethnicity and to investigate prospectively their risk of adverse pregnancy outcome in relationship with the cytokines levels in their circulation.

METHODS

We conducted a prospective observational study over a period of 1 year of 94 Maltese women presenting with TM at the same hospital and compared their clinical data with those of 564 age-matched controls from the National Obstetric Information System (NOIS) of Malta. Main outcome measures included gestational age and weight at delivery and incidence of adverse pregnancy outcomes. A pilot study was carried out, where in subgroups of 10 women with TM (n=10), non-pregnant women (n=12), normal pregnant controls (n=9) and women presenting with missed-miscarriage (n=11), the plasma levels of β-human chorionic gonadotrophin (β-hCG), tumour necrosis factor α (TNFα), interferon γ (IFNγ), interleukin-6 (IL-6), interleukin-10 (IL-10) and TNF-receptors 1 (R1) and 2 (R2) were measured.

RESULTS

Of the women presenting with TM, 25 (26.6%) proceeded to complete miscarriage. The TM group had also a significantly higher incidence of antepartum haemorrhage (p<0.005), pre-eclampsia (p<0.05), foetal growth restriction (p<0.05), premature labour (p<0.001) and retained placenta (p<0.005). In the pilot biochemical analysis, significantly (p<0.05) higher levels of TNFα and lower levels of TNFR2 were found in the TM subgroup compared to non-pregnant controls. The ratio TNFα/IL-10 was significantly (p<0.05) higher and the β-hCG levels was significantly lower (p<0.01) in missed-miscarriage and non-pregnant subgroups than in TM and normal pregnant controls. The IFNγ/1L-10 and IFNγ/1L-6 ratio were significantly (<0.001) different between the four subgroups with the lowest level found in TM. No similar gradient was found for the TNFα/1L-6 ratio.

CONCLUSION

Women presenting with TM are at significantly increased risk of adverse pregnancy outcome and the pathophysiology of these conditions involves a change in the Th1/Th2 balance. Changes in levels of cytokines could help to predict and thus prevent the development of some of these complications.

Outbreak of norovirus infection in a nursing home for the elderly in Malta, November-December 2008

In norovirus outbreak in a nursing home in Malta in November and December 2008, 44 people were affected. 35 of 91 residents and nine of 44 employees were symptomatic. The overall attack rate among residents was 38.5% [corrected]. The outbreak lasted 17 days and the symptoms were mild.

Can leprosy be eradicated with chemotherapy? An evaluation of the Malta Leprosy Eradication Project

The Malta Leprosy Eradication Project (MLEP) was proposed in 1971 by Freerksen with the aim of eradicating leprosy in Malta. The project involved re-treatment of all known cases in Malta as of 1972 and all new cases thereafter with a regimen consisting of Isoprodian (a combination of dapsone, prothionamide and isoniazid) and rifampicin for varying intervals depending on the severity of their disease and their response to treatment. Overall the response to therapy was excellent with an extremely low relapse rate. During the 30 years of the project the incidence of leprosy steadily decreased continuing a decline that had started at least two decades earlier and Freerksen declared the disease eradicated from Malta in 2001. Although given the long incubation period of leprosy cases may still be occasionally detected in the future, the disease has been basically eradicated at this time and there are no patients currently receiving treatment. This work was done at the leprosy clinic, Boffa Hospital, Floriana, Malta.

Estimating the burden and cost of infectious intestinal disease in the Maltese community

The aim of this study was to estimate the burden of infectious intestinal disease (IID) and cost of illness at the community level from a societal aspect. A retrospective, age-stratified cross-sectional telephone study was carried out in Malta in 2004-2005. The number of cases, resources used and cost of resources were computed. The resources involved direct costs (health-care services, stool culture tests, medicines and personal costs) and indirect costs (costs from lost employment by cases and caregivers). This study estimated 0.421 (95% CI 0.092-0.771) separate episodes of IID per person per year in Malta which corresponds to 164 471 (95% CI 35 941-301 205) episodes of IID per year or 450 (95% CI 98-825) episodes of IID each day. The largest proportion of cost is due to provision of health-care services with euro10 454 901 [Maltese liri (Lm) 4 558 970] per year; followed by euro963 295 (Lm 2 209 393) in lost productivity; euro1 286 286 (Lm 561 078) in medicines; euro152 335 (Lm 66 452) in stool culture testing and euro71 487 (Lm 31 183) in personal costs, giving a total cost of illness of over euro16 million (7 million Lm) per year. The burden and cost of IID are high enough to justify efforts to control the illness. Such estimates are important to assess the cost-effectiveness of proposed specific interventions.

A common, symptom-based case definition for gastroenteritis

National studies determining the burden of gastroenteritis have defined gastroenteritis by its clinical picture, using symptoms to classify cases and non-cases. The use of different case definitions has complicated inter-country comparisons. We selected four case definitions from the literature, applied these to population data from Australia, Canada, Ireland, Malta and the United States, and evaluated how the epidemiology of illness varied. Based on the results, we developed a standard case definition. The choice of case definition impacted on the observed incidence of gastroenteritis, with a 1.5-2.1 times difference between definitions in a given country. The proportion of cases with bloody diarrhoea, fever, and the proportion who sought medical care and submitted a stool sample also varied. The mean age of cases varied by <5 years under the four definitions. To ensure comparability of results between studies, we recommend a standard symptom-based case definition, and minimum set of results to be reported.

Cutaneous melanoma in the Maltese Islands: 2000–2004

This study aimed to, prospectively, over the 5-year period 2000-2004, accurately determine features of cutaneous melanoma in the Maltese Islands. Data from clinicians were supplemented by histology reports, and where necessary, histology slides were reviewed. Information collected included demographic details including age and gender, anatomical site, Clark's level, Breslow thickness and clinico-pathological melanoma type. During the study period the age-standardised (European Standard Population) rates for invasive melanoma were 8.81 per 100,000 (males) and 7.29 per 100,000 (females) and increased with age. By the end of the study, information on 166 cases of primary invasive cutaneous malignant melanoma were collected. The commonest site affected in males was the trunk (54%) and in females the lower limbs (41%). Overall, 33.8% of invasive melanomas had a Breslow thickness >1.5mm. The initial melanoma excision was performed by a dermatologist in 68.2% and plastic surgeon in 20.8%. More cases presented in late spring and summer, particularly in females. Melanoma incidence in Malta is lower than that in high-incidence countries and northern Europe and is similar to that in southern Europe. However, incidence appears to be increasing and a relatively high proportion of patients present with thick lesions emphasising the importance of continued efforts to diagnose cases earlier.

Are children attending child play areas at risk of infectious diseases? What can be done?

AIMS

Child play areas can pose a risk to children of infectious diseases. The prolonged presence of micro-organisms in the environment has already been established. In order to quantify this risk, specific studies are required when carrying out a risk assessment.

METHODS

In order to assess the microbiological hazard in play areas in Malta, a study was performed during 2005, which consisted of an examination of the hygienic practices carried out in play areas by means of face-to-face interviews; inspections of the premises; environmental sampling and testing, and a study on the awareness and attitudes of parents to risk factors (face-to-face interviews). Follow up studies were performed after recommendations on risk management were provided.

RESULTS

Overall, the hygienic practices in play areas were satisfactory. Of the premises 66% were licensed, 55% of the food handlers were registered, appropriate cooking and cooling facilities were available for most of the premises, temperature control records were available at 80% of premises, 60% were using disinfectant for cleaning play area surfaces and monitoring of refrigerated vehicles was carried out by 60%. There was an overall improvement after recommendations were given. At the first inspection, 67% of the premises were categorized as being fair and 33% as being good. On repeat inspection, after recommendations were made, the grading of the premises were: excellent 7%, satisfactory 33%, good 53% and fair 7%. The results of the environmental swabs taken had low counts of indicator organisms indicating a good overall hygienic condition. Parents stated that 58% of the areas were in good hygienic condition but lacked adequate hand-washing facilities for children. All parents agreed with the importance of hand hygiene and that infectious diseases can be transmitted via contaminated objects and from one person to another.

CONCLUSION

An effective control strategy needs to be implemented involving all stakeholders to ensure that effective hygienic practices in play areas are available to protect children from infectious diseases.

The magnitude and distribution of infectious intestinal disease in Malta: a population-based study

Routine sources of information on infectious intestinal disease (IID) capture a fraction of the actual disease burden. Population studies are required to measure the burden of illness. A retrospective age-stratified cross-sectional telephone study was carried out in Malta in order to estimate the magnitude and distribution of IID at population level. A random sample of 3504 persons was interviewed by a structured questionnaire between April 2004 and December 2005. The response rate was 99.7%. From the study, the observed standardized monthly prevalence was 3.18% (95% CI 0.7-5.74) with 0.421 (95% CI 0.092-0.771) episodes of IID per person per year. The monthly prevalence was higher in the <5 years age group and in females aged 31-44 years. The mean duration of illness was 6.8 days and a median duration of 3 days. A bimodal seasonal distribution was observed with peaks in June-July and October-November.