Re-operation rates in breast cancer after breast conserving surgery in Malta

The Agatha Breast Unit at Mater Dei Hospital, Malta performed 340 wide local excisions for cancer in 2013-4. Further surgery for close or involved surgical margins was performed in 45 cases (13%), of these 26 (58%) underwent cavity excision and 19 (42%) underwent mastectomy. Residual tumour was found in 9 (35%) in the cavity excision group and 13 (68%) of the mastectomy group. The authors discuss how their unit follows the recommendations of the “Toolbox to reduce lumpectomy reoperations and improve cosmetic outcome in breast cancer patients of the American Society of Breast Surgeons Consensus Conference” and what can be done to reduce re-operation rates further.peer-reviewe

The rise of pertussis in Malta in 2011 : a case for adolescent and adult pertussis booster vaccination

Notwithstanding the high rates of pertussis infant vaccination coverage in developed countries, Bortedella pertussis infections are manifesting a changing epidemiological pattern of disease. Of notable concern is the rise of pertussis in adolescents and adults. This changing picture is largely attributable to waning immunity after natural infection or vaccination. The belief that pertussis is chiefly a childhood disease is a common misconception. A significant rise of pertussis cases in Malta in older age groups was recorded in 2011. The addition of an adolescent and/or an adult booster dose against pertussis should be strongly considered.peer-reviewe

Surgery for Colorectal Cancer in Older People

Life expectancy has been increasing, and an increasing number of older patients are presenting with colorectal cancer. Surgical management of colorectal cancer in these patients poses a unique challenge, requiring a multidisciplinary team approach, as they have more comorbidities and lower functional reserves. An accurate diagnosis, a thorough patient assessment and individualized treatment is crucial in order to achieve the best possible outcome. While the overall postoperative mortality rates were significantly higher in the over 75 age group, it seems that age itself is not a risk factor for surgery. Older patients presented with more locally advanced disease, a factor that increased the overall postoperative mortality. Comorbid conditions increase the risk of postoperative mortality in these patients. When comparing different age groups with similar American Society of Anesthesiologists (ASA) scores, no significant difference was found in postoperative mortality. Laparoscopic surgery was shown to be beneficial for the elderly, with low morbidity and mortality and a shortened hospital stay. Patients with rectal cancer benefit from transanal endoscopic surgery as a primary procedure or as part of a ‘watch and wait’ strategy following neoadjuvant chemoradiotherapy. Early elective surgery and the avoidance of emergency major surgery whenever possible, by for example the use of stents followed by elective resection in cases of colonic obstruction, will help improve outcomes

Preliminary report on the sector inquiry on the supply of infant milk formula in the public health sector and the impact of that supply on the private retail market for : a) from birth infant formula, b) follow-on formula and c) toddler milk or other formula for the period 2013 -2019

On 4 June 2019, the Office for Competition received a letter from one of the local suppliers of infant formula and similar products alleging that the public contract for the supply of infant formula to Mater Dei Hospital is distorting competition in the private retail market for the focal product. Breastfeeding is recognised by the World Health Organisation as the best feeding practice to nourish an infant. However, this inquiry focuses on the competition aspects of the market in cases where the parents use and purchase infant formula in the first years of their infant’s life. If, for any reason, an infant is not breastfed, then an infant formula is the only appropriate alternative milk source from the age of zero to one year. Following preliminary investigations, the Office for Competition initiated a sector inquiry on the supply of infant milk formula in the public health sector covering the 2013 – 2019 period, in terms of Article 11A (1) of the Competition Act (Cap. 379 of the Laws of Malta). The sector inquiry assessed whether the procurement process adopted by the Central Procurement and Supplies Unit is distorting competition in the secondary markets. This preliminary report presents the findings of the Office for Competition and concludes that the procurement process adopted by the Central Procurement and Supplies Unit at Mater Dei Hospital is distorting competition in the secondary market.peer-reviewe

PROGNOSTIC POWER OF INFLAMMATORY RESPONSE SCORING SYSTEMS IN PERIAMPULLARY PANCREATIC CANCER: A SYSTEMATIC REVIEW

Introduction: Assessment of systemic inflammatory response forms the basis of several scoring systems that attempt to prognosticate patients with periampullary pancreatic carcinoma (PPC). We assessed the validity of three of these scoring systems for patients’ prognosis following intervention for PPC: Glasgow prognostic score (GPS) and its modified version (mGPS), platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR).Methods: EMBASE and MEDLINE databases were searched for all published studies until September 2018 using comprehensive text word and MeSH terms. Meta-analysis of observational studies in epidemiology guidelines was followed. All identified studies were analysed and relevant studies were included in the review.Results: Three studies which assessed the role of GPS, four studies that evaluated the use of NLR and three that assessed the role of PLR in patients with PPC were identified. None of these studies demonstrated any value in the pre-operative assessment of patients with PPC. The limited number of studies available precluded further statistical analysis.Conclusions: Based on available evidence, GPS, NLR and PLR do not appear to be useful scoring systems to predict prognosis of patients with PPC. Larger studies are warranted before the application of inflammatory scoring systems could be recommended in patients with PPC.Key words: Periampullary cancer, Glasgow prognostic score, modified Glasgow prognostic score, platelet-lymphocyte ratio, neutrophil-lymphocyte rati

Postcholecystectomy diarrhoea rate and predictive factors : a systematic review of the literature

Cholecystectomy is one of the most common surgical procedures performed worldwide to treat gallstone-related disease. Postcholecystectomy diarrhoea (PCD) is a well-reported phenomenon, however, the actual rate, predictive factors and mechanism of action have not been well determined. A systematic review was undertaken to determine the rate and predictive factors associated with diarrhoea in the postcholecystectomy setting. The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. Databases searched included Medline, Embase, Pubmed, Cochrane and Google Scholar up to 29 September 2020. The inclusion criteria consisted of cohort studies or randomised trials which investigated the rate of PCD and predictive factors. Case reports, case series, conference abstracts and expert opinion pieces were excluded as were other systematic reviews as all the original articles from those reviews were included in this review. Papers that did not include PCD as a separate entity were excluded. Bias assessment was performed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomised controlled trials as appropriate. Data were extracted by two authors (AF and JAA) and an overall rate of PCD was calculated. Predictive factors were also extracted and compared between studies. 1204 papers were obtained and 21 were found to contain relevant information about PCD, including the number of patients developing diarrhoea, method of symptom assessment and time of onset postcholecystectomy. A pooled total of 3476 patients were included across the identified studies with 462 (13.3%) patients developing PCD. Possible predictive factors varied across all studies, with characteristics such as gender, age and weight of patients postulated as being predictive of PCD, with no agreement across studies. PCD is therefore relatively common (13.3%). This has important implications for patient consent. Patients ought to be investigated early for bile acid diarrhoea in suspected PCD. More studies are required to determine the possible predictive factors for PCD. Limitations of the study included that most studies were not powered for calculation of PCD, and assessment methods between studies varied. CRD42019140444. [Abstract copyright: © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Can designers be proactively supported as from product specifications?

During the design process, designers are concerned with two main types of issues - issues related to “what needs to be achieved” or “whats” and issues related to “how these needs will be met” or “hows”. A literature review carried out revealed that means which proactively make designers aware of artefact life-cycle consequences (LCCs) arising from both their “whats” and “hows” and which guide them on how to minimise or avoid any negative consequences, are lacking. This research thus contributes an approach framework to meet this aim. The approach framework developed is further implemented as a prototype computer-based tool and subsequently evaluated. Based on the feedback obtained from the evaluation, future research directions are also proposed.peer-reviewe

Rates of Bile Acid Diarrhoea After Cholecystectomy:A Multicentre Audit

Introduction: Bile acid diarrhoea (BAD) can occur due to disruption to the enterohepatic circulation, e.g. following cholecystectomy. Post-cholecystectomy diarrhoea has been reported in 2.1–57.2% of patients; however, this is not necessarily due to BAD. The aim of this study was to determine the rates of bile acid diarrhoea diagnosis after cholecystectomy and to consider investigation practices. Methods: A retrospective analysis of electronic databases from five large centres detailing patients who underwent laparoscopic cholecystectomy between 2013 and 2017 was cross-referenced with a list of patients who underwent 75SeHCAT testing. A 7-day retention time of <15% was deemed to be positive. Patient demographics and time from surgery to investigation were collected and compared for significance (p < 0.05). Results: A total of 9439 patients underwent a laparoscopic cholecystectomy between 1 January 2013 and 31 December 2017 in the five centres. In total, 202 patients (2.1%) underwent investigation for diarrhoea via 75SeHCAT, of which 64 patients (31.6%) had a 75SeHCAT test result of >15%, while 62.8% of those investigated were diagnosed with bile acid diarrhoea (BAD). In total, 133 (65.8%) patients also underwent endoscopy and 74 (36.6%) patients had a CT scan. Median time from surgery to 75SeHCAT test was 672 days (SD ± 482 days). Discussion/Conclusion: Only a small proportion of patients, post-cholecystectomy, were investigated for diarrhoea with significant time delay to diagnosis. The true prevalence of BAD after cholecystectomy may be much higher, and clinicians need to have an increased awareness of this condition due to its amenability to treatment. 75SeHCAT is a useful tool for diagnosis of bile acid diarrhoea