Subarachnoid Haemorrhage in Malta : Are outcomes adversely affected due to lack of a local neurovascular service?

Objective: This study was performed to assess the incidence, treatment and outcome of non-traumatic Subarachnoid Haemorrhage (SAH) in an island which does not offer a neurovascular service and to determine whether such limitation is associated with a poor outcome. Method: Data of adult patients with a diagnosis of non-traumatic SAH was analysed retrospectively over a two-year period from January 01, 2009 to December 31, 2010. Results: The incidence of SAH in Malta is 3.16 cases per 100 000 population per year. An underlying aneurysm was found in 50% of all cases investigated with angiography. These patients were transported to the United Kingdom for definitve management and the outcome of all these patients at 6 months was excellent. (modified Rankin Scale of 0 or 1). Conclusions: With the incidence of non-traumatic SAH being in the low range, setting up an interventional neuroradiology service in our country to treat aneurysmal SAH would not have the required numbers to maintain expertise and would probably translate into worse clinical outcomes. Despite having geographical and logistic limitations, our standards of care and survival rates are not below those of other international centres. Outcomes for patients with low initial Hunt and Hess scores have not been adversely.peer-reviewe

A 5-year study on the epidemiology and outcome of patients with non-traumatic subarachnoid hemorrhage in Malta

Objective: The aim of this study was to measure the incidence, treatment and outcome of non-traumatic Subarachnoid Haemorrhage (SAH) cases occurring in Malta during the five-year period between January 2011 and December 2015, in order to determine whether the lack of a local neurovascular service is associated with a poor outcome. Method: A retrospective analysis of adult patients (above the age of 16) diagnosed with non-traumatic SAH was carried out. The data collected included a five-year period from January 1st 2011 till December 31st 2015. Results: The incidence of SAH was estimated at 4.04 cases per 100,000 population per year. An underlying aneurysm was found to be the cause of the SAH in 69.1 % of cases investigated with CT angiography or Cerebral Angiography. In these patients, definitive management in the form of coiling or clipping of the aneurysm was carried out in the United Kingdom as part of an agreement between countries, within days. The outcome of these patients measured at 6 months using the Modified Rankin Scale (MRS) was found to be excellent. Conclusion: Despite our geographical and logistical limitations, outcomes of those patients with initial low Hunt and Hess (H+H) scores have not been affected by the lack of a local neurovascular service. Results are comparable to those of other international centres. Further studies looking into feasibility of expanding our local services are being carried out.peer-reviewe

Omeprazole-induced delirium

Delirium is a common manifestation in the elderly, with studies quoting a prevalence of up to 14% in the community in those aged 85 years and older. It occurs in 10-34% of patients living in long term care facilities and occurs in 30% of patients presenting to the accident and emergency departments. Despite the fact that 10-42% suffer from delirium during a hospital stay, complicating 17-61% of major surgical procedures, it is unfortunately only recognized in 20-50% of cases. Despite the higher prevalence in the elderly population, it may present in all age groups, identified as per the ‘American Psychiatric Association’ (APA) Diagnostic and Statistical Manual (DSM-IVTR and DSM-V Proposed Revision) criteria. Medications are potential causes for delirium, accounting for as much as 39% of cases of delirium in the elderly, with the latter population being more at risk than other age groups due to altered pharmacokinetic and pharmacodynamics associated with the aging process.peer-reviewe

Primary CNS lymphoma with intravitreal metastasis : using vitreous cavity samples to monitor response to therapy

A fifty-eight year old male patient presented to the ophthalmic department with a 3 day history of reduced visual acuity, blurred vision and floaters, associated with recent lethargy, headaches and behavioural changes. Fundal examination revealed a bilateral vitritis. Steroid therapy was started. MRI of the brain revealed multiple hypodense and hyperdense lesions. Vitrectomy was performed in view of the poor response to steroids. A biopsy showed non-hodgkin B-Cell lymphoma. The patient was started on intravenous Methotrexate and Cytarabine. Repeat vitreous cavity biopsies were performed in order to assess response to therapy. All biopsies to date have revealed evidence of on-going lymphoma.peer-reviewe

Taxanes as a Risk Factor for Acute Adverse Reactions to Iodinated Contrast Media in Cancer Patients

BACKGROUND. The impact of cytotoxic agents on the risk of acute allergy-like adverse reactions (ARs) to intravenous iodinated contrast media (ICM) injections is unknown. METHODS. We retrospectively reviewed 13,565 computed tomography (CT) scans performed in a consecutive cohort of cancer patients from January 1, 2010 to December 31, 2012. Episodes of acute ICM-related ARs were reported to the pharmacovigilance officer. The following matched comparisons were made: tax code, gender, primary tumor, antineoplastic therapy, and date of last cycle. Concomitant antineoplastic treatment was classified into five groups: platinum, taxane, platinum plus taxane, other, and no treatment group (no therapy had been administered in the previous 24 months). Logistic regression was used to estimate odds ratio (OR) and 95% confidence interval (CI) to evaluate the risk of acute ICM-related ARs. RESULTS. Of 10,472 contrast-enhanced CT scans, 97 (0.93%; 95% CI: 0.74–1.11) ICM-related ARs were reported, 11 of which (0.1%) were severe, including one fatality. The overall incidence was significantly higher in patients aged <65 years (p = .0062) and in the platinum plus taxane and taxane groups (p = .007), whereas no correlation was found with gender, number of previous CT scans, site of disease, or treatment setting. Multivariate analysis confirmed an increased risk for patients aged <65 years (OR: 1.73; 95% CI: 1.14–2.63) and for the taxane group (in comparison with the no treatment group; OR: 2.06; 95% CI: 1.02–4.16). CONCLUSION. Among cancer patients, concomitant treatment with taxanes and younger age would seem to be risk factors for ICM-related ARs

Source apportionment for indoor air pollution: Current challenges and future directions

Source apportionment (SA) for indoor air pollution is challenging due to the multiplicity and high variability of indoor sources, the complex physical and chemical processes that act as primary sources, sinks and sources of precursors that lead to secondary formation, and the interconnection with the outdoor environment. While the major indoor sources have been recognized, there is still a need for understanding the contribution of indoor versus outdoor-generated pollutants penetrating indoors, and how SA is influenced by the complex processes that occur in indoor environments. This paper reviews our current understanding of SA, through reviewing information on the SA techniques used, the targeted pollutants that have been studied to date, and their source apportionment, along with limitations or knowledge gaps in this research field. The majority (78 %) of SA studies to date focused on PM chemical composition/size distribution, with fewer studies covering organic compounds such as ketones, carbonyls and aldehydes. Regarding the SA method used, the majority of studies have used Positive Matrix Factorization (31 %), Principal Component Analysis (26 %) and Chemical Mass Balance (7 %) receptor models. The indoor PM sources identified to date include building materials and furniture emissions, indoor combustion-related sources, cooking-related sources, resuspension, cleaning and consumer products emissions, secondary-generated pollutants indoors and other products and activity-related emissions. The outdoor environment contribution to the measured pollutant indoors varies considerably (<10 %- 90 %) among the studies. Future challenges for this research area include the need for optimization of indoor air quality monitoring and data selection as well as the incorporation of physical and chemical processes in indoor air into source apportionment methodology

Vasoactivity of AG014699, a clinically active small molecule inhibitor of poly(ADP-ribose) polymerase: a contributory factor to chemopotentiation in vivo?

PURPOSE: Poly(ADP-ribose) polymerase plays an important role in DNA repair and PARP inhibitors can enhance the activity of DNA damaging agents in vitro and in vivo. AG014699 is a potent PARP inhibitor in Phase II clinical development. However the range of therapeutics with which AG014699 could interact via a DNA-repair based mechanism is limited. We aimed to investigate a novel, vascular-based activity of AG014699, underlying in vivo chemosensitisation, that could widen its clinical application. EXPERIMENTAL DESIGN: Temozolomide response was analysed in vitro and in vivo. Vessel dynamics were monitored using “mismatch” following the administration of perfusion markers and real-time analysis of fluorescently-labeled albumin uptake in to tumours established in dorsal window chambers. Further mechanistic investigations employed ex vivo assays of vascular smooth muscle relaxation, gut motility and myosin light chain kinase inhibition. RESULTS: AG014699 failed to sensitise SW620 cells to temozolomide in vitro but induced pronounced enhancement in vivo. AG014699 (1mg/kg) improved tumour perfusion comparably with the control agents nicotinamide (1g/kg) and AG14361 (fore-runner to AG014699; 10mg/kg). AG014699 and AG14361 relaxed pre-constricted vascular smooth muscle more potently than the standard agent, hydralazine, with no impact on gut motility. AG014699 inhibited myosin light chain kinase at concentrations that relaxed isolated arteries, whereas AG14361 had no effect. CONCLUSION: Increased vessel perfusion elicited by AG014699 could increase tumour drug accumulation and therapeutic response. Vasoactive concentrations of AG014699 do not cause detrimental side-effects to gut motility and may increase the range of therapeutics with which AG014699 could be combined with for clinical benefit