A narrative review of interventions addressing the parental-fetal relationship

Background Expectant parents develop varying degrees of emotional affiliation with the unborn child. Interventions supporting this relationship may be beneficial given its link to maternal health behaviour during pregnancy, as well as the parental–infant bond after birth. Aim To identify and describe the effects of programmes and strategies that have addressed the parental–fetal relationship. Method English-language primary studies, published between 2005–2015, were identified and their methodological quality was assessed. Databases used included CINAHL, Cochrane Library, MEDLINE, PsycINFO and Web of Science. Key search terms included maternal/paternal–fetal attachment, prenatal bond, parental–fetal relationship and intervention. RCTs, non-RCTs, observational and non-comparative studies, before and after studies and case studies were included. Findings Twenty-seven papers were included. Studies evaluated the effects of various strategies, including ultrasound and screening procedures, fetal awareness interventions, social and psychological support techniques, educational programmes and relaxation strategies. Results are inconsistent due to the diversity of interventions and significant variation in methodological quality. Conclusion There is insufficient evidence to support definitive conclusions regarding the efficacy of any included intervention. A number of limitations, such as non-probability sampling, lack of blinding, and insufficient follow-up weaken the evidence. The inclusion of fathers in only three studies reflects the overall neglect of men in research regarding the prenatal relationship. Further in-depth study of the nature of the maternal/paternal–fetal relationship may be needed in order to allow for the identification of interventions that are consistently beneficial and worthwhile

Discitis

Discitis is an inflammatory condition of the intervertebral disc or disc space. It is an uncommon condition which occurs mostly in young children or as a post-operative complication, such as following an epidural. It is extremely rare in the elderly as disc size and sponginess decreases with age and consequently the risk of infection decreases. In this case, discitis occurred spontaneously in an elderly patient and was complicated by a psoas abscess. The patient also suffers from acute renal failure, chronic heart failure, left sided pneumonia and shingles (Herpes Zoster) in dermatome S3. A trapped spinal nerve occurring at the intervertebral foramen is a common complication in fact, the subject did suffer from sciatica for the past 30 years.peer-reviewe

Liver abscess following ingestion of a foreign object

A 31 year old, previously healthy female presented to A&E on 24/07/2012 with a 2 day history of colicky epigastric pain and spiking fever; however on investigation no pathology was found except for an ovarian cyst of 4cm. It was concluded that it was unlikely that the cyst was causing pain and fever and the patient was discharged. She was given proton pump inhibitors for 2 weeks and pain improved, however on stopping therapy, the pain became much more severe, with radiation to the back. She presented to A&E again on 05/08/2012. A more detailed history elicited the fact that she had ingested half a toothpick by mistake 3 weeks previously. Imaging showed the formation of an abscess between the stomach and liver; which needed drainage.peer-reviewe

Reducing the expense of ear wax

Ear wax is one of the commonest presenting complaints both in Ear Nose and Throat surgery and in General Practice. The commonest treatment by far given for this condition is Arachis oil (Cerumol®). Results from various studies however show that this appears not to be the most effective treatment and that cheaper options exist which may drastically reduce the costs incurred by the Health Department in this respect. We hereby outline the advantages of the use of 0.9% saline drops in the treatment of ear wax.peer-reviewe

Validation of a Polymerase Chain Reaction technique for Kidd blood group genotyping

The Kidd blood group antigens, Jkª and Jkᵇ , are two of the main surface markers which are found on the membrane of red blood cells. The determination of whether a donor or a recipient has the Jkª and/or the Jkᵇ antigens is crucially important to have a successful transfusion without the development of adverse incompatibility-related reactions. In Malta, routine serological-based tests are applied with the purpose of differentiating between homozygous and heterozygous states for the Jk antigens respectively. Although these tests are highly specific and sensitive, there are particular clinical scenarios where haemagglutination assays are not suitable for determining the individual’s Kidd blood group status. Additionally, the alternative genotyping procedure has never been applied in Malta within the context of blood grouping. The current study was therefore carried out to determine whether a molecular-based technique such as Polymerase Chain Reaction – Restriction Fragment Length Polymorphism analysis (PCR-RFLP) is a suitable alternative procedure for distinguishing amongst the three different Kidd phenotypes. After extracting deoxyribonucleic acid (DNA) from 50 blood samples obtained from serologically-tested healthy blood donors who expressed at least one of the Kidd antigens, PCR-RFLP analyses were carried out. The results of the latter were then compared with those previously obtained with haemagglutination and a complete match was observed between the two. Therefore, this PCR-RFLP method was confirmed as a suitable alternative laboratory technique that can be used to determine efficiently the Kidd blood group of both donors and recipients, in an accurate manner without subjectivity as encountered in the case of haemagglutination. This research further facilitates the introduction of molecular-based techniques in molecular blood transfusion.peer-reviewe

Review of the financial and medicolegal implications of nasal fractures seen at St Luke’s Hospital

Simple nasal bone fractures are the third most common type of all fractures leading to numerous patient visits at the Accident & Emergency department. Nasal fractures are commonly over-investigated in St Luke’s hospital leading to a substantial financial burden on our health system. In this article we review the frequency of simple nasal fractures as well as the necessity or otherwise of nasal x-ray imaging in addition to the financial and health consequences that result from nasal x-ray imaging. These issues are also discussed from a legal perspective.peer-reviewe

Local attitudes in the treatment of low prognosis head and neck squamous cell carcinoma

The incidence of head and neck carcinoma in Malta is 2.44 per 100,000 population, with 5-year survival rate of 20%. International studies have however shown that head and neck squamous cell carcinoma (HNSCC) carries an average 30% survival rate. The cost of treatment of low prognosis HNSCC patients in Malta is roughly €62,500 per year per person and considering that 7 patients out of those diagnosed are treated curatively annually, the total cost would increase to nearly half a million Euros per annum. In view of this, one is bound to ask the question whether not treating patients with a 30% survival rate is justifiable, especially in view that surgical and oncologic treatment can result in severe disfigurement and poses great physical and psychological stress on patients. No studies about local decision-making with respect to HNSCC have been published. This study set out to explore this issue from the ethical point of view, taking into account a number of variables with respect to treatment and the patient factors. A pre-determined set of questions was formulated and these questions were tackled by ten medical professionals, nine of which had direct contact with HNSCC patients. Issues such as informed consent, old age, quality of life, social variables, autonomy, healthcare rationing, medico-legal problems and past experiences with patients have been identified and discussed with reference to the local situation. It was noted that the majority of interviewed professionals (70%), still emphasised the need to provide full treatment for low prognosis HNSCC.peer-reviewe

Patients’ and physicians’ experiences of atrial fibrillation and anticoagulation therapy:a qualitative journey

Background: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF) however it is often underutilized and sometimes refused by patients. This programme of work included a meta-synthesis and two inter-linking studies aiming to explore patients’ and physicians’ experiences of AF and OAC. Methods: A meta-synthesis of qualitative evidence was conducted which informed the empirical work. Semi-structured individual interviews were utilised. Study 1: Three AF patient sub-groups were interviewed; accepted (n=4), refused (n=4), or discontinued (n=3) warfarin. Study 2: Four physician sub-groups (n=4 each group) prescribing OAC to AF patients were interviewed: consultant cardiologists, consultant general physicians, general practitioners and cardiology registrars. Data was analysed using interpretative phenomenological analysis. Results: Study 1: Three over-arching themes comprised patients’ experiences: (1) the initial consultation, (2) life after the consultation, and (3) patients’ reflections. Patients commented on the relief and reassurance experienced during the consultation but they perceived the decision making process mostly led by the physician. Lack of education and take-home materials distributed during the initial consultation was highlighted. Patients who had experienced stroke themselves or were caregivers, were more receptive to education aimed towards stroke risk reduction rather than bleeding risk. Warfarin monitoring was challenging for patients, however some patients perceived it as beneficial as it served to enhance patient-physician relationship. Study 2: Two over-arching themes emerged from physicians’ experiences: (1) communicating information and (2) challenges with OAC prescription for AF. Physicians’ approach to the consultation style shifted through a continuum of compliance-adherence-concordance during the consultation. They aimed for concordance, however challenges such as time and the perceived patient trust in them as the expert, led to physicians adopting a paternalistic approach. Physicians also pointed out challenges associated with guideline adherence and the need to adopt a multi-disciplinary approach, where other health professionals could provide on-going education. Conclusion: This programme of work has illustrated the benefit of taking an in depth phenomenological approach to understanding the lived experience of the physician-patient consultation. Together with the meta-synthesis, this work has strengthened the evidence base and demonstrated that there is a need to target patients' and physicians' ability to communicate with each other in a comprehensible way

Audit on the use of radiological investigations in the management of rhinosinusitis

Objectives: The aim of this audit is to establish the cost to the Maltese health system from the use of radiological imaging in managing rhinosinusitis and to identify areas in which these costs can be minimised by following guidelines on the management of rhinosinusitis. Methods: All plain radiographs and computed tomography scans (CT) of the paranasal sinuses requested in the Mater Dei Hospital over a one year period were analysed. Data was collected regarding: the quantity of investigations ordered, age of the patients, cost and requesting department. Results: Over one year: 205 CT scans and 113 sets of plain radiographs of the paranasal sinuses were requested, costing a total of euro103,440. The majority (73%) were elective requests made by ENT consultants. Five percent of CT scans were requested for patients less than 10 years of age. Conclusion: Rhinosinusitis is diagnosed clinically, only requiring radiological investigation in more complex cases best managed by specialists in ENT. Plain radiographs have limited use in the management of rhinosinusitis. Judicious use of imaging requests whilst following clinical guidelines is required to save money and minimise patient exposure to ionising radiation.peer-reviewe

Primary localised laryngeal amyloidosis : an atypical presentation

Primary localised laryngeal amyloidosis is a rare disease that classically presents with dysphonia. We present a case of a 38-year-old woman who presented with a history of early morning haemoptysis, progressively worsening hoarseness and intermittent dysphagia. A bulky left false vocal cord was seen on examination. A computed tomography scan of the neck and trunk revealed thickening of the left side of the larynx with associated asymmetry. Direct laryngoscopy showed a round, well-circumscribed lesion on the left false vocal cord and histological examination of the lesion confirmed the presence of amyloid. Systemic disease was ruled out and the patient was treated with endoscopic excision of the mass through carbon dioxide laser technology. The patient’s symptoms improved and the patient is being followed up yearly to exclude disease recurrence. The report highlights the presentation, diagnosis and appropriate management of localised laryngeal amyloidosis.peer-reviewe