Domiciliary nasal respiratory support : first experiences in Malta

Nasal respiratory support is a non-invasive alternative to conventional assisted ventilation with endotracheal intubation, or the more cumbersome negative pressure ventilators. The two main types of this relatively new therapy are nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP) respiratory support, which are mostly used in chronic hypoventilatory states and obstructive sleep apnoea (OSA) respectively. We have introduced these two types of respiratory support to five patients suffering from neuromuscular disorders and twenty-four patients with OSA with marked improvement in the quality of life of all patients concerned. Our experiences with these patients should hopefully lead to further development in the diagnostic and therapeutic facilities in this field in Malta.peer-reviewe

Problems associated with the diagnosis and the prescribing of anti-psychotic medication in children and adolescents for psychiatric conditions, by non-psychiatric specialists

Aim: The objective of this study is to assess the accuracy of the diagnosis and appropriateness of antipsychotic medication prescribed to children and adolescents referred to child guidance clinic, and how many of these remained on the said medication after consultant psychiatrist and multidisciplinary team review. Method: A retrospective case notes review of all the children referred to a child guidance clinic in the period June 2005 to July 2006 were analysed, looking specifically at the referral tickets, the treatment on first interview with a member of the multidisciplinary team at the clinic, the working diagnosis of the team, and the management plan after at least six months of follow up at child guidance clinic. There was very good interrater reliability between the two observers looking at the case notes. Results: One hundred and fifty four (63.1%) out of a total of 244 children who were referred carried an admission diagnosis, which differed from the working diagnosis after 6 months. A total of 66 children (27%) were started on various types of psychiatric treatment prior to referral. Thirty (45.5%) of these were prescribed sulpiride, an atypical neuroleptic. Following review by the multi-disciplinary team, the medication of 25 (83.3%) of these children was terminated or altered. Conclusion: This report highlights the need of consultation liaison with general practitioners and also Continued Medical Education courses for general practice management in child and adolescent psychiatry. It is advisable that non psychiatric specialists limit the use of antipsychotic medication to children and adolescents without expert advice and in addition, should refer all such children with urgency.peer-reviewe

Future low-carbon transport scenarios: Practice theory-based visioning for backcasting studies

Backcasting is a well-established methodology particularly suitable for analyzing complex problems where the business-as-usual projection is no longer appropriate, which can be used to effectively address the challenges of climate change mitigation in transport. It is characterised by designing endpoints in the future and working backward from these visions to establish policy pathways that can achieve desired futures. The visioning phase, which involves the construction of a set of scenarios describing alternative futures, is the first phase in backcasting, and engaging different stakeholders during the visioning phase is considered an important aspect in transport studies. This paper aims to demonstrate the findings from a participatory visioning exercise carried out as part of a backcasting study on sustainable transport in the islands of Malta. It is based on a methodological approach that combines social practice theory with stakeholder workshops. The visioning exercise resulted in the development of four different scenarios: the business-as-usual scenario and three alternative scenarios for transport in 2050 in Malta; High-Tech Mobility (with a focus on clean technology); Local Mobility (with more local travel and reducing the need to travel over longer distances); and Green and Active Mobility (where active forms of travel are prioritised over motorised forms of transport). In the alternative scenarios, the elements of mobility practices and other social practices influencing mobility have been reconfigured to allow for low-carbon travel and significantly reducing GHG emissions. The results of this study demonstrate how insights from a theory of social practices approach can be utilized to provide narratives for future visions in transport backcasting studies, and how this approach could open new possibilities for the transition towards more sustainable mobility through the reconfiguration of mobility and other everyday social practices

Participatory Policy Packaging for Transport Backcasting: A Pathway for Reducing CO<inf>2</inf> Emissions from Transport in Malta

Significant emission reductions are needed in the transport sector to reach climate change mitigation objectives. Backcasting, a type of scenario-analysis approach, is a useful tool for the analysis of possible alternative transport futures and strategies to arrive at these futures when the business-as-usual projection is no longer sustainable. The backcasting approach consists of establishing desirable futures and examining the pathways by which those futures can be reached. This paper focuses on the policy packaging phase of a transport backcasting study carried out in the context of Malta as a case study. The aim of this paper is to contribute to the existing literature on transport and climate change using the case of Malta, which presents a context of high dependency on private cars and difficulty in transitioning to sustainable mobility. This paper tests the usefulness of a practice-based approach to transport backcasting. The results of this backcasting framework are a set of climate policies that target different elements of mobility practices and suggest that interventions for sustainable mobility should go beyond transport and target other spheres of social life. Collaboration between stakeholders and participation of citizens during the backcasting process was key to making the policy design process more participatory. Results of this study show how new approaches can open possibilities for a transition towards more sustainable mobility and contribute to widening the knowledge in the field of transport backcasting studies

Advances in friction stir welding of steel : Project HILDA

A microstructure and property evaluation of friction stir welded DH36 6mm plate has been undertaken. The study examined a wide range of process parameters and, from this, a process parameter envelope has been developed and an initial process parameter set established that gives good welding properties. Thermo-mechanical deformation studies were developed to generate flow stress regimes over a range of stain rates and temperatures and these data will support the on-going local numerical modelling development. A preliminary thermo-fluid model has been developed to predict temperature and material flow during the FSW of steel grade DH36. In this model, materials are considered as highly viscous incompressible fluid. The welded material is flowing around the rotating tool thanks to the modelling of the friction at tool/workpiece interface. In parallel, a global numerical model is being developed to predict the inherent residual stresses and distortion of FSW butt welded assemblies often in excess of 6m long plate

An echocardiographic comparison of sutureless and conventional aortic valve replacement : a matched case-control study

Background: Patients at a high operative risk for conventional aortic valve replacement (AVR) may be offered sutureless valve implantation. Sutureless valves resemble conventional valves but incorporate an anchoring mechanism without using annular sutures. Methods Pre-operative and six month post-operative echocardiography data from our first year, single centre experience of sutureless valves was compared to conventional aortic valve replacements in patients matched for operative risk. Left ventricular ejection fraction, mean and peak AV gradients and inter-ventricular septal thickness, effective orifice area (EOA) and indexed effective orifice area (iEOA) were measured. Results The drops in mean and peak pre- to post-operative gradients were greater in the sutureless group, p=0.039 and p=0.001 respectively. Post-operative EOA was 1.69 cm2 and 1.26 cm2 (p=0.001) in the sutureless and conventional groups. Similarly iEOA was 0.93 cm2 and 0.74 cm2 (p=0.001) in the sutureless and conventional groups. There was also a reduction in patient prosthesis mismatch (PPM) in the sutureless group as compared to the conventional group (Chi square test p=0.026). Post-operative inter-ventricular septal thickness was 1.13 cm2 in the sutureless group and 1.35 cm2 in the conventional group (p=0.011). Conclusions Use of sutureless valves with a stent framework resulted in larger EOA and iEOA and a diminution in PPM; and lead to a statistically significant faster regression in inter-ventricular septal thickness that is a measure of left ventricular mass. The rate and extent of regression in left ventricular hypertrophy after AVR is important since it determines long-term survival including mortality, heart failure and decreased admission rates.peer-reviewe

Crystalline phases involved in the hydration of calcium silicate-based cements: Semi-quantitative Rietveld X-ray diffraction analysis

Chemical comparisons of powder and hydrated forms of calcium silicate cements (CSCs) and calculation of alterations in tricalcium silicate (Ca3SiO5) calcium hydroxide (Ca(OH)2) are essential for understanding their hydration processes. This study aimed to evaluate and compare these changes in ProRoot MTA, Biodentine and CEM cement. Powder and hydrated forms of tooth coloured ProRoot MTA, Biodentine and CEM cement were subjected to X-ray diffraction (XRD) analysis with Rietveld refinement to semi-quantitatively identify and quantify the main phases involved in their hydration process. Data were reported descriptively. Reduction in Ca3SiO5 and formation of Ca(OH)2 were seen after the hydration of ProRoot MTA and Biodentine; however, in the case of CEM cement, no reduction of Ca3SiO5 and no formation of Ca(OH)2 were detected. The highest percentages of amorphous phases were seen in Biodentine samples. Ettringite was detected in the hydrated forms of ProRoot MTA and CEM cement but not in Biodentine

Pathophysiological mechanism of post-lobectomy air leaks

Background: Air leak post-lobectomy continues to remain a significant clinical problem, with upper lobectomy associated with higher air leak rates. This paper investigated the pathophysiological role of pleural stress in the development of post-lobectomy air leak.Methods: Preoperative characteristics and postoperative data from 367 consecutive video assisted thoracic surgery (VATS) lobectomy resections from one centre were collected prospectively between January 2014 and March 2017. Computer modelling of a lung model using finite element analysis (FEA) was used to calculate pleural stress in differing areas of the lung.Results: Air leak following upper lobectomy was significantly higher than after middle or lower lobectomy (6.3% versus 2.5%, P=0.044), resulting in a significant six-day increase in mean hospital stay, P=0.004. The computer simulation model of the lung showed that an apical bullet shape was subject to eightyfold higher stress than the base of the lung model.Conclusions: After upper lobectomy, the bullet shape of the apex of the exposed lower lobe was associated with high pleural stress, and a reduction in mechanical support by the chest wall to the visceral pleura due to initial post-op lack of chest wall confluence. It is suggested that such higher stress in the lower lobe apex explains the higher parenchymal air leak post-upper lobectomy. The pleural stress model also accounts for the higher incidence of right-sided prolonged air leak post-resection.peer-reviewe

The role of memory in distinguishing risky decisions from experience and description

People’s risk preferences differ for choices based on described probabilities versus those based on information learned through experience. For decisions from description, people are typically more risk averse for gains than for losses. In contrast, for decisions from experience, people are sometimes more risk seeking for gains than losses, especially for choices with the possibility of extreme outcomes (big wins or big losses), which are systematically overweighed in memory. Using a within-subject design, this study evaluated whether this memory bias plays a role in the differences in risky choice between description and experience. As in previous studies, people were more risk seeking for losses than for gains in description but showed the opposite pattern in experience. People also more readily remembered the extreme outcomes and judged them as having occurred more frequently. These memory biases correlated with risk preferences in decisions from experience but not in decisions from description. These results suggest that systematic memory biases may be responsible for some of the differences in risk preference across description and experience