Clinicians’ adherence to local antibiotic guidelines for upper respiratory tract infections in the ear, nose & throat casualty department of a public general hospital

Background: In Malta, resistance to antibiotics constitutes a major threat to public health. This study aims to assess clinicians’ adherence to local antibiotic guidelines when treating cases of acute otitis media, acute tonsillitis and rhinosinusitis, that present to the ear, nose and throat (ENT) casualty department in Malta’s public general hospital, as well as to recommend methods for improving adherence and minimising overprescribing. Methodology: Data on first line antibiotic prescribing regimens was retrieved from ENT casualty sheets between February and March 2015 for adult patients (>12years) diagnosed with acute otitis media, acute tonsillitis and persistent rhinosinusitis. On an audit form, aspects of the prescribed antibiotic were benchmarked to local infection control antibiotic guidelines of 2011 to evaluate adherence. Results: From 1010 casualty records, 188 were antibiotic prescriptions, of which 93 (49.4%) were correctly indicated as per guidelines. From the indicated prescriptions 81 (87%) were assessable, out of which full adherence was only observed in 6 (7%) of prescriptions. All of these were for rhinosinusitis. Full adherence in rhinosinusitis was found to be 43%, whilst no adherence was found in the other infections. The most prescribed antibacterial for all three infections was co-amoxiclav. Conclusion: The current antibiotic guidelines have not been adequately implemented as adherence to antibiotic choice alone was low in all infections. This may have an impact on antibiotic-resistant rates and infection incident rates. Hence to improve adherence to local antibiotic guidelines, it is recommended that these should be clear, regularly updated, well disseminated and reinforced. The addition of a care pathway may further improve appropriate antibiotic use.peer-reviewe

Concordance with the British Society of Rheumatology (BSR) 2010 recommendations on eligibility criteria for the first biologic agent

Aims: The aim of this study is to assess concordance with the British Society of Rheumatology (BSR) 2010 recommendations on the use of biologic therapy in Rheumatoid Arthritis (RA). The Disease Activity Score in 28 joints (DAS 28), a composite numerical score is included in these recommendations to assess disease activity and response to treatment. Methods: Clinical notes of fifty patients who were commenced on biologic treatment between March 2010 and June 2011 were reviewed for documentation of DAS 28 scores at baseline, after approximately 6 months of commencement of treatment and at approximately 6 monthly intervals during treatment. Results: Twenty two patients were eligible for this audit. Of these patients only half had a DAS 28 score performed prior to starting treatment, four patients had the score performed within 3-9 months of commencement of therapy and only 2 patients had continuous scores performed at six monthly intervals during treatment. Conclusions: This audit shows that we are not adhering to the BSR recommendations. In order to improve our adherence we plan to train all staff in contact with patients on biologic treatment to perform DAS 28 scores and have a DAS 28 calculator readily available at out patients. A proforma is being developed for patients on biologic therapy to ensure that DAS 28 scores are performed at baseline and during treatment.peer-reviewe

Coexistence of Takayasu Arteritis and Crohn’s Disease in a Maltese patient

Takayasu arteritis (TA) and Crohn’s disease (CD) are uncommon chronic granulomatous disorders affecting the large arteries and the gastrointestinal tract, respectively. At least 40 occurrences of these two conditions in the same patient have been reported in the literature, raising the possibility of an association between them. We report the coexistence of TA and CD in a young Maltese patient and review the literature to discuss possible aetiological mechanisms that might explain this association.peer-reviewe

Comments

The subject for this issue’s Comments section represents a significant departure from what we have previously published. International Journal of Advertising Editor, Douglas West, recently presented awards for reviewing excellence to two members of the Editorial Review Board, Barbara Stern at Rutgers University and Albert Caruana at the University of Malta. It was our feeling that their views on the reviewing process would be of interest not only to potential contributors, but also to other members of our Editorial Review Board. Having been a reviewer for a number of journals over the past 20 years, I am always happy to see how others approach the reviewing process. We can always learn from the best. Barbara posits a meaningful series of steps in the review process from an assessment of the references to a final evaluation decision, while Albert discusses the particular challenges faced by every reviewer. Albert stresses the need for the reviewer to put themselves in the mindset of the authors and to allow time after the initial completion of the review to think over the suggestions for the authors before sending them out. We hope you will find these essays both informative and valuable. These different perspectives are really quite complementary. As always, we would welcome your comments at [email protected]

Monitoring of thyroid function tests in hypothyroid patients on levothyroxine

The study aims to identify and recommend ways of improving thyroid function monitoring. Over a three month period, eighty-eight patients with clinical and subclinical primary hypothyroidism on long-term levothyroxine therapy were seen by GPs at the Chronic Disease Managment Clinic. The monitoring intervals of thyroid function tests for patients with controlled and uncontrolled primary hypothyroidism were benchmarked with the American Association of Clinical Endocrinologists guidelines. The overall average compliance for clinical hypothyroid cases was 69% (n=15) and 40% (n=9) for the subclinical hypothyroid cases. In the clinical hypothyroid cases compliance was 71% (n=15) and 67% (n=14) for controlled and uncontrolled cases, respectively. In the subclinical hypothyroid cases compliance was 43% (n=10) and 35% (n=8) for controlled and uncontrolled cases, respectively. Knowledge of the guidelines amongst GPs should be increased especially when it comes to the management of subclinical hypothyroidism, and in cases of uncontrolled hypothyroidism in general. This is possible through better dissemination, availability and reinforcement of such guidelines.peer-reviewe

Built-in premium effects within exotic FX options

Purpose: This paper explains the analysis of built-in premium within ‘premium-free’ FX Option strategies, also known as ‘exotic options’. The aim is to analyse whether such an increase in built-in premium would have an effect on the outcome of the strategies. Methodology: The analysis was conducted through three different currency pairs, namely, the EURUSD, EURJPY and EURGBP, throughout a period between 2007 to 2014. The authors used the Bloomberg terminal to design two different option strategies: Window Forward Extra and At Expiry Forward Extra. These strategies are known as low risk hedging strategies within the FX options industry. The authors examined different combinations of changes in built-in premium and analysed the respective outcome with each combination. The outcomes were compared to analyse whether an increase in built-in premium would have an effect on the outcome of the strategy. A test was also conducted should these strategies be used as a speculative tool. The strategies were built on a 1 year tenor which is rolled over every month. Hence, each month a hedge using the strategy for 1 year was conducted. The authors used back dated implied volatilies when performing the back-testing in order for results to be realistic. Findings: In most cases it was found that there was no effect on the outcome of the strategy. However, this was only valid if an expiry at a time is taken. On the other hand, when taking into account the whole sample, even though only 3% of the times there was an effect on the outcome of the strategy, the total result finds that an increase in built-in premium has an effect on the outcome of the strategy. Such result was found to be statistically significant using a paired sample t-test. This applied for all currency pairs under review. When analysing the exotic option strategies for speculative purposes, the authors found that in most cases it would have been better for brokers to take higher risk and receive an upfront Premium.peer-reviewe

Eli, Eli, lama sabaqtani?

Din il-poeżija bl-isem `Eli, Eli, lama sabaqtani?’ ta’ John Caruana dehret fil-ġurnal Il-Malti : Rivista tal-Akkademja tal-Malti ħarġa letterarja, 93.peer-reviewe

Colonoscopy screening in moderate-risk family groups

Colorectal cancer is one of the commonest forms of cancer in the Maltese population. It can be treated successfully if detected early. Education and screening are the major components of early detection. The aim of this study was to determine the pattern of colonoscopy screening in patients at moderate risk of developing colorectal cancer in a surgical firm at Mater Dei Hospital. 90 patients that fit into the moderate-risk category were identified from the firm’s endoscopy database. The pattern of screening was then compared to the NICE guidelines. It was found that colonoscopy screening was more aggressive than recommended by the NICE guidelines.peer-reviewe