Benchmarking local practice in view of introduction of thrombolysis for stroke in Malta

The aim of the study was to benchmark the quality of local stroke care in view of introduction of thrombolysis. Stroke patients admitted to Mater Dei Hospital over 6 weeks in 2008 were recruited. A questionnaire based on the 2006 Royal College of Physicians (RCP) National Sentinel Stroke Audit phase II (Clinical Audit) was used. Results were compared to the 2008 RCP National Sentinel Stroke Audit phase II (Clinical Audit) report. 42 confirmed strokes were admitted. All patients underwent CT scanning within 24 hours. 97% received aspirin within 48 hours. 26.2% spent >50% of their stay in the neurology ward. 81% were discharged alive. At 24 hours from admission, 54.7% were not screened for swallowing. 47.6% were not assessed by an occupational therapist. 81% were assessed by physiotherapy at 72 hours of admission. None of the patients had documented goals set by a multi- disciplinary team. If thrombolysis were available, 16.7% would have been eligible. The commonest contraindications were late presentation (52.4%) and age >80 years (35.7%). Local results compared well to the RCP 2008 results in initiation of aspirin, imaging, and nutrition. However, we noted need for improvement in the assessment of swallowing, mood and cognitive function as well as involvement of a multidisciplinary team. Since then, adherence to international guidelines has improved by the introduction of thrombolysis, a dedicated multidisciplinary service and the use of local guidelines for stroke.peer-reviewe

2019 ESC/EAS guidelines for the management of dyslipidaemias : Lipid modification to reduce cardiovascular risk

Correction: Volume: 292 Pages: 160-162 DOI: 10.1016/j.atherosclerosis.2019.11.020 Published: JAN 2020Peer reviewe

Cancer recurrence times from a branching process model

As cancer advances, cells often spread from the primary tumor to other parts of the body and form metastases. This is the main cause of cancer related mortality. Here we investigate a conceptually simple model of metastasis formation where metastatic lesions are initiated at a rate which depends on the size of the primary tumor. The evolution of each metastasis is described as an independent branching process. We assume that the primary tumor is resected at a given size and study the earliest time at which any metastasis reaches a minimal detectable size. The parameters of our model are estimated independently for breast, colorectal, headneck, lung and prostate cancers. We use these estimates to compare predictions from our model with values reported in clinical literature. For some cancer types, we find a remarkably wide range of resection sizes such that metastases are very likely to be present, but none of them are detectable. Our model predicts that only very early resections can prevent recurrence, and that small delays in the time of surgery can significantly increase the recurrence probability.Comment: 26 pages, 9 figures, 4 table

Caseous mitral annular calcification mimicking a lung tumor on chest X-ray

Mitral annular calcification (MAC) is a common condition of the mitral valve apparatus. A case involving caseous calcification, a rare variant of MAC is presented. This variant which has a benign course can present as an intracardiac mass and needs to be differentiated from more sinister causes of calcified cardiac masses such as tumor, abscess, and infective vegetation. Often, this requires multimodality imaging with echocardiography, computed tomography, and magnetic resonance imaging. Features of caseous calcification of the mitral valve on these imaging modalities are reviewed as the associations and clinical features.peer-reviewe

The impact of passive and active smoking on inflammation, lipid profile and the risk of myocardial infarction

Objective: To investigate the effect of passive smoking, active smoking and smoking cessation on inflammation, lipid profile and the risk of myocardial infarction (MI). Methods: A total of 423 cases with a first MI and 465 population controls from the Maltese Acute Myocardial Infarction (MAMI) Study were analysed. Data were collected through an interviewer-led questionnaire, and morning fasting blood samples were obtained. ORs adjusted for the conventional risk factors of MI (aORs) were calculated as an estimate of the relative risk of MI. The influence of smoking on biochemical parameters was determined among controls. Results: Current smokers had a 2.7-fold (95% CI 1.7 to 4.2) and ex-smokers a 1.6-fold (95% CI 1.0 to 2.4) increased risk of MI. Risk increased with increasing pack-years and was accompanied by an increase in high-sensitivity C reactive protein levels and an abnormal lipid profile. Smoking cessation was associated with lower triglyceride levels. Exposure to passive smoking increased the risk of MI (aOR 3.2 (95% CI 1.7 to 6.3)), with the OR being higher for individuals exposed to passive smoking in a home rather than in a public setting (aOR 2.0 (95% CI 0.7 to 5.6) vs aOR 1.2 (95% CI 0.7 to 2.0)). Passive smoke exposure was associated with higher levels of total cholesterol, triglycerides and total cholesterol:high-density lipoprotein cholesterol ratio compared with individuals not exposed to passive smoking. Conclusions: Both active and passive smoking are strong risk factors for MI. This risk increased with increasing pack-years and decreased with smoking cessation. Such effects may be partly mediated through the influence of smoking on inflammation and lipid metabolism

The impact of frequency, pattern, intensity, and type of alcohol consumption, and its combined effect with smoking on inflammation, lipid profile, and the risk of myocardial infarction

Aim: To determine the risk of myocardial infarction (MI) associated with pattern, frequency, and intensity of alcohol consumption, type of alcoholic beverage, and the combined effect of alcohol and smoking on risk of MI, inflammation, and lipid profile. Method: A total of 423 cases with a first MI and 465 controls from the Maltese Acute Myocardial Infarction (MAMI) Study were analysed. Data was collected through an extensive interviewer-led questionnaire, along with measurements of various blood parameters. Medians and the Mann–Whitney test were used to assess effect of different drinking patterns, frequency, intensity, and smoking and drinking combinations on hs-CRP and lipid profile. Odds ratios, adjusted for the conventional risk factors of MI (AdjORs), were calculated as an estimate of the relative risk of MI. Results: Regular alcohol consumption protected against MI [AdjOR 0.6 (95% CI 0.4–0.9)] while daily binge drinking increased risk [AdjOR 5.0 (95% CI 1.6–15.0)] relative to regular drinkers who did not binge drink. Whereas moderate weekly consumption of wine protected against MI, high weekly consumption of beer conveyed a deleterious effect. Alcohol consumption decreased risk of MI independent of smoking status. Frequent alcohol consumption was associated with higher HDL-, non-HDL-, total cholesterol and triglycerides, and lower hs-CRP. Total and HDL-cholesterol increased and BMI decreased with increasing quantity of weekly alcohol consumption relative to the non-regular drinkers. The effect of smoking on lipid profile and hs-CRP was less pronounced in current drinkers than in those who were non-regular drinkers. Conclusion: The protective effect of alcohol consumption was dependent on the pattern, frequency, type, and intensity of alcohol consumed. Alcohol modified the effects of smoking on the lipid profile. Regular drinking attenuated the effect of smoking on hs-CRP and lipid profile

The impact of passive and active smoking on inflammation, lipid profile and the risk of myocardial infarction

Objective To investigate the effect of passive smoking, active smoking and smoking cessation on inflammation, lipid profile and the risk of myocardial infarction (MI)Methods A total of 423 cases with a first MI and 465 population controls from the Maltese Acute Myocardial Infarction (MAMI) Study were analysed. Data were collected through an interviewer-led questionnaire, and morning fasting blood samples were obtained. ORs adjusted for the conventional risk factors of MI (aORs) were calculated as an estimate of the relative risk of MI. The influence of smoking on biochemical parameters was determined among controls.Results Current smokers had a 2.7-fold (95%CI 1.7 to 4.2) and ex-smokers a 1.6-fold (95%CI 1.0 to 2.4) increased risk of MI. Risk increased with increasing pack-years and was accompanied by an increase in highsensitivity C reactive protein levels and an abnormal lipid profile. Smoking cessation was associated with lower triglyceride levels. Exposure to passive smoking increased the risk of MI (aOR 3.2 (95% CI 1.7 to 6.3)), with the OR being higher for individuals exposed to passive smoking in a home rather than in a public setting (aOR 2.0 (95% CI 0.7 to 5.6) vs aOR 1.2 (95% CI 0.7 to 2.0)). Passive smoke exposure was associated with higher levels of total cholesterol, triglycerides and total cholesterol:high-density lipoprotein cholesterol ratio compared with individuals not exposed to passive smoking.Conclusions Both active and passive smoking are strong risk factors for MI. This risk increased with increasing pack-years and decreased with smoking cessation. Such effects may be partly mediated through the influence of smoking on inflammation and lipid metabolism.peer-reviewe

Conventional risk factors for myocardial infarction in the Maltese population - results from the Maltese Acute Myocardial Infarction (MAMI) study

This study aimed to determine the influence of some conventional risk factors for Myocardial Infarction (MI) in the Maltese population. Some 429 cases with a first MI, 434 controls and some 190 relatives of cases have been recruited in the Maltese Acute Myocardial Infarction (MAMI) study. Data has been collected through an interviewer-led questionnaire, physical measurements and biochemistry and haematology testing. Odds ratios (OR) were calculated and adjusted (AdjOR) for age, gender, smoking/drinking alcohol, hypertension, diabetes, hypercholesterolaemia and body mass index. Smoking, diabetes, hypertension, hypercholesterolaemia and a family history of MI are amongst the risk factors associated with an increased risk of MI in the Maltese. Both active and passive smoking are associated with a 3-fold increased risk for MI. Whereas regular drinking (having at least one drink per week for one year) is associated with a decreased risk for MI [AdjOR 0.6 (95% CI 0.4-0.8], the risk associated with daily binge drinking (six or more drinks in the same occasion) is very high reaching an OR of 5.8 (95% CI 1.2-27.1). The risk associated with diabetes varies depending on the level of control. Uncontrolled diabetes (defined as HbA1C levels above 6.5%) is associated with a 3-fold increased risk of MI [AdjOR 3.0 (95% CI 1.9-4.7)], whereas controlled diabetics showed no increased risk of MI [AdjOR 0.9 (95% CI 0.4-2.1)]. The conventional risk factors in the Maltese population are similar to those of other Western countries. Attention needs to be given to improving glucose control in diabetes. Passive smoking is as strong a risk factor as active smoking and the risk associated with alcohol consumption varies depending on the pattern and frequency of drinking. Regular binge drinking is a particularly strong risk factor for MI

The effect of smoking, alcohol and coffee consumption on inflammation and the risk of myocardial infarction

The aim of the study was to investigate the effect of smoking, alcohol and coffee consumption on the risk of myocardial infarction (MI) and on the generation of an inflammatory response. Data on 423 cases with MI and 465 controls was obtained through an interviewer-led questionnaire as part of the Maltese Acute Myocardial Infarction (MAMI) Study. Regular alcohol drinkers were subjects who had at least one drink/week for one year. Binge drinkers were those having ≥6 drinks on one occasion this last year. [excerpt]peer-reviewe

Combined effect of smoking and the -148C>T fibrinogen polymorphism and the risk of myocardial infarction in the Maltese population

Fibrinogen is a soluble glycoprotein that acts as a clotting factor and acute phase reactant. Plasma fibrinogen levels are affected by environmental and demographic factors including gender, advancing age and seasonality. Polymorphisms within the three fibrinogen genes, FGA, FGB, and FGG, encoding the Aα, Bβ and γ chains respectively, also influence plasma fibrinogen levels. The fibrinogen genes have been extensively studied. However, there are conflicting results on whether individual single nucleotide polymorphisms (SNPs) within these genes confer an increased risk of Myocardial Infarction (MI). The -148C>T SNP (rs1800787) is a promoter SNP in FGB, the rate-limiting gene in fibrinogen synthesis. In this study, 1062 samples from the Maltese Acute Myocardial Infarction (MAMI) Study were tested for the -148C>T SNP using PCR-RFLP (polymerase chain reaction and restriction fragment length polymorphism) with Hind III. [excerpt]peer-reviewe