Sense and sensibilities

There are many aspects relating to our profession that lead to varying degrees of inner and outer conflict. These have to be looked at objectively, rationalised and managed appropriately so that they inflict the least possible damage to us, to those around us and particularly to the individuals whose wellbeing is our avowed quest.peer-reviewe

Ischaemic heart disease

It is said that in order to know where you are and where you are going necessitates the knowledge of where you have come from. I recently had one of those memorable 'once in a lifetime' experiences celebrating a 30 year graduation anniversary with cherished friends and colleagues, some of whom I had not seen for years.peer-reviewe

Congestive cardiac failure

'Common. costly and deadly'. This in a nutshell describes the condition we traditionally refer to as Cardiac Failure. Indeed 'Circulatory failure' would be a more appropriate term as it is a combination of factors that involve not only the heart but other organs such as the kidney and brain as well as the peripheral circulation. The management of this condition includes pharmacological and surgical approaches as well as a number of devices that have been developed in recent years in order to improve the significant morbidity as well as mortality associated with it.peer-reviewe

Health and the Economy : a statement of concern

The relationship between health and the economy is an intimate and complex one. The economy of health and the apportioning of funds to different medical services and health care programs are issues that depend on the health profile of a given community as well as the expectations of its members. Decisions ultimately depend on available resources and political priorities. Health and the economy cannot be isolated and contrasted, as the integrity of a given economic system clearly depends on the state of health of the community both at an individual level as well as at a population level.peer-reviewe

Transcatheter closure of Ventricular Septal defects in Malta : initial experience

Ventricular septal defects (VSD) consist of deficiencies of the wall separating the two ventricles. VSDs are the commonest congenital cardiac defects. Small VSDs rarely require intervention, however, larger defects cause ventricular volume overload with or without heart failure or pulmonary hypertension and may, therefore, require closure. Traditionally, closure has been an open heart surgical procedure. In recent years, various devices have been developed to close a wide variety of cardiac defects including atrial septal defects and patent arterial ducts through transcatheter interventional techniques. Recently, AGA Medical Corporation have introduced a range of Amplatzer VSD occluders which include specific devices for perimembranous (PM), muscular and post myocardial infarction (MI) VSDs. Atrial septal defect and patent foramen ovale closure has been carried out at St. Luke's Hospital in Malta for the past three years. This year, for the first time, we have closed three VSDs in three individuals; two children with large perimembranous defects and an elderly gentleman with a large post-MI VSD. This paper will discuss this technique and initial results.peer-reviewe

Early ambulation and discharge after four French femoral artery catheterisation for diagnostic coronary angiography

One of the bottlenecks experienced by cardiac catheterisation laboratories is the amount of time that patients must remain on the unit after femoral artery puncture. This remains a contentious issue and there are a few studies to guide units with regard to how early it is possible to safely ambulate and discharge patients home.peer-reviewe

Transcatheter device closure of atrial septal defect and patent foramen ovale in Malta

Significant atrial septal defects (ASD) are closed, surgically or through a transcatheter device, in order to avoid pulmonary hypertension in late life. A patent foramen ovale (PFO) may need to be closed because of transient shunt reversal resulting in transient ischaemic events or stroke. We report the Maltese experience to date in transcatheter closure of these defects. A total of 46 ASDs and 51 PFOs have been successfully closed at our unit (total 97), with very low complication rates, rates that compare very favourably with results from larger international centres.peer-reviewe

CYP2C19 genetic polymorphisms in Maltese patients on clopidogrel therapy

Introduction and Aims: The prevalence of CYP2C19 genetic polymorphisms in the Maltese population is not reported. The aims were to determine CYP2C19 *2 and *17 allele frequencies and CYP2C19 genotype distribution in a cohort of Maltese patients on clopidogrel and to compare observed frequencies of the CYP2C19 *2 allele and *2/*2 genotype to other populations bordering the Mediterranean Sea. Methods: Genotyping for the CYP2C19 *2 and *17 alleles in Maltese patients on clopidogrel was performed using TaqMan® drug metabolism assays. The frequency of both alleles and six genotypes (*1/*1, *1/*2, *2/*2, *1/*17, *17/*17, *2/*17) were determined. Observed frequencies of the CYP2C19 *2 allele and *2/*2 genotype were compared to fourteen populations bordering the Mediterranean Sea (p>0.05 indicated similar prevalence) Results: Frequencies of the CYP2C19 *2 and *17 alleles in the 244 patients genotyped were 12.3% and 15.4% respectively. CYP2C19 genotype distribution was: *1/*1 (52.1%), *1/*17 (22.5%), *1/*2 (18.0%), 2/*17 (6.6%), *17/*17 (0.8%) and *2/*2 (0). Prevalence of the *2 allele in the Maltese cohort was similar to all fourteen populations bordering the Mediterranean Sea, while prevalence of *2/*2 was similar to Egyptian, Moroccan, Southern French, Slovenian, Turkish and Tunisian populations (p>0.05). Conclusions: This study provides an indication of the prevalence of CYP2C19 polymorphisms in Maltese patients. The high percentage of patients with CYP2C19 IM or UM phenotype demonstrates that CYP2C19 genotyping could aid clinicians to individualise treatment with clopidogrel and other drugs metabolised by the CYP2C19 enzyme.peer-reviewe

CYP2C19*2 allele carrier status and coronary in-stent restenosis : is there an association?

Background and objective: The CYP2C19*2 allele is associated with reduced clopidogrel bioactivation, increasing the risk of complications after percutaneous coronary intervention (PCI), particularly stent thrombosis. Recently published data suggests that CYP2C19*2 allele carriers have a higher risk for in-stent restenosis (ISR) after endovascular treatment. Very few studies have investigated the relationship between CYP2C19*2 and coronary ISR, with no significant association reported. The objective of this study was to assess the relationship between CYP2C19*2 allele carrier status and coronary ISR. Methods: Patients with previous PCI with stenting and who were scheduled for elective PCI after coronary angiogram were recruited from the cardiac catheterization suite over a 12-month period. The angiography report of each patient was perused to identify patients requiring PCI due to ISR. For patients with angiography-confirmed ISR, date of previous PCI to the restenosed stent was noted. CYP2C19*2 genotyping was undertaken using a TaqMan® Drug Metabolism assay. The association between CYP2C19*2 allele carrier status and incidence of coronary ISR within 1 year was assessed using Fisher’s exact test (p < 0.05 significance) and by calculating the odds ratio (OR) with a 95% confidence interval (CI). Results: Of the 82 patients with previous PCI, 29 (35.4%) had angiography-confirmed ISR (12 carriers, 17 noncarriers of CYP2C19*2). In 13 (44.8%) of these patients, the restenosed stent was deployed within 1 year and the patients were on clopidogrel therapy at the time of repeat PCI (8 carriers, 5 non-carriers of CYP2C19*2). The association between CYP2C19*2 allele carrier status and ISR within 1 year was not statistically significant (Fisher’s exact p = 0.067; OR: 4.80, 95% CI: 0.98–23.54, p = 0.053). Conclusions: Despite a higher proportion of CYP2C19*2 allele carriers exhibiting ISR within 1 year compared to non-carriers, the association was not statistically significant. This result may be attributed to the small sample size, and larger prospective studies are recommended to further assess this association.peer-reviewe

Imħallef

Ġabra ta’ poeżiji u proża li tinkludi: “Bel esprit” ta’ Ġużè Galea – The passion tree, 1967 ta’ Wallace Ph. Gulia – Minn Betlehem għall-kalvarju ta’ A. Cremona – Id-dmir ta’ Albert M. Cassola – Epitaffju għalija ta’ Oliver Friggieri – Il-fjur tiegħi ta’ Riccarda Borg Fernandez – Il-ġenju ta’ Vic. Apap – Malta tibki.... ta’ Spiro Buhagiar – Battikata ta’ Ewġenju Fenech – L-imħallef ta’ Vic. Apap.peer-reviewe