Orbital pseudotumour masquerading as Wegener’s granulomatosis

A twenty-two year old female patient presented with new onset bilateral hard orbital masses and progressively worse tear lake problems. Computed tomography of the orbits revealed poorly differentiated bilateral orbital masses. Laboratory investigation revealed ANCA positivity. Routine biochemical investigations were all within normal limits. CXR was also normal. Biopsy of the orbital masses revealed non-specific histological findings. An initial diagnosis of Granulomatosis with Polyangitis (GPA) was postulated. Oral steroids were given followed by a rapid response to steroid therapy. The working diagnosis of GPA was abandoned and a diagnosis of idiopathic orbital inflammation (IOI), or orbital pseudotumour was made owing to the benign, non-infective, inflammatory pathology with no evident systemic or local cause. Tailoring off of steroids resulted in repeated flare ups, resulting in the initiation of methotrexate therapy. The patient is in remission and is currently on combined steroid and methotrexate treatment. IOI is a diagnosis of exclusion and a rapid response to steroids serves as a diagnostic aid but is not in itself diagnostic.peer-reviewe

Assessing the analgesic benefit of phacoemulsification under topical anesthesia using pre-operative nepafenac 0.1%

Background: To compare the intra-operative analgesic benefit of cataract surgery under topical anesthesia with and without pre-operative NSAIDs, namely nepafenac 0.1% (Alcon Laboratories Inc, Nevanec® , Fort Worth, TX, USA) Method: In a study carried out at Mater Dei Hospital, Ophthalmic department, Malta, 199 patients with a cataract were divided into two groups. 100 eyes received nepafenac 0.1% pre-operatively while 99 eyes did not. Intra-operative discomfort was judged by assessing facial grimacing, restlessness, irritability and distress and the results were noted. Patients were divided into refractive error groups, namely myopic, hypermetropic and emmetropic. Results: Pre-operative nepafenac 0.1% produced significantly more pain free cataract surgeries, resulting in a discomfort rate of 9% vs 28% in the group where pre-operative nepafenac 0.1% was not used. Pain was also most evidently observed on insertion of the phaco handpiece. This may be said for patients in all refractive errors groups. Conclusions: The analgesic efficacy of nepafenac 0.1% pre-operatively is significant in reduced intra-operative discomfort during cataract surgery repair under topical analgesia.peer-reviewe

Primary CNS lymphoma with intravitreal metastasis : using vitreous cavity samples to monitor response to therapy

A fifty-eight year old male patient presented to the ophthalmic department with a 3 day history of reduced visual acuity, blurred vision and floaters, associated with recent lethargy, headaches and behavioural changes. Fundal examination revealed a bilateral vitritis. Steroid therapy was started. MRI of the brain revealed multiple hypodense and hyperdense lesions. Vitrectomy was performed in view of the poor response to steroids. A biopsy showed non-hodgkin B-Cell lymphoma. The patient was started on intravenous Methotrexate and Cytarabine. Repeat vitreous cavity biopsies were performed in order to assess response to therapy. All biopsies to date have revealed evidence of on-going lymphoma.peer-reviewe

A retrospective study on the Maltese population of the outcome of retinal detachment repair after the removal of silicone oil

Background: Silicone oils of different viscosities are used in the treatment of retinal detachments of varying pathology. Method: Seventy-two cases of retinal detachments managed with silicone oil were reviewed in a retrospective chart analyses. Eighty nine patients were reviewed from which data on primary pathology, type of silicone oil, duration of oil “in situ” and complications (including emulsification, increased intraocular pressure (IOP), re-detachment, cataract and presence of CME) were compiled. Of this number, 72 patients with post- operative follow-up of two years or more and documentation of the above parameters were included. The data was carefully analysed in an effort to determine the primary factor or factors of the varying silicone oil substitutes utilized responsible for the successful or non-successful re- attachment of the retina. Results: Retinal re-detachment rate is greater when Silicone Oil (SO) is removed before 12 months. Complex vs non-complex retinal re- detachments in sub-group analysis indicates superiority of retention of SO for greater than 12 months. Emulsification is greater in low viscosity SO (1300cts). Conclusion: The complication rates witnessed in this retrospective study are comparable to the findings of published studies present in the ophthalmic literature on an international scale. The findings of this study support the hypothesis that it is the duration of the SO “in situ” as opposed to the viscosity or other SO attributes which ultimately influences the re-detachment rate.peer-reviewe

Preliminary trabeculectomy results using the Moorfields safer surgery technique in Malta

Purpose: To review the results of the Moorfields Safer Surgery System (MSSS) for trabeculectomy, recently introduced in Malta. Methods: Patient files were reviewed from data collected over an 18 month period, from the Maltese national teaching hospital, Mater Dei Hospital. Files of all patients undergoing primary trabeculectomy with a minimum of 12 months follow up data available were reviewed. Primary outcome measure of success was defined as a 30% drop in final post-operative intraocular pressure (IOP) at 1 year. Secondary outcome measure of success was final post-op IOP of less than 21mmHg. Unqualified success was defined as satisfactory IOP without the need of anti-glaucoma medication, while qualified success was defined as satisfactory IOP in those patients requiring anti-glaucoma medication. Results: 43 eyes (mean age = 66.2 yrs ± 11.7) were analysed. The mean pre-operative IOP was 27.0mmHg ± 4.6. Mean post-op IOP at one year was 15.3mmHg ±2.7. Unqualified success for the primary outcome measure was achieved in 64.1% of patients while the qualified success was achieved in 82.1%. Unqualified success for the secondary outcome measure was achieved in 72.7% and a qualified success, of 94.8% was obtained. There was 6.8% failure rate. Conclusions: The results from this first review using the Moorfields safe surgery system for Trabeculectomy surgery in the Maltese islands compares well to the current literature.peer-reviewe

Ghajn Klieb, (Rabat, Malta)

Between October and December 1999 a team of local and foreign undergraduates from the University of Malta carried out a survey of the site at Ghajn Klieb outside Rabat. The exercise constituted the practical part of a unit on the Principles of Archaeological Surveying directed by Dr Nicholas Vella of the Department of Classics & Archaeology. For the survey the team was joined by Hanna Stager, a graduate of the same department, who also researched some of the references used in this article. Initial reconnaissance of the site was carried out on 15 October 1999 with Nathaniel Cutajar and Michelle B uhagiar, Curator and Assistant Curator respectively at the National Museum of Archaeology. The scatter of surface ceramics and the existence of previously known and unknown features revealed the extent and potential of the site. It was decided that the locality of Ghajn Klieb warranted systematic study that could be carried out in various stages, with the longterm aim being an assessment of human activity and cultural behaviour at the site. The Museums Department gave the go-ahead for this project, and permission to collect the surface ceramics was granted. This short report is intended to give an outline of the work undertaken to date. Emphasis is placed on the field methods adopted and on the presentation of what we believe to be worth talking about at this stage. An effort is here made by the senior author to unravel the collaborative nature of the exercise by lending weight to individual thoughts and interpretations that arose while work progressed in the field.peer-reviewe

The COVID-19 long-term care situation in the islands of Malta and Gozo

1) The pandemic response team had been in place well before the first COVID-19 case was registered in Malta. The first case was registered on the 7 March 2020, and during the first 2 weeks of the pandemic all cases were imported. A mandatory 2-week quarantine was put in place for all in-coming travellers during the second week of the pandemic. 2) Malta’s size and population were potentially favourable towards ensuring better COVID-19 control measures. Nine (9) deaths have been recorded to date. 3) The Superintendent of Public Health together with the COVID-19 Response Team were key towards ensuring effective and timely mitigation efforts both with the general public as well as ensuring that the local health care system was robust enough to meet the needs brought about by the pandemic. 4) The daily medical bulletins broadcast by the Superintendent of Public Health kept the public continually updated on COVID-19 matters. The bulletins provide the Public Health Authority with a publicly accessible platform to focus and strengthen health promotion efforts in respect to the COVID-19 pandemic. 5) Swabbing and contact tracing within the 3 testing hubs on the Island were key towards controlling the pandemic. 6) A series of measures were put in place early on with the key aim of ordering categories of persons referred to as ‘vulnerable’, to remain segregated in their residences, (except in the cases of attendance for medical appointments, obtain medical care or treatment, acquire food, medicine, other daily necessities, or to attend to any other essential or urgent personal matters). 7) The voluntary response by management and health care professionals within the care homes on the Island was paramount towards recording no deaths within these facilities; the majority of care homes were in lockdown for 12 weeks, whilst other care homes worked on 1, 2 or 3 week shifts. Swabbing of health care professionals was mandatory prior to assuming duties within the residential care facilities. 8) As of the 4 May 2020, the Superintendent of Public Health embarked on a stepwise relaxation of measures. The first measure was followed by the second and third relaxation of measures on the 22 May 2020 and 5 June 2020.peer-reviewe

Altered supraspinal motor networks in survivors of poliomyelitis: a cortico-muscular coherence study

Objective Poliomyelitis results in changes to the anterior horn cell. The full extent of cortical network changes in the motor physiology of polio survivors has not been established. Our aim was to investigate how focal degeneration of the lower motor neurons (LMN) in infancy/childhood affects motor network connectivity in adult survivors of polio. Methods Surface electroencephalography (EEG) and electromyography (EMG) were recorded during an isometric pincer grip task in 25 patients and 11 healthy controls. Spectral signal analysis of cortico-muscular (EEG-EMG) coherence (CMC) was used to identify the cortical regions that are functionally synchronous and connected to the periphery during the pincer grip task. Results A pattern of CMC was noted in polio survivors that was not present in healthy individuals. Significant CMC in low gamma frequency bands (30–47 Hz) was observed in frontal and parietal regions. Conclusion These findings imply a differential engagement of cortical networks in polio survivors that extends beyond the motor cortex and suggest a disease-related functional reorganisation of the cortical motor network. Significance This research has implications for other similar LMN conditions, including spinal muscular atrophy (SMA). CMC has potential in future clinical trials as a biomarker of altered function in motor networks in post-polio syndrome, SMA, and other related conditions

Development of pulsed plasma thruster for a Pico-Satellite

The University of Malta Astronics research group has been developing a family of low cost PocketQube (PQ) picosatellites, with the smallest having a total mass of under 250 g and dimensions of a 5 cm cube. These satellites will be launched in low metastable orbits where an electric propulsion system will be required to maintain the orbit and perform other orbital manoeuvres. The Pulsed Plasma Thruster (PPT) is a promising technology for creating such miniaturised propulsion systems. However, scaling down this technology to fit inside PQs presents new challenges. Hence, different configurations of the coaxial PPT with reliable integrated ignition mechanisms are being developed as part of this project. This paper describes the overall mission feasibility of using PPT technology to reduce a 500g 2p PQ’s orbit decay at an altitude of 500 km. Two PPT configurations with carbonisation mitigation efforts having a total discharge energy of 0.338J per pulse were developed and an analysis of the PPT PQ subsystems is provided. The results include the developed PPT PQ, a simulation of the electric field strength of the two PPT configurations, and the plasma plume generated by the thrusters.peer-reviewe

Leukemic blasts program bone marrow adipocytes to generate a protumoral microenvironment

Despite currently available therapies most patients diagnosed with acute myeloid leukemia (AML) die of their disease. Tumor-host interactions are critical for the survival and proliferation of cancer cells; accordingly, we hypothesise that specific targeting of the tumor microenvironment may constitute an alternative or additional strategy to conventional tumor-directed chemotherapy. Since adipocytes have been shown to promote breast and prostate cancer proliferation, and because the bone marrow adipose tissue (MAT) accounts for up to 70% of bone marrow volume in adult humans, we examined the adipocyte-leukaemia cell interactions to determine if they are essential for the growth and survival of AML. Using in-vivo and in-vitro models of AML we show that bone marrow adipocytes from the tumor microenvironment support the survival and proliferation of malignant cells from patients with AML. We show that AML blasts alter metabolic processes in adipocytes to induce phosphorylation of hormone-sensitive lipase and consequently activate lipolysis, which then enables the transfer of fatty acids from adipocytes to AML blasts. In addition, we report that fatty acid binding protein-4 (FABP4) mRNA is up-regulated in adipocytes and AML when in co-culture. FABP4 inhibition using FABP4 shRNA knockdown or a small molecule inhibitor prevents AML proliferation on adipocytes. Moreover, knockdown of FABP4 increases survival in Hoxa9/Meis1-driven AML model. Finally, knockdown of carnitine palmitoyltransferase IA (CPT1A) in an AML patient-derived xenograft model improves survival. Here we report the first description of AML programming bone marrow adipocytes to generate a pro-tumoral microenvironment