Management of epilepsy

Figures for the incidence of epilepsy in Malta are not available. The overall figure for epilepsy given by the Royal College of General Practitioners (Reid 1960) is 4.82 per 1,000 population. As there is no reason to expect and difference in the incidence in these Islands, one can expect that there are at least 1,500 epileptics in Malta. This would mean that all general practitioners would, at some time, come across a patient with epilepsy.peer-reviewe

Carotid artery disease screening : assessment of criteria

The Department of Radiology at St. Luke’s Hospital has provided a screening service for stroke related disease since April 1991. This consisted of Duplex Ultrasound screening (DUS) for Extracranial Carotid Artery Disease (ECAD) followed by angiography or intra-arterial digital subtraction angiography (lADSA) or digital intravenous angiography (DIVA) if ultrasound screening was positive for significant disease. The aim of this study was to evaluate in the local context, the various criteria for assessment already established overseas and to devise the best combination of these criteria to improve the detection of disease, thus improving the quality of the•local screening service. 504 patients have been screened for stroke related disease. Twelve patients (6M : 6F) with significant disease, who were considered for surgery, were referred for angiography, IADSA or DIVA. Comparison of these two modalities, DUS and vascular study, were made on 22 sides for the Multicentre Criteria (MCC), the Modified Seattle Criteria (MSC) and the Modified Washington Criteria (MWC). The accuracy, sensitivity, specificity, positive predictive value and negative predictive value were calculated for the MCC, the MSC and the MWC for peak systolic velocity. For the MCC the end diastolic velocity, the systolic velocity ratio and the diastolic velocity ratio were also compiled. The highest precision for extra cranial carotid artery disease screening can be achieved by a combination of the MCC or MSC for peak systolic velocity and with the systolic velocity ratio for the MCC.peer-reviewe

Migraine

Migraine is perhaps one of the commonest ailments afflicting mankind. Two of the most important studies about the prevalence of migraine are the American Migraine Studies 1 and 2. The first study was carried out in 1989 and the second in 1999. These studies showed that the prevalence of migraine remained the same overall. In 1989, 5,7% of the male population had migraine, while in 1999, the figure was 6,5%. The prevalence rates for women were 17,6% in 1989 and 18,2% in 1999. The diagnosis of migraine was based on the criteria established by the International Headache Society (IHS).peer-reviewe

Torsade de Pointes : a diagnostic pitfall

Torsade de pointes is an unusual arrhythmia which is found in certain well defined clinical situations. The authors present two cases of Torsade de pointes which were admitted on two consecutive days, where the diagnosis was not immediately appreciated. It is important that one should become familiar with the E.C.G. appearance and be aware of the possible aetiology so that appropriate treatment can be initiated.peer-reviewe

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

Etiological and epidemiological factors in facial palsy

The present study is an analysis of 243 patients with facial palsy referred to St. Luke's Hospital Malta during the six year period extending from October 1965 to October 1971. The vast majority of the patients' records collected were from the Medical, Pediatric, Orthopedic, E.N.T. and Physiotherapy Departments. The records were analysed with special reference to: onset of symptoms, age, sex, side of palsy, date of referral to hospital, town of origin and referring doctor. A history of hypertension and diabetes mellitus, previous occurrences of facial palsy and any other relevant illness were also recorded. The sex distribution was also compared with that in other series because of the recent Egyptian reports of facial palsy developing more often in females. The age groups of the Maltese patients were also analysed and compared with those in some other studies. Following this study, it was concluded that probably there were no significant geographical variations. In the older age groups, however, atherosclerosis, diabetes and hypertension are postulated as aggravating factors. Underlying diabetes and hypertension should, therefore, be excluded in patients with Bell's Palsy, all the more so, because of the increased risks, if such patients are treated with steroids.peer-reviewe

Subarachnoid Haemorrhage in Malta : Are outcomes adversely affected due to lack of a local neurovascular service?

Objective: This study was performed to assess the incidence, treatment and outcome of non-traumatic Subarachnoid Haemorrhage (SAH) in an island which does not offer a neurovascular service and to determine whether such limitation is associated with a poor outcome. Method: Data of adult patients with a diagnosis of non-traumatic SAH was analysed retrospectively over a two-year period from January 01, 2009 to December 31, 2010. Results: The incidence of SAH in Malta is 3.16 cases per 100 000 population per year. An underlying aneurysm was found in 50% of all cases investigated with angiography. These patients were transported to the United Kingdom for definitve management and the outcome of all these patients at 6 months was excellent. (modified Rankin Scale of 0 or 1). Conclusions: With the incidence of non-traumatic SAH being in the low range, setting up an interventional neuroradiology service in our country to treat aneurysmal SAH would not have the required numbers to maintain expertise and would probably translate into worse clinical outcomes. Despite having geographical and logistic limitations, our standards of care and survival rates are not below those of other international centres. Outcomes for patients with low initial Hunt and Hess scores have not been adversely.peer-reviewe

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

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