A review of acute bacterial meningitis in childhood

This paper reviews the epidemiology, pathogenesis and management of acute bacterial meningitis in childhood. The epidemiology of this infection has undergone significant changes with the implementation of effective immunisation, antibiotic therapy and chemoprophylaxis. The reported incidence of bacterial meningitis in children in the Maltese Islands is low compared to other countries. A high index of suspicion is required to diagnose the onset of bacterial meningitis especially in infants. Third-generation cephalosporins are currently the antibiotics of choice for the acute disease. The timely administration of penicillin may be life saving in cases of meningococcal septicaemia. Adjuvant therapy such as dexamethasone may reduce the occurrence and the severity of sequelae, in particular sensorineural hearing loss. Chemoprophylaxis with rifampicin has played an important role in curtailing epidemics of meningococcal disease. The Haemophilus influenzae type b (Hib) vaccine has made a significant impact on the incidence of H. influenzae meningitis in children. Effective vaccines against pneumococci and meningococci (type b) do not yet exist, however ongoing research seeks to produce these vaccines in an effort to emulate the successful outcome attained by the Hib vaccine.peer-reviewe

Obstetrics and gynaecology

A review of publications relating to significant advances in the specialty of Obstetrics and Gynaecology over the past four years will be discussed: topics reviewed will have an important impact on reducing maternal/fetal morbidity and mortality and should improve on woman's health care.peer-reviewe

Psychotropic treatment in patients undergoing gynaecological procedures

Background: Around 27% of the adult population in Europe has at some point suffered from a mental disorder in the past year. Patients with psychiatric illness have different needs and require specific medication review prior to surgery in view of the risks from anesthesia, the direct and indirect effects of psychotropics, risk of withdrawal symptoms, and risk of psychiatric recurrence or relapse. Gynaecological patients, particularly those going through the menopausal transition phase have an associated risk of psychiatric conditions especially mood disorders. This audit is set to determine the link between psychotropic drug use and patients seen at gynaecological pre-operative assessment clinic, the most encountered diagnosis, how this relates to age together with analysis of most common drugs used to treat these patients. -- Methods: Data of 123 patients from 24 weekly pre-operative assessment clinics was collected. The number of patients listed in each clinic was documented together with the patient’s age. Patients on psychotropic medication were analysed to note diagnoses of each case and treatment used. -- Results: 21.1% of patients suffered from a mental health illness requiring psychotropic medication. Their average age was that of 51 years. The most common diagnosis was depression, summing up to 9.8% of all patients, followed by anxiety at 6.5%. -- Conclusion: Depression and anxiety are leading mental health illnesses both in this cohort and the general population. Such patients have lower pain threshold which affects their recovery. Some psychotropics have severe interactions with anaesthetic thus need to be stopped prior to surgery after evaluation of risks such as drug withdrawal and deterioration in mental health.peer-reviewe

Skin ageing

Cutaneous ageing manifests itself as a progressive reduction in maximum function and reserve capacity of skin tissue. It is not a unique and uniform biological event. Skin comprises three layers: epidermis, dermis and subcutaneous tissue. Collagen atrophy is a major factor in skin ageing. There is a strong correlation between skin collagen loss and estrogen deficiency due to the menopause. Skin ageing, especially in the face, is associated with a progressive increase in extensibility and a reduction in elasticity. With increasing age, the skin also becomes more fragile and susceptible to trauma, leading to more lacerations and bruising. Furthermore, wound healing is impaired in older women. Estrogen use after the menopause increases collagen content, dermal thickness and elasticity, and it decreases the likelihood of senile dry skin. Large-scale clinical trials are necessary to help make informed recommendations regarding postmenopausal estrogen use and its role in the prevention of skin ageing.peer-reviewe

Clinical practice guideline on induction of labour and antenatal surveillance of the post-dates pregnancy

Thomas Denman in 1756, at a meeting in London, suggested that induction of labour may be a useful treatment for cephalo-pelvic disproportion which was at the time, a common cause of maternal and foetal mortality. By 1788 induction of labour was met by general approval by the British Obstetric establishment. Thirty years later Rigby the Younger hailed induction of labour “as perhaps the greatest improvement in operative midwifery since the invention and gradual improvement of the forceps”. (Hibbard 2000). Note must be taken of the discretion this latter statement portrays, a reflection of erudite Obstetric caution. Obstetric caution is also required in modern day Induction of Labour whereby the rates of this obstetric intervention have increased substantially over the past twenty years. In the U.S. induction of labour, increased from 9.5 percent in 1990 to 22.1 percent in 2004. Similarly in 2004 and 2005, one in every five deliveries in the UK was induced (NICE CG70).peer-reviewe

Primary hyperparathyroidism in pregnancy : case report and review

A twenty-six year old secundagravida booked her pregnancy at 14 weeks gestation. It was noted in the past obstetric history that the woman had lost her first child at 41 weeks gestation, delivering a stillborn baby weighing 4.2kg. At 34 weeks into the second pregnancy mild polyhydramnios was noted and the patient was admitted. During her hospitalisation the patient complained of having passed a small renal stone. Two serum calcium levels were found to be significantly elevated 3.36mmol/l and 3.2mmol/l. Serum parathormone was found to be significantly elevated - 247pg/ml (Normal levels: 12.0 - 72.0pg/ml) and an ultrasound scan of the neck confirmed the presence of a parathyroid adenoma. A parathyroidectomy was performed and the postoperative period was uneventful. The rest of the pregnancy was uneventful and at 38 weeks gestation a healthy child was delivered vaginally. In view of this woman’s past history and the events occurring during the second pregnancy it may be useful to consider obtaining serum levels of calcium in cases of idiopathic stillbirth.peer-reviewe

Maternal risks associated with pregnancy in women with advanced maternal age

Introduction: The trend towards delayed motherhood has accelerated in developed countries over the last few decades. Advanced maternal age (AMA) is defined as age 35 years and older at the estimated date of delivery. Objective: The aim of this large retrospective cohort study is to assess for the association between AMA and adverse maternal outcomes after adjustment for confounding factors in maternal characteristics and in the obstetric history. Study Design: Mothers of 20 years and older, who delivered singleton babies in Malta and Gozo between 1st January 2000 and 31st December 2014 were studied. All data was derived from the National Obstetric Information System. Results: The study population included 55,943 singleton births. 12.2% (6,838) of mothers were between 35 – 39 years and 2.4% (1,325) were 40 years and older. Significant difference was found between maternal age and BMI (p < 0.0001), maternal smoking status (p < 0.0001), non-insulin dependent diabetes mellitus (p = 0.004), history of stillbirth (p < 0.0001), gestational diabetes (p < 0.0001), pregnancy – induced – hypertension (p = 0.008) and pre-eclampsia (p = 0.008). Significant difference was also found between maternal age and mode of delivery (p < 0.0001). Regression analysis revealed persistent significant differences between maternal age and different maternal outcomes. Conclusion: This study demonstrates that AMA in Malta significantly increases the risk for hypertension in pregnancy, gestational diabetes and caesarean delivery. Care providers need to be aware of these increased risks and adjust their obstetric management according to the individual to ensure optimal maternal outcomes.peer-reviewe

Term admissions to neonatal intensive care unit : a Maltese observational study

Objective: This study aimed to identify the number of term infants admitted to the Maltese Neonatal and Paediatric Intensive Care Unit (NPICU) between January and June 2016, as well as factors contributing to their admission. Methods: All term infants (37+ weeks gestation) born in January-June 2016, transferred from Central Delivery Suite or Obstetric Wards to NPICU were identified. Patient registers, electronic case summaries, and the National Obstetric Information System (NOIS) database were used, with approval from the Data Protection Office, to collect data for a retrospective case control study. Results: Of the term infants born in these 6 months, 5.2% (101) were admitted to NPICU resulting in 42.6% of all admissions. The mean gestational age was 39 weeks (95% CI 38.8, 39.3) and mean birth weight was 3.3kg (95% CI 3.2, 3.4). More than half had been born by elective and emergency Caesarean section (26% and 27% respectively). Commonest reason for admission was respiratory distress (37%). Others included non-bilious vomiting (20%), congenital abnormalities (13%), hyperbilirubinaemia (8%), and infection (4%). Statistically significant factors associated with admission were operative delivery, threatened abortion and maternal infection during pregnancy, maternal insulin dependent diabetes mellitus, and low Apgar scores. Conclusion: The significant contributing factors should be targeted and further evaluation over a longer time-frame with an interdisciplinary team carried out in an effort to reduce rate of admissions and improve quality of care.peer-reviewe