Attitudes of family doctors, attached to the Department of Family Medicine, towards consulting and treating young people

Background: There is a perceived concern that there is no law which governs the right of young people (YP), defined as ages 15-18, to be treated by doctors and to have their privacy protected from their parents or legal guardians. On the other hand doctors seem not to be covered by a specific law which allows them to see and treat this age group, although the Medical Council has expressed itself once in this regard. Method: This study aimed to assess the perception of doctors to seeing young adults alone since they are considered vulnerable because of their age and may not express concerns and practices if in front of parents or guardians. In this regard a questionnaire was delivered to family doctors attached with the department of family medicine at the University of Malta. Results: the response rate was 72.5%. Most respondents were males. Most (89.6%) agreed that YP have a right toe speak to the family doctor alone. Doctors are happy to discuss various topics with YP alone, but in certain issues, find difficulty in providing treatment to YP alone. There seems to be a significant difference in attitude towards the sex of the doctor with respect to the sex of the patient. Conclusion: The study was meant to be a pilot study including those doctors attached to the Department of Family Medicine at the Medical School, with a future study planned on a larger number. The significance and importance of the results however merited previous publication of this study as a sentinel. Doctors are largely concerned about the law and are sometimes reluctant to see young adults alone even if they feel that they should be able to do so. The importance of having a clarification of the law by an amendment is discussed.peer-reviewe

Air pollution and inflammatory bowel disease

The exact mechanisms through which IBD occurs are currently not known. There are several genetic and environmental factors that are implicated. What is known is that the incidence of IBD is commoner in Industrialised countries and in countries which are becoming more industrialised, the incidence of IBD is increasing. Pollution is one of the environmental factors that could be implicated in the increase in its incidence. In this review article we analyse the effects of pollution on the gut and the studies which try and shed light on the association between IBD and air pollution.peer-reviewe

Rapidity of diagnosis and management of H. Pylori in the endoscopy unit at Mater Dei Hospital

This article has been reprinted in Malta Medical School Gazette, Volume 2, Issue 1 in 2018.Introduction: H.pylori infection has been associated with various gastric pathologies and its prevalence varies between different countries. Furthermore, there is an increasing antibiotic resistance and the eradication rates have declined. There is clinical and administrative pressure as to provide the Rapid Urease Test (RUT) result as quickly as possible and ideally prior to discharge from the endoscopy unit. Results: A total of 542 patients fulfilled the inclusion criteria. The patient`s mean age was 54.6 years and 52.4% were female. The main clinical indications for an Oesophago-Gastro-Duodenoscopy (OGD) were dyspepsia (44.7%) and GORD (24.5%). The overall positivity rate was 15% of which 8.7% were early positive and 6.3% were late positive. Analysis of patients’ age with RUT positivity revealed that patients above the age of 60 years were more likely to have a positive result (p=0.013). There was no statistical significance between the H.pylori results and smoking (p= 0.6). In this study, there was a variety of 10 different eradication regimes prescribed, the most popular being the use of a PPI 20mg BD + Amoxicillin 1g BD + Clarithromycin 500mg BD for 10 days (total of 27 cases) versus 14 days (23 cases). Conclusion: This study demonstrates the importance of checking the RUT taken at endoscopy at 24 hours as this has given a 42% increase in the yield for H.pylori. It also demonstrates that various regimens are used in clinical practice. In view of the relatively low prevalence of H.pylori, especially amongst young patients, maybe it is prime time that treatment of H.pylori is specifically managed by culture and sensitivity to avoid worsening clarithromycin-resistance.peer-reviewe

Small bowel radiation enteritis diagnosed by capsule endoscopy

Our patient is a middle-aged woman who had been diagnosed with uterine leiomyosarcoma for which she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. She received adjuvant radiotherapy which was delivered over a period of 4 weeks and which involved 20 fractions of 225cGy each for a total of 4500cGy, followed by a further two courses of pelvic radiotherapy in view of local recurrence. She presented to us with severe transfusion-dependent anaemia associated with loose stools and abdominal pain 1 year after initial surgery. Abdominal CT and oesophagogastroduodenoscopy were normal and a colonoscopy revealed large stains with fresh blood and small clots on normal mucosa in the caecum and ascending colon. Since the impression was that the source of bleeding was from the small intestine the patient was thus scheduled to have video capsule endoscopy (VCE) after ensuring that there was no retention of the patency capsule.peer-reviewe

Streptococcus gallolyticus bacteraemia in hepatobiliary–pancreatic and colonic pathologies

Background: Streptococcus gallolyticus bacteraemia has been associated with several pathologies, including bacterial endocarditis and colorectal cancer. Aims: In this study, we have analysed whether Streptococcus gallolyticus bacteraemia is associated with an increased risk of hepatobiliary and colonic pathology. The association with other pathologies and the antibiotic sensitivities of Streptococcus gallolyticus were also analysed. Design: Observational retrospective study. Methods: The case notes of patients with documented Streptococcus gallolyticus bacteraemia between 2007 and 2012 at Mater Dei hospital (Malta) were reviewed. Demographic and clinical data, including co-morbidities, clinical investigations, antibiotic sensitivities and mortality were analysed. Results: A total of 42 patients (33 males, 9 females) were recruited. Two patients were pre-term infants and were therefore excluded from the study. Mean age of the cohort population studied was 72 years (SD ± 14). One-year survival rate was 62%. Gastrointestinal (colonic and hepatobiliary-pancreatic) pathologies were present in 59.5% of patients with 16% of this group having more than one gastrointestinal pathology. High incidence rates of underlying diabetes mellitus (28.6%), valvular heart disease (21.4%) and malignancies (21.4%) were noted in this study. Furthermore, we observed that 14.3% of patients had an underlying respiratory pathology. Streptococcus gallolyticus was 100% sensitive to cefotaxime and vancomycin but was highly resistant to clindamycin, erythromycin and tetracycline. Conclusions: Streptococcus gallolyticus bacteraemia is commoner in the elderly and in those with multiple underlying co-morbidities. The high incidence of gastrointestinal pathologies among patients with Streptococcus gallolyticus bacteraemia (59.5%) suggests that a thorough work-up for colonic and hepatobiliary/pancreatic pathology should be carried out in these patients.peer-reviewe

Pneumonia and mortality after percutaneous endoscopic gastrostomy insertion

Background/aims: Percutaneous endoscopic gastrostomy feeding provides enteral nutrition to patients with neurological dysphagia. Thirty-day mortality rates of 4-26% have been reported, with pneumonia being the common cause post-percutaneous endoscopic gastrostomy insertion. Materials and Methods: This retrospective analysis of percutaneous endoscopic gastrostomy tube insertions in Malta (January 2008 - June 2010) compares the incidence of pneumonia in patients fed through a nasogastric tube versus in those fed via a percutaneous endoscopic gastrostomy tube. We analyzed the indications, poor prognostic factors and mortality for percutaneous endoscopic gastrostomy insertion. Results: Ninety-seven patients underwent percutaneous endoscopic gastrostomy insertion. Fifty-four patients received nasogastric feeds before percutaneous endoscopic gastrostomy feeds. Patients on nasogastric feeds developed 32 episodes of pneumonia over a total of 7884 days of feeds (1 every 246 days). Patients with percutaneous endoscopic gastrostomy feeds after a period of nasogastric feeds developed 48 pneumonia episodes over 36,238 days (1 every 755 days). Patients with percutaneous endoscopic gastrostomy feeds without previous nasogastric feeds developed 28 pneumonia episodes over 23,983 days (1 every 856 days), and this was statistically significant (χ2 test p value <0.005). Forty-seven patients had died at the time of data collection, with 29 patients dying from pneumonia. One-week mortality was 3%, 30-day mortality was 8% and 1-year mortality was 39%. All patients dying within the first week and 50% of those dying within 30 days of the procedure died following pneumonia. Conclusions: There was a statistically significant decrease in the number of pneumonia episodes among patients receiving percutaneous endoscopic gastrostomy feeds versus nasogastric feeds. However, pneumonia is still the major cause of death among percutaneous endoscopic gastrostomy patients.peer-reviewe

Diverticular disease : a review on pathophysiology and recent evidence

Diverticular disease is common condition globally, especially in Western countries. Diverticulitis, Symptomatic uncomplicated Diverticular disease and Segmental Colitis associated with diverticula constitute diverticular disease. Although most patients with diverticula are asymptomatic, around 25% of patients will experience symptoms whilst 5% of patients have an episode of acute diverticulitis. The prevalence increases with age with more than one theory being put forward to explain its pathogenesis. Faecolith entrapment in diverticula results in colonic mucosal damage and oedema, bacterial proliferation and toxin accumulation leading to perforation. This mechanism may explain diverticulitis in elderly patients with multiple, larger diverticula. Ischaemic damage could be the cause of acute diverticulitis in younger patients with sparse diverticula where more frequent and forceful muscular contractions in response to colonic stimuli occlude the vasculature leading to ischaemia and microperforation. Chronic colonic active inflammation in the presence of diverticular disease is termed Segmental colitis associated with diverticulosis. Its pathophysiology is still indeterminate but together with its clinical picture, may mimic Inflammatory Bowel Disease. Treatment includes a high fibre diet together with antibiotics and/or salicylates with surgery in severe cases. Indications for elective surgery in diverticular disease have changed over the past decades as this may not suggest a reduction in morbidity and mortality. Prophylaxis with probiotics, laxatives, anti-spasmotics, anticholinergic drugs and salicylates are at the centre of recent studies. Studies are also challenging previously believed facts regarding dietary fibre, nuts and seeds whilst emphasizing the effect of healthy lifestyle and smoking on the increasing incidence of DD.peer-reviewe

Genetic and Serological Markers in Identifying Unclassified Colitis

In 5–15% of the patients with inflammatory bowel disease (IBD) limited to the colon, it is difficult to distinguish histologically between ulcerative and Crohn’s colitis. This is described as unclassified colitis. Distinguishing between the two is important in terms of prognosis, since patients with Crohn’s disease (CD) have a higher risk of strictures and fistulae, which may predict a more severe disease course, as well as an increased risk for surgery. In addition, colectomy may be curative in ulcerative colitis patients not responding to medical therapy, while Crohn’s patients undergoing colectomy can have relapses in other areas of the bowel and, therefore, need to be followed-up. In inflammatory bowel disease, intestinal inflammation is believed to occur secondary to an altered immune response in a genetically susceptible host. Genetic and serological markers (antibodies) may have a role in identifying unclassified colitis. Anti-Saccharomyces cerevisiae antibody (ASCA) and anti-neutrophil cytoplasmic antibodies (pANCA) have the highest sensitivity in distinguishing ulcerative from Crohn’s colitis. Nucleotide oligomerization domain 2 (NOD2) and autophagy-related 16-like 1 (ATG16L1) polymorphisms are strongly associated with Crohn’s disease, while epithelial barrier genes are significantly associated with ulcerative colitis. This chapter describes which gene polymorphisms and serological markers may be used to distinguish between ulcerative colitis and Crohn’s disease in patients with histologically unclassified colitis

Screening in-patients for risk of malnutrition

Introduction: Malnutrition is used to define an imbalance in nutrition and is seen in hospitalized patients. The aim of this study was to assess the risk of malnutrition in patients admitted to the acute medical wards. The ‘Malnutrition universal screening tool’, was used as a gold standard.Material and Methods: Data was collected from adult patients from acute medical wards. The data collected included the identification number, age, gender, reason for admission, comorbidities, weight, height, unplanned weight loss in the last 3-6 months and the number of days of no nutritional intake. By means of the MUST, the overall risk of malnutrition score was obtained and its management was recorded.Results: Fifty patients were recruited and 18% were found to be at medium risk of malnutrition while 36% were found to be at high risk. Only 2% of such patients had a dietician referral and/or adherence to the guideline. Despite 58% of patients were found to have a Body Mass Index score of 0, 21% of these had a BMI score of >30kg/m 2 , with 14% of which were admitted secondary to a cardiovascular or respiratory cause.Discussion: Skills and time are required to diagnose a patient with malnutrition. However, the MUST screening tool, enables this to be done quickly and ppropriately. Moreover, implementation of mandatory nutritional screening on admission will allow an increase in dietician referrals and the correct management of this along with the patient’s illness, leading to a faster recovery, shorter hospital stay and better long term prognosis.peer-reviewe