The diabetes epidemic in Malta

A note of appreciation and acknowledgement is forwarded to Professor Julian Mamo, Professor Josanne Vassallo and Professor Neville Calleja for their continuous support and advice during the academic progression.Aim: The small European Mediterranean island state of Malta is a highly prevalent type 2 diabetes (T2DM) country. Over recent decades drastic environmental, cultural and ethnic changes occurred and it was considered timely to undergo a cross-sectional survey to establish up-to-date prevalence of T2DM, its socio-geographical distribution and ultimately estimating the economic burden of T2DM. Methods: A health examination survey was conducted (2014-16) including a representative sample of the adult population stratified by 18-70 years, gender and locality (n=3,947; males n=1,997 male). The survey consisted of a socio-demographic questionnaire, various health examination measurements and blood samples for fasting blood glucose (FBG). Prevalence for T2DM (depending on medical history, medication and FBG >7mmol/L) were calculated for the general population as well as for each of the districts making up the Maltese Islands. The economic burden of T2DM for 2017 and projected burden for 2045 were calculated using secondary sources and by incorporating 2% compound interest per annum respectively. Results: A total response rate of 47.15% was obtained, with a mean age of 48 years for males and 46 years for females. Out of the total adjusted population (n=3,947, male n=1,998), the prevalence of T2DM was of 10.31%, with 6.31% already known to have T2DM while 4% were newly diagnosed. Females were diagnosed with T2DM at an earlier age than the males. No significant geographical T2DM prevalence differences were established. The total annual diabetes health care expenditure was approximately €107,316,517.82 for 2017, while the projected expenditure for 2045 was estimated at €244,136,040. Conclusion: Malta is a country with a high prevalence of diabetes. The females were observed to be at an earlier risk of developing undiagnosed diabetes compared to males. Although geographical location did not appear to have significant effect on T2DM distribution, this disease contributes to a high economic burden. The expected exponential increase in diabetes prevalence is subsequently expected to affect negatively the healthcare expenditure. This puts forward the recommendation for development of early screening programmes as part of preventive action strategies.The author is extremely grateful for the strong support forthcoming from the University of Malta (through the Medical School and Research Innovative Development Trust department) and from the Alfred Mizzi Foundation as major sponsors, as well as that of a host of others, including Atlas Health Insurance (Malta). The in-kind support and encouragement of the Parliamentary Secretariat for Health of the Government of Malta is also gratefully acknowledged.peer-reviewe

Three-year follow-up mortality rate in Malta

Introduction: Primary osteoporosis is a major factor in fragility hip fractures. The index fracture is loaded with morbidity and increased mortality in these very fragile patients. The aim of the study was to evaluate the mortality rate after 3 months, 1 year and 3 years post hip fracture with possible identification of any relationship between different hip fracture types and mortality. Method: A retrospective analysis of all hip fracture patients admitted to Mater Dei Hospital, from January to December 2011 was performed. Data was gathered from the operating theatre notes, the patient archiving and communication system and the electronic case summary software. The mortality data was achieved from the National Mortality Registry. Statistical analysis was performed. Results: Out of 281 patients with a hip fracture, 47% died (mortality group) within 3 years with a female predominance (68.9%). Within the mortality group, sustaining an intertrochanteric fracture exhibited a statistical difference between the females and males. Within 90 days of a hip fracture, the mortality rate was of 12.8% with the majority of the patients sustaining an intertrochanteric. The median survival period following hip fractures was 190 days for subcapital, 297 days for intertrochanteric and 427 days for subtrochanteric fractures. Conclusion: The mortality rate in our study compares well with the published results of similar studies. A team effort aimed at giving the best possible care and minimize the morbidity and mortality should be endeavored. This should encompass the whole pathway, starting with prevention and finishing with appropriate community care after hospital discharge.peer-reviewe

Assessing the outcome of patients who underwent a primary percutaneous coronary intervention

Introduction: Patients presenting with acute ST- elevation myocardial infarction (STEMI) of less than 12 hours from onset of chest pain are candidates for primary percutaneous coronary intervention (PPCI). Aim: To assess the patients’ outcome after 12 months of their admission by a retrospective observational study. Methodology: Data of patients admitted with STEMI and preceding to PPCI between 1st of January 2011 to 30th of June 2011 were analyzed. A total of 105 patients were recruited, identified and analyzed by using Cardiac Investigation and Patient Record (CIPR) software. Survival outcomes were determined by mortality data obtained from the Department of Information, Health and Research. Results: Out of the 105 patients having PPCI, the majority were men (81%). 8.6% died within one year. 20% had scheduled repeat coronary angiography, 9.5% requiring further PCI. 0.95% had target vessel revascularization while another 0.95% was referred for coronary artery bypass grafting (CABG) due to triple vessel coronary disease. Unplanned re-admissions rate due to another episode of chest pain was of 5.7%, out of which one presented with another STEMI requiring PPCI. The other patients underwent inpatient coronary angiogram, with 2 proceeding to PCI. The remaining 63% did not experience any other cardiovascular related episodes. Conclusion: This analysis showed that the re- admission rates over a year requiring further interventions were low as was the death rate. Only one target vessel revascularization was performed suggesting that the majority of the PPCI’s performed were successful. This is important when assessing the quality of cardiovascular interventional service provided by our state health system.peer-reviewe

A study of general practice consultations at Mosta Health Centre, Malta

Primary care is the first contact for patients with health related problems. In Malta, primary health is provided by both private and state sectors. The state services are free-of-charge and provide a 24 hrs walk-in GP service at health centres as well as community care, immunisation and local clinics (bereg) for free prescriptions and blood pressure monitoring. The aim of this study was to obtain basic demographic data and reasons for encounter (RfEs) of patients attending Mosta Health Centre from 8am to 5pm between 16th July and 7th October 2012. The RfE data were collected with the International Classification of Primary Care Version 2 (ICPC-2) and compared with data from local and international studies. Patients attending the clinic during the first author’s allocated time at the GP clinic were anonymously recorded and data collected was organised according to gender, age, locality and RfE. The RfEs were classified according to ICPC-2 criteria. A total of 271 patients were reviewed, where 132 were male and 139 females. The age of patients ranged between 2 months and 86 years. The majority of patients were from Mosta and St. Paul’s Bay. The commonest RfE according to ICPC-2 was musculoskeletal complaints. Data collected showed that in general practice the reasons for consultations is vast with the most common RfEs being musculoskeletal problems, administrative work, health check-ups, respiratory problems and blood pressure monitoring. Improvement of the primary care services with an increase in resources would decrease the burden on secondary care.peer-reviewe

Portal vein thrombosis : a case report and literature review

A case report of Portal Vein Thrombosis (PVT) as a complication of protein S deficiency. PVT has been increasingly diagnosed over the years, particularly through the use of ultrasound-Doppler equipment. The lifetime risk of getting PVT in the general population has recently reported to be 1%.1 While this condition has traditionally been associated with cirrhosis or liver malignancy, it may also occur without any liver disease. The case report is followed by a discussion of the aetiology and clinical presentations of PVT, as well as a review of the investigations and management proposed in the literature.peer-reviewe

Bisphosphonates : a cost benefit analysis patient

Introduction: Osteoporotic hip fractures are common in elderly. There is increased risk of sustaining other fractures that incur financial burden on the health system. Prescription of bisphosphonates after osteoporotic hip fracture surgery has been shown to reduce the overall incidence of re-fractures. Methods: All osteoporotic hip fractures treated surgically in Mater Dei Hospital in the year 2011 were analysed in this observational retrospective study. The inclusion criteria were all primary osteoporotic hip fractures. The initiation, or not, of anti-osteoporotic treatment upon discharge from hospital was reviewed. The mortality and re-fracture rate of this cohort was reviewed for a period of 3 years. The cost of hospitalization for hip fracture and re-fractures was calculated based on local health services costs and compared to the benefits of providing a free bisphosphonate medication to each patient. Results: The osteoporotic hip fracture care pathway did not include initiation of anti-osteoporotic therapy after operations. A re-fracture rate of 11.7% over three years predominantly in female patients was observed. In the first year following hip fracture, an estimated direct medical health expenditure due to re-fractures was of €37,642.55 - €48,835.19. Conclusion: Prescribing a bisphosphonate has been found to reduce both the re-fracture and mortality rates. In our study, a bisphosphonate prescription could have reduced the all cause mortality rate of 25.3% to 15.18% over the first year of hip fracture, as well as reduced the financial and social burden incurred due to a re-fracture.peer-reviewe

Outcome of low back pain patients referred to orthopeadic outpatient clinic

Background: Musculoskeletal complaints are the commonest encounters in primary care. Low back pain management is commonly initiated by the family practitioner. Guidelines are limited as to when patients should be referred for specialist treatment by the orthopaedic department. Objectives: Evaluate the justification of low back pain referrals to Orthopedic outpatients (OOP), Mater Dei Hospital, Malta and assess whether these merited specialist consultation. Method: Anonymous data was collected over a 3- month period, where 100 low back pain new case referrals were evaluated during OOP. Data collection was based on routine questions normally brought forward during a consultation and a management plan which was documented in a spreadsheet. Data was analyzed using the same software. Results: Out of the total number of patients reviewed, 57 had been referred for the first time to OOP. Out of these, only 10 required an MRI with a scheduled follow up appointment. The remainder were referred for physiotherapy or pain clinic and discharged to follow-up in the community by the primary care physician. Out of 43 patients who had had previous OOP appointments complaining of lower back pain, 5 patients required an MRI and follow up appointment, remainder were discharged with physiotherapy or pain clinic appointments. Conclusion: The majority of patients seen at OOP could have been managed in primary care. It reflects the importance of developing local management guidelines for low back pain, which would assist general practitioners. It is indicative that referral to OOP should only be triggered when all treatment options available in the primary care are exhausted. This would lead to patients achieving targeted treatment timely within the community, resulting in shorter waiting time for outpatient visits.peer-reviewe

Is obesity all about excess food and sedentary lifestyle?

Obesity has been on the rise over the years leading to an global epidemic. Policies and preventive strategies have been developed and disseminated focusing on the declared main contributors of obesity; overconsumption of convenient food and lack of physical activity. However it is easy to overlook the fact that obesity is a complex disease and one needs to understand the foundations causing this condition. Underlying cofounding factors need to be uncovered and understood before obesity management is initiated.peer-reviewe

The diabetes epidemic in Malta

Aim: The small European Mediterranean island state of Malta is a highly prevalent type 2 diabetes (T2DM) country. Over recent decades drastic environmental, cultural and ethnic changes occurred and it was considered timely to undergo a cross-sectional survey to establish up-to-date prevalence of T2DM, its socio-geographical distribution and ultimately estimating the economic burden of T2DM. Methods: A health examination survey was conducted (2014-16) including a representative sample of the adult population stratified by 18-70 years, gender and locality (n=3,947; males n=1,997 male). The survey consisted of a socio-demographic questionnaire, various health examination measurements and blood samples for fasting blood glucose (FBG). Prevalence for T2DM (depending on medical history, medication and FBG >7mmol/L) were calculated for the general population as well as for each of the districts making up the Maltese Islands. The economic burden of T2DM for 2017 and projected burden for 2045 were calculated using secondary sources and by incorporating 2% compound interest per annum respectively. Results: A total response rate of 47.15% was obtained, with a mean age of 48 years for males and 46 years for females. Out of the total adjusted population (n=3,947, male n=1,998), the prevalence of T2DM was of 10.31%, with 6.31% already known to have T2DM while 4% were newly diagnosed. Females were diagnosed with T2DM at an earlier age than the males. No significant geographical T2DM prevalence differences were established. The total annual diabetes health care expenditure was approximately €107,316,517.82 for 2017, while the projected expenditure for 2045 was estimated at €244,136,040. Conclusion: Malta is a country with a high prevalence of diabetes. The females were observed to be at an earlier risk of developing undiagnosed diabetes compared to males. Although geographical location did not appear to have significant effect on T2DM distribution, this disease contributes to a high economic burden. The expected exponential increase in diabetes prevalence is subsequently expected to affect negatively the healthcare expenditure. This puts forward the recommendation for development of early screening programmes as part of preventive action strategies

Guideline for screening and diagnosing gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is on the rise, especially with the increase in obesity in childbearing women as well as the rising prevalence of diabetes mellitus type 2. The Maltese gestational women are of no exception especially with an established link to intra-uterine nutritional environment adverse effects as well as to genetic factors. There is no set international screening strategy for GDM and so diagnosis differs between countries. The most common diagnostic test for GDM is by performing a 75g oral glucose tolerance test (oGTT). Most countries and organizations including the World Health Organization have adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosing GDM. Performing a 75g OGTT on all women at risk of GDM is expensive as well as unpleasant for the women. A combination of risk criteria including pre-pregnancy body mass index with random plasma glucose and/or fasting plasma glucose based on Maltese and Mediterranean population studies have shown to be a useful screening tool. This tool would help identify women likely to have an abnormal or normal oGTT without the need to perform an oGTT. A screening GDM protocol is essential to pick up and manage at an early stage those that are at risk to develop GDM without the need to have an oGTT performed in every pregnant woman. This would result in better perinatal and maternal outcomes.peer-reviewe