Clinicians’ adherence to local antibiotic guidelines for upper respiratory tract infections in the ear, nose & throat casualty department of a public general hospital

Background: In Malta, resistance to antibiotics constitutes a major threat to public health. This study aims to assess clinicians’ adherence to local antibiotic guidelines when treating cases of acute otitis media, acute tonsillitis and rhinosinusitis, that present to the ear, nose and throat (ENT) casualty department in Malta’s public general hospital, as well as to recommend methods for improving adherence and minimising overprescribing. Methodology: Data on first line antibiotic prescribing regimens was retrieved from ENT casualty sheets between February and March 2015 for adult patients (>12years) diagnosed with acute otitis media, acute tonsillitis and persistent rhinosinusitis. On an audit form, aspects of the prescribed antibiotic were benchmarked to local infection control antibiotic guidelines of 2011 to evaluate adherence. Results: From 1010 casualty records, 188 were antibiotic prescriptions, of which 93 (49.4%) were correctly indicated as per guidelines. From the indicated prescriptions 81 (87%) were assessable, out of which full adherence was only observed in 6 (7%) of prescriptions. All of these were for rhinosinusitis. Full adherence in rhinosinusitis was found to be 43%, whilst no adherence was found in the other infections. The most prescribed antibacterial for all three infections was co-amoxiclav. Conclusion: The current antibiotic guidelines have not been adequately implemented as adherence to antibiotic choice alone was low in all infections. This may have an impact on antibiotic-resistant rates and infection incident rates. Hence to improve adherence to local antibiotic guidelines, it is recommended that these should be clear, regularly updated, well disseminated and reinforced. The addition of a care pathway may further improve appropriate antibiotic use.peer-reviewe

Monitoring of thyroid function tests in hypothyroid patients on levothyroxine

The study aims to identify and recommend ways of improving thyroid function monitoring. Over a three month period, eighty-eight patients with clinical and subclinical primary hypothyroidism on long-term levothyroxine therapy were seen by GPs at the Chronic Disease Managment Clinic. The monitoring intervals of thyroid function tests for patients with controlled and uncontrolled primary hypothyroidism were benchmarked with the American Association of Clinical Endocrinologists guidelines. The overall average compliance for clinical hypothyroid cases was 69% (n=15) and 40% (n=9) for the subclinical hypothyroid cases. In the clinical hypothyroid cases compliance was 71% (n=15) and 67% (n=14) for controlled and uncontrolled cases, respectively. In the subclinical hypothyroid cases compliance was 43% (n=10) and 35% (n=8) for controlled and uncontrolled cases, respectively. Knowledge of the guidelines amongst GPs should be increased especially when it comes to the management of subclinical hypothyroidism, and in cases of uncontrolled hypothyroidism in general. This is possible through better dissemination, availability and reinforcement of such guidelines.peer-reviewe

Colonoscopy screening in moderate-risk family groups

Colorectal cancer is one of the commonest forms of cancer in the Maltese population. It can be treated successfully if detected early. Education and screening are the major components of early detection. The aim of this study was to determine the pattern of colonoscopy screening in patients at moderate risk of developing colorectal cancer in a surgical firm at Mater Dei Hospital. 90 patients that fit into the moderate-risk category were identified from the firm’s endoscopy database. The pattern of screening was then compared to the NICE guidelines. It was found that colonoscopy screening was more aggressive than recommended by the NICE guidelines.peer-reviewe

An audit on the practice of performing a chest X–Ray in infants with bronchiolitis

Introduction: Bronchiolitis is one of the most common medical emergencies in infancy. One in three infants will develop bronchiolitis in the first year of life. 2 - 3% of these require hospitalisation. Aim: To assess adherence to the National Institute for Health and Care Excellence (NICE) and American Academy of Paediatrics Clinical Practice Guidelines for Bronchiolitis regarding the practice of performing a chest X - ray in infants aged less than 6 months presenting with viral bronchiolitis. Methodology: Data was collected on infants aged less than 6 months presenting to the Accident and Emergency department (A&E), Mater Dei Hospital, Malta or admitted with bronchiolitis between January - April 2016 and October - February 2016 - 2017. The data was retrieved retrospectively from medical records, processed and compared to the guidelines. Approval was obtained from the Audit Committee and Data Protection Act Committee. Results: 148 patients were included in the study. 81 (54.7%) had a chest X - ray. 67 (82.7%) of the chest X - rays taken were normal. 28 (34.6%) of the chest X - rays taken were indicated according to the guidelines. Only 9 out of the 81 chest X - rays taken (11.1%) led to a change in management. Conclusion: Overall percentage compliance to the guidelines was 64.2%. Compliance may be improved by having an easily available local guideline, familiarising paediatric trainees with the guidelines and increasing awareness of the harmful effects of radiation.peer-reviewe

The aetiology of acute gastroenteritis in children in Malta and the role of empirical antibiotics in this condition

BACKGROUND: Rotavirus is the leading cause of gastroenteritis in Europe. No specific clinical feature differentiates bacterial from viral gastroenteritis. Acute gastroenteritis self-resolves without antibiotics in the majority of healthy children regardless of the aetiology. Empirical antibiotics should only be prescribed for specific indications, as stated in the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) / European Society for Pediatrics Infectious Diseases (ESPID) Evidence-Based Guidelines for the Management of Acute Gastroenteritis in Children in Europe. This audit aimed to assess the prevalence of the different pathogens causing acute gastroenteritis in children in Malta and to establish whether empirical antibiotics are being prescribed according to the aforementioned guidelines.METHOD: All children admitted to Mater Dei Hospital between 1st September 2019 and 29th February 2020 with acute gastroenteritis were included. The data was collected retrospectively from iSOFT Clinical Manager and medical records. The results were compared to the aforementioned guidelines.RESULTS: Rotavirus was the most commonly identified pathogen accounting for 37.9% of all cases. Non-typhoid Salmonella was the commonest bacterial cause. Empirical antibiotics were prescribed in 20.3% of all cases but were indicated in 8.4%. Empirical antibiotics were only indicated in 37.9% of the patients who received them. The commonest indicator was severe toxaemia.CONCLUSION: Rotavirus is the leading cause of acute gastroenteritis in children in Malta. The majority of patients (79.7%) were not prescribed empirical antibiotics in accordance with the guidelines. However, only 37.9% of the prescribed empirical antibiotics were indicated, hence their use could still be reduced further.peer-reviewe

Diagnostic implications of genetic copy number variation in epilepsy plus

Objective Copy number variations (CNVs) represent a significant genetic risk for several neurodevelopmental disorders including epilepsy. As knowledge increases, reanalysis of existing data is essential. Reliable estimates of the contribution of CNVs to epilepsies from sizeable populations are not available. Methods We assembled a cohort of 1255 patients with preexisting array comparative genomic hybridization or single nucleotide polymorphism array based CNV data. All patients had epilepsy plus, defined as epilepsy with comorbid features, including intellectual disability, psychiatric symptoms, and other neurological and nonneurological features. CNV classification was conducted using a systematic filtering workflow adapted to epilepsy. Results Of 1097 patients remaining after genetic data quality control, 120 individuals (10.9%) carried at least one autosomal CNV classified as pathogenic; 19 individuals (1.7%) carried at least one autosomal CNV classified as possibly pathogenic. Eleven patients (1%) carried more than one (possibly) pathogenic CNV. We identified CNVs covering recently reported (HNRNPU) or emerging (RORB) epilepsy genes, and further delineated the phenotype associated with mutations of these genes. Additional novel epilepsy candidate genes emerge from our study. Comparing phenotypic features of pathogenic CNV carriers to those of noncarriers of pathogenic CNVs, we show that patients with nonneurological comorbidities, especially dysmorphism, were more likely to carry pathogenic CNVs (odds ratio = 4.09, confidence interval = 2.51-6.68; P = 2.34 x 10(-9)). Meta-analysis including data from published control groups showed that the presence or absence of epilepsy did not affect the detected frequency of CNVs. Significance The use of a specifically adapted workflow enabled identification of pathogenic autosomal CNVs in 10.9% of patients with epilepsy plus, which rose to 12.7% when we also considered possibly pathogenic CNVs. Our data indicate that epilepsy with comorbid features should be considered an indication for patients to be selected for a diagnostic algorithm including CNV detection. Collaborative large-scale CNV reanalysis leads to novel declaration of pathogenicity in unexplained cases and can promote discovery of promising candidate epilepsy genes

Diagnostic implications of genetic copy number variation in epilepsy plus

OBJECTIVE: Copy number variations (CNVs) represent a significant genetic risk for several neurodevelopmental disorders including epilepsy. As knowledge increases, reanalysis of existing data is essential. Reliable estimates of the contribution of CNVs to epilepsies from sizeable populations are not available. METHODS: We assembled a cohort of 1255 patients with preexisting array comparative genomic hybridization or single nucleotide polymorphism array based CNV data. All patients had "epilepsy plus," defined as epilepsy with comorbid features, including intellectual disability, psychiatric symptoms, and other neurological and nonneurological features. CNV classification was conducted using a systematic filtering workflow adapted to epilepsy. RESULTS: Of 1097 patients remaining after genetic data quality control, 120 individuals (10.9%) carried at least one autosomal CNV classified as pathogenic; 19 individuals (1.7%) carried at least one autosomal CNV classified as possibly pathogenic. Eleven patients (1%) carried more than one (possibly) pathogenic CNV. We identified CNVs covering recently reported (HNRNPU) or emerging (RORB) epilepsy genes, and further delineated the phenotype associated with mutations of these genes. Additional novel epilepsy candidate genes emerge from our study. Comparing phenotypic features of pathogenic CNV carriers to those of noncarriers of pathogenic CNVs, we show that patients with nonneurological comorbidities, especially dysmorphism, were more likely to carry pathogenic CNVs (odds ratio = 4.09, confidence interval = 2.51-6.68; P = 2.34 × 10-9 ). Meta-analysis including data from published control groups showed that the presence or absence of epilepsy did not affect the detected frequency of CNVs. SIGNIFICANCE: The use of a specifically adapted workflow enabled identification of pathogenic autosomal CNVs in 10.9% of patients with epilepsy plus, which rose to 12.7% when we also considered possibly pathogenic CNVs. Our data indicate that epilepsy with comorbid features should be considered an indication for patients to be selected for a diagnostic algorithm including CNV detection. Collaborative large-scale CNV reanalysis leads to novel declaration of pathogenicity in unexplained cases and can promote discovery of promising candidate epilepsy genes.status: publishe